Maximal Sterile Barrier Research Articles

Impact of Routine Intensive Care Unit Surveillance Cultures and Resultant Barrier Precautions on Hospital‐Wide Methicillin‐ResistantStaphylococcus aureusBacteremia

Serial interventions are often used to reduce the risk of health care-associated methicillin-resistant Staphylococcus aureus (MRSA) infections. To our knowledge, the relative impact of these interventions has not previously been ascertained. We conducted a retrospective study of 4 major infection control interventions using an interrupted time series design to evaluate their impact on MRSA bacteremia in an 800-bed hospital with 8 intensive care units (ICUs). Interventions were introduced 1 at a time during a 9-year period and involved the promotion of compliance with maximal sterile barrier precautions during central venous catheter placement, the institution of alcohol-based hand rubs for hand disinfection, the introduction of a hand hygiene campaign, and the institution of routine nares surveillance cultures for MRSA in all ICUs for patients on ICU admission and weekly thereafter while in the ICU. Positive cultures resulted in the initiation of contact isolation precautions. Using segmented regression analyses, we evaluated changes in monthly incidence and prevalence of MRSA bacteremia from their predicted values. Methicillin-susceptible Staphylococcus aureus bacteremia was monitored as a control. Routine surveillance cultures and subsequent contact isolation precautions resulted in substantial reductions in MRSA bacteremia in both ICUs and non-ICUs. In 16 months, the incidence density of MRSA bacteremia decreased by 75% in ICUs (P=.007) and by 40% in non-ICUs (P=.008), leading to a 67% hospital-wide reduction in the incidence density of MRSA bacteremia (P=.002). Methicillin-susceptible S. aureus bacteremia rates remained stable during this time. The other interventions were not associated with a statistically significant change in MRSA bacteremia. Routine surveillance for MRSA in ICUs allowed earlier initiation of contact isolation precautions and was associated with large and statistically significant reductions in the incidence of MRSA bacteremia in the ICUs and hospital wide. In contrast, no similar decrease was attributable to the other infection control interventions.

Pediatric: Nurse-Placed Peripherally Inserted Central Catheters in an Interventional Radiology Setting Improves Outcomes

Pioneering quality performance management for the vascular access needs in children is of critical importance. Specifically, appropriate assessment and timely intervention of central line access are priorities. Santolucito (2001) indicates that improved triage of appropriate vascular access intervention, for example Peripherally Inserted Central Catheters (PICC) placement, could reduce the trauma and costs of multiple conventional short peripheral IV catheter insertions, as well as potentially reducing length of hospital stay. “Failure to establish a reliable vascular access prior to discharge often results in postponed discharge dates, prolonged hospitalization and increased cost.” A proactive approach to known barriers related to catheter selection and care will be pivotal to the success of the Pediatric-placed PICC. We embarked on a unique approach to improve outcomes in children. As a result Vascular Access Nurses currently place PICCs in the Interventional Radiology setting. The team consists of a Radiology Nurse, a Vascular Access Nurse, a Radiology Technologist, and an Interventional Radiology Attending Physician. In this model patients are evaluated for appropriateness of a nurse-placed PICC, sedation, urgency, and scheduled accordingly. In the Interventional Radiology setting the patient receives IV sedation, PICC lines are placed using maximum sterile barrier technique, ultrasound and fluoroscopy capability. This is made possible only with the expertise of all team members. Significant results of this patient care model include efficiency, patient safety, and cost effectiveness.

