Introduction to healthcare-associated infections
Hospital associated infections (HAI) a patient safety issue of concern to all hospitals
The Joint Commission considers the reduction of hospital-associated infections as an essential intervention in the provision of safe patient care.
Prevalence of HAI as reported in Magill et al. (2014)
In 2011, 722,000 HAIs were reported in American acute care hospitals
One in every twenty-five hospital patient gets at least one HAI on any given day
More than 50% of the HAIs occur outside intensive care units
Effect of HAIs on health care system
An estimated 75,000 HAI patients die while hospitalized (Magil et al., 2014)
HAIs lead to longer length of stay
HAIs are associated with increased medical costs: the overall direct medical costs of HAI to American were $28.4 billion to 33.8 billion
Cost of 5 leading HAIs were 9.8 billion (Zimlichman et al., 2013)
Most common infections in 2011 (Magill et al., 2014)
Pneumonia accounted for 157, 500 cases
Surgical site infections from any surgical procedure performed to hospitalized patients accounted for 157,500 cases
Gastrointestinal illness was reported in 123,100 cases
Urinary tract infections were observed in 93,300 cases
Primary bloodstream infections accounted for 71,900 infection cases
Purpose of the paper
The Joint Commission recommends use of evidence-based practices to prevent bloodstream infections from central lines.
The primary purpose of this paper is to review literature on the best practices in the prevention of blood infections from central lines, with a view of identifying the most effective strategies
The paper is also intended to provide recommendations for practice
Prevention of Central line-associated bloodstream infections (CLABSI):
Organizations should position the prevention of CLABSI as an essential institutional goal as this has been found to be associated with reductions in CLABSI (Saint et al., 2014)
Patients at risk of intensive care unit patients, oncology patients, intraoperative patients, and patients receiving hemodialysis through catheters
Factors associated with increased risk for CLABSI are prolonged hospitalization before the catheter is inserted, prolonged catheterization duration, heavy microbial colonization at the catheter hub and insertion site, femoral catherization in adults, low nurse to patient ratio in the intensive care unit, and so forth (see Advani et al., 2011; Marschall et al., 2014, for more risk factors).
Researchers have investigated ways of reducing or preventing CLABSI. The strategies reported in literature suggest that prevention of CLABSIs should start before insertion and continue during maintenance (Marschall et al., 2014).
Before the insertion, clinicians should make sure that there is an appropriate indication for catheter use, based on the best evidence available (Marschall et al., 2014).
Some strategies that might work to ascertain the appropriateness of an indication for catheter use are collaboratives, bladder scanners, catheter reminders or stop orders or nurse-initiated discontinuation. Saint and colleagues found that frequent use of these strategies in Michigan hospitals was associated with a 25% reduction in the catheter-associated infections compared to only 6% observed in the hospitals outside Michigan where the prevention methods were not used (Saint et al., 2013).
Intervention bundles: Several studies have reported the effectiveness of intervention bundles for the prevention of CLABSI.
Marsteller et al. (2012) reported a causal relationship between a multifaceted intervention designed by the Johns Hopkins Quality and Safety Research Group, to enhance safety and the use of evidence-based practices in the prevention of CLABSI. The bundle consisted of five evidence-based practices, including hand hygiene, use of full barrier precautions, not placing line at femoral site, site cleansing with chlorhexidine, and removal of unnecessary lines. The intervention reduced CLABSI in the intervention group by 81% compared the 69% reduction in the intervention group (Marsteller et al., 2012)
Miller and colleagues compared the effectiveness of two prevention bundles among pediatric patients. On one end, they had two central line care bundles (insertion and maintenance bundoles), while on the other, they had 2 additional interventions, namely; chlorhidine scrub and chlorhexidine-impregnated sponges. They found that CLABSI rate decreased from 5.2 cases per 1000 line days to 2.3 per 1000 line days. They did not see any significant difference in the reduction of infections between the standard bundle and the bundle with the additional practices (Miller et al., 2011).
