Multiple Interventions, Improved Procedures and Technology Help UNC Hospitals Reduce CLABSIs

Employing multiple interventions and armed with technology, clinicians at the University of North Carolina Hospitals worked with their hospital epidemiologists and infection preventionists and were able to reduce their rate of central line-associated bloodstream infections (CLABSIs) by 85 percent over the last 10 years, according to UNC researchers. Interventions ranged from proper catheter insertion and maintenance, to the use of chlorhexidine gluconate as an antiseptic.

William Rutala, MPH, PhD, director of hospital epidemiology at UNC Hospitals and one of four authors of the study published in the August 2010 issue of Infection Control and Hospital Epidemiology, reports that this feat resulted in the prevention of an estimated 887 infections and 244 deaths and saved the hospitals more than $20 million in treatment costs. In addition to Rutala, authors of the study were David Weber, MD, MPH, Vickie Brown, RN, MPH, and Emily Sickbert-Bennett, PhD, all members of UNC Hospitals' infection prevention department.

"We believe that these multiple interventions and new technological advances will continue to aid in the dramatic reduction in the rate of central-line associated bloodstream infections among intensive care unit patients and demonstrates UNC Health Cares commitment to improving patient safety," Rutala says.

Each year CLABSIs cause more than 30,000 deaths in U.S. hospitals and cost the U.S. healthcare system an estimated $2 billion. "The majority of patients in ICUs have a central venous catheter in order to provide monitoring and medications, thus, even though CLA-BSI is not a common event the high frequency of catheter use leads to a large number of infections," Rutala explains. "We are getting better through technology and training at reducing this large number of infections."

CLABSIs pose such a significant problem that next year the Centers for Medicare and Medicaid Services (CMS) will begin requiring hospitals that accept Medicare and Medicaid to report these healthcare-acquired infections to the Centers for Disease Control and Prevention (CDC). "The new reporting requirements plus lack of CMS reimbursement will provide important incentives for hospitals to reduce CLA-BSI. This is especially true when implementation of new technologies results in additional expenditures (e.g., CHG-pad, antimicrobial-impregnated catheter)."

In 1999, the central line infection rate at UNC Hospitals was 8.9 infections per 1,000 catheter days. By 2009 that had been reduced to 1.3 infections per 1,000 catheter days, the study found. Starting in 2000, UNC Hospitals began introducing new infection prevention practices aimed at reducing the number of central line infections. That year medical staff received enhanced education about proper catheter insertion and maintenance. In addition, staff began using a highly effective antiseptic containing chlorhexidine gluconate and alcohol to prepare the skin for catheter insertion.

"In general, technology is superior to changing human behavior for reducing risk," Rutala says. "Fortunately, we have new technological advances for reducing CLA-BSI but compliance with guidelines (e.g., hand hygiene) is also critical."

Rutala adds, "Each year we introduced a new intervention and the infection rate continued to decrease. Additional training for nurses was added in 2001 and in 2003 medical staff began using customized kits that included a full body drape for the patient and safety devices to prevent needlestick injuries."

In 2006, the medicine intensive care unit (ICU) began using a bundle of measures recommended by the Institute for Healthcare Improvement (IHI). The bundle included a paper checklist that nurses used while physicians were inserting a central line.

"The bundles, which are based on process measures and limited interventions, are an excellent method of reducing HAIs," Rutala says. "The bundle components were individually demonstrated, in general, to reduce infections. However, the bundles were not expected to be the sole method for reducing HAIs. All other infection prevention measures of demonstrated value should also be implemented."

"The nurses used the checklist to make sure that everyones hands were washed, that the full-body drape was used, that the appropriate site was chosen, and that the skin prep was done correctly," Sickbert-Bennett says. "The medicine ICU then shared their success story with the other ICUs, and now all of the ICUs are using this checklist approach for proper insertion of the central lines."

The UNC researchers emphasize that no single intervention, by itself, was responsible for the overall reduction in central line infections. Instead, the "sequential introduction of improved procedures and new technologies resulted in a sustained and progressive decrease" in infection rates across all of the intensive care units at UNC Hospitals.

"UNC Health Care bases it infection prevention recommendations on interventions with scientifically-demonstrated benefit," Rutala says. "If the science supports introducing new technology or training we believe it should be rapidly introduced."

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