Recommendations and Reports about Central Venous Catheter-Related Infection

Central venous catheters (CVCs) are used to deliver a variety of therapies, as well as for measurement of hemodynamic parameters. The major associated complication is catheter-related blood stream infection (CRBSI). Review of the pertinent English-language literature. The incidence of CRBSI depends on how such infections are defined. Generally, the term includes all BSIs in patients with CVCs when other sources can be excluded, and if a culture of the catheter tip demonstrates a substantial number of colonies of the organism found in the blood stream. Important pathogenic determinants of catheter-related infection are the material of which the device is made and the intrinsic virulence of the organism. The site at which a catheter is placed influences the risk of infection. The types of organisms that most commonly cause hospital-acquired BSIs have changed over time. Migration of skin organisms at the insertion site into the cutaneous catheter tract with colonization of the catheter tip is the most common route of infection. Good hand hygiene before catheter insertion, combined with proper aseptic technique during its manipulation, provides protection against infection; maximal sterile barrier precautions during insertion reduce the incidence of CRBSI. Catheters that are coated or impregnated with antimicrobial or antiseptic agents can decrease the risk and the associated hospital costs. No studies have demonstrated that oral or parenteral antibacterial or antifungal drugs reduce the incidence of CRBSI in adults. Use of anticoagulants might have a role in the prevention of CRBSI. Catheter replacement at scheduled intervals has not lowered rates of local or systemic complications. Central venous catheters are used commonly to deliver a variety of therapies, such as large amounts of fluid or blood products during surgery or in intensive care units, chemotherapy, and parenteral nutrition, as well as for measurement of hemodynamic variables. The major complication associated with CVCs is CRBSI.

Adding a Chlorhexidine Patch to the IHI Bundle: Goal Zero in Reducing Central Line-Associated Bacteremia

BACKGROUND/OBJECTIVES: The Institute for Healthcare Improvement (IHI) as well as other regional initiatives has outlined evidence-based best practices for improving rates of central line-associated bacteremia (CLAB). Brookdale University MC has since 2000 implemented various interventions, including education, proper hand hygiene, maximal sterile barriers, chlorhexidine skin antisepsis, and optimal site care with a result of reducing CLAB in adult ICUs from 24.8 to 3.1 CLABs per 1000 catheter days. We report on an 8-month study that assessed the effect of adding to the bundle a chlorhexidine impregnated patch on the occurrence of bacteremia. METHODS: Subjects in the study included all patients in 4 adult ICUs (30-beds) who had central lines inserted. Central lines included triple-lumen, dialysis, swan-ganz, and peripherally inserted central lines. CLAB definition used was that as published by the National Nosocomial Infection Study (NNIS) group. Group I patients (n = 277; May 2005-Aug 2005) had bundle interventions as outlined above. Group II patients (n = 226; Sep 2005-Dec 2005) had a chlorhexidine-impregnated patch (Biopatch, Johnson & Johnson, Somerville, NJ) placed at the catheter insertion site. Compliance with the individual components of the protocol was assessed by direct observation of the insertion site. RESULTS: Compliance with the chlorhexidine patch protocol was measured 36 times in the 4 ICUs during the Group II period and rose to the following maximum levels: Patch at catheter site - 98%; blue side on patch placed facing up (100%). CLAB rates were significantly reduced from 3.1 per 1000 catheter days in the Group I period to 0.0 per 1000 catheter days in the Group II period after introduction of a chlorhexidine patch (<i>p</i> ≤ 0.5). No adverse reactions were noted in any patient. Based on a mean cost of $45,254 per CLAB as published by the Centers for Disease Control, the avoided costs for the institution (minus the cost of product) is estimated to be $314,678 per year. CONCLUSIONS: The results of this study suggest that the use of a chlorhexidine patch adds considerably to a CLAB reduction bundle, as well as contributing to reduced infection costs.

Getting Physicians To Comply: Improving Adherence to Full Barriers during Central-Line Insertions

BACKGROUND/OBJECTIVES: A 467-staffed bed tertiary hospital was the setting for this study. Barrier precautions audits for central-line insertion showed inconsistent practices for full body sterile drapes. Different sized drapes were used; only 17% used a “full-body” drape. Sterile gown usage was just 71%. The audit revealed a need to improve the existing process. An organizational learning approach to achieve sustained change was employed. Objective was to achieve 100% adherence with full barrier practices. METHODS: Organizational and personal learning were the focus, including: • Infection Control Department research for the optimal “large” drape size. • Using a staff focus involving, - Intensive care unit (ICU) intensivists for input on drape size. - ICU nursing staff for process auditing. • Using environmental cues to reinforce learning and provide standardization. - A visual poster defining “full body” drapes - Redesigned central line kits for consistency and inclusion of the large drape. - Adding an extra large sterile gown on the central line insertion cart. • Education - On maximal sterile barriers for Residents/physicians - Personal learning through an education newsletter for nursing staff. RESULTS: A follow-up audit after the learning process in the intensive care units showed consistent sterile gown and full body sterile drape usage. Results Pre-intervention 2004 (n = 24) Post-intervention 2005 (n = 28) Barriers worn Barriers worn Cap worn (100%) Cap worn (100%) Mask worn (100%) Mask worn (100%) Sterile gown (71%) Sterile gown (100%) Sterile gloves (100%) Sterile gloves (100%) Full body sterile drape (17%) Full body sterile drape (92%) CONCLUSIONS: Health care criteria for performance excellence goals includes using coordinated approaches that result in learning to improve quality. The ICU nurses and intensivists motivated staff to use their full potential toward a homogenous goal. Environmental factors, (e.g., redesigned kit), contributed to sustained practice by limiting choices to the “full body” drape. The poster was a reminder of correct practices in the ICUs. Full barrier education to staff physicians helped achieve credible models for Residents/interns. This multi-faceted approach contibuted to consistent barrier use.