Schulman and colleagues assessed the effectiveness of insertion and maintenance bundles among the 18 regional referral neonatal intensive care units in New York. There was a 67% decrease in CLABSI from 6.4 CLABSIs per 1000 central-line days to 2.1 CLABSIs per 1000 central line CLABSIs (Schulman et al., 2011)
The use of the bundles if accompanied by checklists to monitor adherence to the bundle practices (e.g. Saint et al., 2011; Shulman et al., 2011)
Compliance and correct use of CLABSI prevention bundles may be enhanced through education and training
Fisher and colleagues showed that monthly webinars and quarterly face-to-face learning sessions were associated with increased compliance with CLABSI prevention bundle in neonatal intensive care units. They found that CLABSI rates declined by 71% from 3.94 CLABSIs per 1000 central line days to 1.16 CLABSIs per 10000 central line days, a reduction which was sustained for one year (Fisher et al., 2013)
Discussions
Prevention of CLABSIs should begin from the point when a considerations are being made for catheterizations and proceed throughout the maintenance (Marschall et al., 2014; Saint et al., 2011)
Appropriate evidence-based bundle should be used to ascertain that there is an appropriate indication for catheterization (Saint et al., 2011)
Perceptions that prevention of CLABSIs is a critical organizational goal are associated with reduced cases of CLABSIs (Saint et al., 2011)
There is consistent evidence that evidence-based bundles may reduce rates of CLABSIs in hospitals (Marsteller et al., 2012; Miller et al., 2011; Saint et al., 2013; Schulman et al., 2011)
A checklist should accompany use of prevention bundles, for monitoring the implementation of the bundle to ensure that all the practices are observed (Saint et al., 2011; Schulman et al., 2011)
Compliance with CLABSI prevention bundle may be enhanced through educational and training workshops (Fisher et al., 2013)
There seems to be no standardized prevention bundle that can be applied throughout the country
Recommendations for Practice and Research
Health care organizations should cultivate within their staff the idea that prevention of CLABSIs is an institutional goal that all should work towards
There is need to adopt a formalized, standardized CLABSI prevention bundle.
This means that clinical researchers need to do more research to develop a standardized CLABSI prevention and reduction bundle that may be adopted by hospitals across the country
Before a standardized CLABSI prevention bundle is developed, hospitals should develop their evidence-based bundles to help in the prevention of CLABSIs
Hospitals should organize educational and training workshops for the use of CLABSI prevention bundles
References
Advani, S., Reich, N. G., Sengupta, A., Gosey, L., & Milstone, A. M. (2011). Central line–associated bloodstream infection in hospitalized children with peripherally inserted central venous catheters: Extending risk analyses outside the intensive care unit. Clinical Infectious Diseases, 52(9), 1108-1115.
Magill, S. S., Edwards, J. R., Bamberg, W., Beldavs, Z. G., Dumyati, G., Kainer, M. A., & Ray, S. M. (2014). Multistate point-prevalence survey of health care–associated infections. New England Journal of Medicine, 370(13), 1198-1208.
Marschall, J., Mermel, L. A., Fakih, M., Hadaway, L., Kallen, A., O’Grady, N. P., & Yokoe, D. S. (2014). Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infection Control & Hospital Epidemiology, 35(S2), S89-S107.
Marsteller, J. A., Sexton, J. B., Hsu, Y. J., Hsiao, C. J., Holzmueller, C. G., Pronovost, P. J., & Thompson, D. A. (2012). A multicenter, phased, cluster-randomized controlled trial to reduce central line-associated bloodstream infections in intensive care units. Critical Care Medicine, 40(11), 2933-2939.
Miller, M. R., Niedner, M. F., Huskins, W. C., Colantuoni, E., Yenokyan, G., Moss, M., & Brilli, R. J. (2011). Reducing PICU central line–associated bloodstream infections: 3-year results. Pediatrics, 128(5), e1077-e1083.
Saint, S., Greene, M. T., Kowalski, C. P., Watson, S. R., Hofer, T. P., & Krein, S. L. (2013). Preventing catheter-associated urinary tract infection in the United States: A national comparative study. JAMA Internal Medicine, 173(10), 874-879.
Zimlichman, E., Henderson, D., Tamir, O., Franz, C., Song, P., Yamin, C. K., & Bates, D. W. (2013). Health care–associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Internal Medicine, 173(22), 2039-2046.
Zingg, W., Holmes, A., Dettenkofer, M., Goetting, T., Secci, F., Clack, L., & Pittet, D. (2015). Hospital organisation, management, and structure for prevention of health-care-associated infection: a systematic review and expert consensus. The Lancet Infectious Diseases, 15(2), 212-224.