Review of Selected Comprehensive Cancer Centers' Written Policies for Preventing Catheter-Related Bloodstream Infections

ISSUE: Cancer (CA) patients often require long-term central venous catheter (CVC) access for intravenous support; catheter-related bloodstream infections (CR-BSI) cause significant morbidity & mortality. The Centers for Disease Control & Prevention (CDC) has published evidence-based guidelines for preventing CR-BSI; Category IA recommendations (Cat IA recs) are strongly supported by well-designed experimental, clinical, or epidemiologic studies. The objective was to determine if Cat IA recs are consistently included in Comprehensive Cancer Center (CCC) CR-BSI prevention policies. PROJECT: The CCC Infection Control Group (C3IC) consists of infection control professionals from 14 CCC. C3IC members voluntarily work together to compare practices & data for preventing infection in CA patients. C3IC compared their individual facility's written policies to prevent CR-BSI with CDC guidelines. For each recommendation, responses were Yes/No; blanks were considered unknown. RESULTS: Ten/14 (71%) C3IC centers submitted policy evaluation. All centers required education about insertion & maintenance of CVCs; 70% required periodic knowledge assessment. Hand hygiene, sterile gloves, & skin disinfection before insertion & sterile dressing on the site were included in 100%; maximal sterile barriers for insertion were specified by 90%. The subclavian was the preferred site for insertion of non-tunneled catheters at 70% of CCC; 20% follow this recommendation though not in their written policy. Half of CCC do not routinely administer antimicrobial prophylaxis before insertion nor use topical antibiotic ointment for non-dialysis sites; 60% specify removal when CVC is no longer necessary. Of 34 Cat 1A recs, only 50% were incorporated in policy at 8-10 centers, while 12/34 (35%) were included at 6 or less. Fourteen (41%) Cat 1A recs were practiced although not included in policy, & 15/34 (44%) were left blank by 1-5 C3ICs, possibly indicating lack of knowledge about those recommendations at their facility. LESSONS LEARNED: Written policy at 10 CCC varies in adherence to CDC evidence-based guidelines for preventing CR-BSI. Actual practice differed from written policy, making identification of facility-specific risk factors & appropriate interventions difficult. Future research will compare CR-BSI rates at C3IC facilities to adherence to CDC CR-BSI prevention guidelines.

The Importance of a Physician Champion in Implementing Practice Change

ISSUE: In Surgical Trauma ICU (SICU), the rate of central line related bloodstream infections (CRBSI), as defined by CDC, was at or above the National Nosocomial Infection Surveillance System(NNIS) mean for several sucessive quarters. There is strong evidence that use of full sterile barriers and chlorhexidine skip prep during insertion of central lines reduces the risk of infection. In an effort to facilitate best practices, a “Barrier Kit” was designed with all necessary supplies and was to be provided to each physician by nursing personnel assisting. These are available in all clinical units. A Central Venous Catheter Insertion form was created to monitor several aspects of central line insertion including use of maximum sterile barriers and chlorhexidine skin prep. These were designed to allow physicians to use them as the procedure note as well. If the physician chose to document the procedure elsewhere, the nurse could complete monitoring information. To facilitate ussage, Materials Management attached a form to each central line kit before delivery to patient care units. Medical Staff and nursing were educated. Compliance with completion of the form was poor and documentation of appropriate barriers and skin prep was less than 100% on completed forms. PROJECT: In April, 2005, the new medical director of SICU accepted the challenge of reducing this infection rate. First, she created a policy on the insertion procedure and presented it for approvel by appropriate medical staff committees. Included in the procedure, nursing personnel assisting the physician were to remind the physician inserting the line if policy was not being followed and complete the form if the physician chose not to. In SICU, if a physician didn't comply, she was to be notified and would discuss policy with that physician. Medical Directors of all units were encouraged to adopt a similar procedure. In SICU a cart was stocked with frequently used central line kits and all needed supplies. She supported a trial of a timed release chlorhexidine gluconate dressing in SICU, and when complete, use of the product on all central lines in the facility. RESULTS: In the four preceeding quarters, the average CRBSI rate in surgical ICU had been 6.8%. In the two quarters following her intervention, there were no CRBSI in the unit. LESSONS LEARNED: Physician involvement and willingness to provide feedback to other physicians is vital in process improvements that require a change in physician practice.

Evidence-Based Practice to Reduce Central Line Infections

In 2003, through the Greater Cincinnati Health Council nine health care systems agreed to participate and fund 50% of a two-year project to reduce hospital-acquired infections among patients in intensive care units (ICU) and following surgery (SIP). Hospitals were randomized to either the CR-BSI or SIP project in the first year, adding the alternative project in year 2. Project leaders, often the infection control professionals, implemented evidence-based practices to reduce catheter-related blood stream infections (CR-BSIs; maximal sterile barriers, chlorhexidine) at their hospitals using a collaborative approach. Team leaders entered process information in a secure deidentifled Web-based database. Of the four initial sites randomized to CR-BSI reduction, all reduced central line infections by 50% (CR-BSI, 1.7 to 0.4/1000 line days, p < .05). At the project midpoint (3 quarters of 2004), adherence to evidence-based practices increased from 30% to nearly 95%. The direct role of hospital leadership and development of a local community of practice, facilitated cooperation of physicians, problem solving, and success. Use of forcing functions (removal of betadine in kits, creation of an accessory pack and a checklist for line insertion) improved reliability. The appropriate floor for central line infections in ICUs is < 1 infection /1,000 line days.

Guidelines for Management of Home Parenteral Support in Adult Chronic Intestinal Failure Patients

Management of home parenteral support in adult benign but chronic intestinal failure patients requires a nutrition support team using disease-specific pathways. Education of patients to ensure they self manage home parenteral nutrition (HPN) is cornerstone to obtain minimal rate of technical complications and improvement in quality of life. Nutritive mixtures, compounded by pharmacists in single "all-in-one" bags, must be tailored according to the nutritional and intestinal status of individual patients with definition of macronutrients and water-electrolyte needs, respectively. Each PN cycle should be complete in essential nutrients to be nutritionally efficient and should have sufficient amounts of amino acids, dextrose, water, minerals, and micronutrients to avoid deficiency. When the nutritional goal is achieved, a minimum number of PN cycles per week should be implemented, guided ideally by digestive balance(s) (In-Out) of macronutrients and minerals of individual patients. Indeed, HPN is, in most cases, a complementary nonexclusive mode of nutritional support. In short gut patients--who represent 75% of chronic intestinal failure patients--encouraging enteral feeding decrease PN delivery and the risk of metabolic liver disease associated with HPN. In short gut patients with no severe renal impairment, blood citrulline dosage, in association with the remnant anatomy, is a tool to delineate transient from permanent intestinal failure. The latter group includes candidates for trophic gut factors and rehabilitative or reconstructive surgery, including intestinal transplantation. Thus, outcome improvement for intestinal failure patients needs intestinal failure teams having expertise in all medical and surgical aspects of this field.

Implementing evidence-based practices to reduce catheter-related bloodstream infections in the intensive care unit

ISSUE: Catheter-related bloodstream infections (CRBSIs) affect over 200,000 patients per year in the United States, increasing mortality risk 4%–35% and costing an estimated $6,000–$40,000 per infection. Strict adherence to evidence-based practices has been shown to reduce nosocomial CRBSI. PROJECT: We studied the reduction of CRBSI using a modified Institute for Healthcare Improvement framework and attention to campaign strategies (military, political, and marketing) at intensive care units (ICUs) from four healthcare systems representing tertiary referral, moderate-sized community, and small rural facilities. We implemented use of maximal sterile barriers (sterile large drape, gown and gloves, mask, cap) and chlorhexidine prep. CRBSI rates were calculated using Centers for Disease Control and Prevention (CDC) definitions. RESULTS: All sites benchmarked infection rates against National Nosocomial Infection Surveillance (NNIS) project, which confirmed practitioners' views that their low infection rate was "acceptable." All sites were able to achieve the stretch goal of reducing CRBSI by 50% (CRBSI 1.7 to 0.4/ 1000 line days, p < 0.05.) There was eradication of all line infections in 50% of the ICUs. Initially, use of chlorhexidine prep and sterile large drapes was initially uncommon (40% and 20%, respectively) but increased to over 90%. Forcing functions such as replacement of iodophor with chlorhexidine in the central line kits, removal of all other available iodophor, creating of a "full barrier" accessory pack, measurement of compliance using a checklist at line insertion, and friendly competition among the hospitals facilitated adherence to best practices. Sharing learning tools and group cooperation with product representatives reduced the costs of interventions. LESSONS LEARNED: Despite local competition among the hospitals, project leaders freely shared achievements and problem-solving strategies to overcome barriers such as data collection, contents and organization of central line carts, and staff and physician cooperation. Benchmarking data unexpectedly establishes a lower limit, creating the perception that no improvement is needed. It was shown that even the "acceptable" low infection rates at these four hospitals could be further lowered by continued adherence to best practices. This project created a system where ICUs can create a new community standard of patient safety and implementation of evidence-based practices even after project completion.

Safe passage campaign to prevent catheter-related bloodstream infections (CR-BSIs) in a tertiary neonatal intensive care unit (NICU)

ISSUE: Inconsistent use of the Center for Disease Control and Prevention (CDC) guidelines for prevention of CR-BSIs as well as lack of clear, concise communication between members of the healthcare team can result in CR-BSIs. Due to fluctuating CRBSI rates, a multiphased "safe passage" campaign was launched in our 50-bed NICU to address both issues. PROJECT: A teamwork and safety culture survey was conducted to provide a baseline measure. This was followed by a central line education and competency program. Each clinician received his or her own copy of a unit-produced DVD entitled "Safe Passage" which demonstrated hand hygiene, maximal sterile barrier precautions, and appropriate catheter site care. Once viewed, competency observation was required. Communication strategies consisted of coaching sessions for nurses and utilization of a standardized clinical communication tool known as SBAR (situation-background-assessment- recommendation/request). The tool helps set the expectation that relevant clinical information is going to be communicated each time the patient is discussed. RESULTS: More than 60% of eligible participants responded to the survey. Over half indicated a positive climate. Low-scoring items pertained to problem resolution and inability to express disagreement. Most clinical staff viewed the DVD and successfully completed the competency. Additional variations in central line management were discovered and eliminated as a result of the program. Coaching sessions for 60 nurses were conducted using theater-based communication tools for "finding-your-voice." Sessions consisted primarily of role play around difficult clinical scenarios and challenging communications. Participation was followed by individual action plans and selection of a "buddy" for feedback and support. Evaluations have been extremely positive. SBAR scenarios pertaining to central line care and management were written. The scenarios were tested with and without the use of the tool. Communication tended to be more concise and factual and less narrative when the tool was used. Individual nurse training using the tool begins in February. LESSONS LEARNED: Eliminating variation in the use of CDC central line guidelines and successful nurse-physician communication is critical for the safe, efficient, and effective patient care. This project outlines a multifaceted, practical approach that we plan to replicate and spread to other areas of our organization.

Use of Maximal Sterile Barriers during Central Venous Catheter Insertion: Clinical and Economic Outcomes

We performed a cost-effectiveness analysis to determine the effect of maximal sterile barriers (MSBs) on reducing central venous catheter (CVC)--related infections. Use of MSBs when placing CVCs may reduce the risk of infections but is more cumbersome, time-consuming, and expensive than other techniques. We developed a decision analytic model in which a patient could have a CVC placed with either an MSB or a less stringent technique. We calculated total direct medical costs and the incidences of catheter-related bloodstream infections, catheter colonization, and death. Use of MSBs lowered costs (from 621 dollars to 369 dollars per catheter insertion) and decreased the incidences of catheter-related bloodstream infections (from 5.3% to 2.8%), catheter colonization with local infection (from 5.5% to 2.9%) and death (from 0.8% to 0.4%). MSBs improved patient safety throughout all sensitivity analyses. Use of MSBs during CVC insertion likely lowers medical costs and decreases the incidences of catheter colonization, catheter-related bloodstream infections, and death. Cost savings were found over a wide range of clinical and economic assumptions, suggesting that MSBs should be routinely used when CVCs are inserted.

Prevention of central venous catheter-related bloodstream infections using non-technologic strategies.

To evaluate the incidence of nosocomial bacteremias related to the use of non-impregnated central venous catheters (CVCs) when only non-technologic strategies were used to prevent them. This was a prospective study of infectious complications of CVCs placed in intensive care unit (ICU) patients from April 1997 to December 2001. The medical-surgical ICU of a tertiary-care, university-affiliated hospital in Argentina. We studied all patients admitted to the ICU using non-impregnated CVCs. Maximal sterile barrier precautions (ie, use of cap, mask, sterile gown, sterile gloves, and large sterile drape), strict handwashing, preparation of the patients' skin with antiseptic solutions, insertion and management of catheters by trained personnel, and continuing quality improvement programs aimed at appropriate insertion and maintenance of catheters were employed. During the study period, 2,525 patients were admitted to the ICU. Eight hundred sixty-eight patients had 1,037 CVCs inserted. The number of CVC-related bloodstream infections (BSIs), acquired in the ICU, was 2.7 per 1,000 CVC-days (13 nosocomial CVC-related BSIs during 4,770 days of CVC use). Microorganisms isolated included methicillin-susceptible Staphylococcus aureus (n = 6), methicillin-resistant S. aureus (n = 2), coagulase-negative methicillin-resistant Staphylococcus (n = 2), Escherichia coli (n = 1), Klebsiella pneumoniae (n = 1), and Enterobacter cloacae (n = 1). A low rate of catheter-related BSI was achieved without antimicrobial-impregnated catheters. The incidence of CVC-associated bacteremias corresponded to the 10th to 20th percentile range of the National Nosocomial Infections Surveillance System hospitals for the same type of ICU.

An outbreak of methicillin-resistant Staphylococcus aureus infections related to central venous catheters for hemodialysis.

To determine risk factors for hemodialysis catheter-related bloodstream infections (HCRBSIs) and investigate whether use of maximal sterile barrier precautions would prevent HCRBSIs. Tertiary-care medical center hemodialysis unit. Open trial with historical comparison and case-control study of risk factors for HCRBSIs. Prospective surveillance was used to compare HCRBSI rates for 1 year before and after implementation of maximal sterile barrier precautions. A case-control study compared 50 case-patients with HCRBSI with 51 randomly selected control-patients. The HCRBSI rate was 1.6% per 100 dialysis runs (CI95, 1.1%-2.3%) in the first year and 0.77% (CI95, 0.5%-1.1%) in the second year (P = .0106). The most frequent cause of HCRBSI was MRSA in the first year (15 of 32) and MSSA in the second year (13 of 18). Ten MRSA blood isolates in the first year were identical by PFGE. Diabetes mellitus was a risk factor for HCRBSI. Age, gender, site of hemodialysis central venous catheter (CVC), other underlying diseases, coma score, APACHE II score, serum albumin level, and cholesterol level were not associated with HCRBSI and did not change between the 2 years. Hospital stay was prolonged for case-patients (32.78 +/- 20.96 days) versus control-patients (22.75 +/- 17.33 days), but mortality did not differ. Use of maximal sterile barrier precautions during the insertion of CVCs reduced HCRBSIs in dialysis patients and seemed cost-effective. Diabetes mellitus was associated with HCRBSI. An outbreak of MRSA in the first year was likely caused by cross-infection via medical personnel.

Prevention of Central Venous Catheter–Related Bloodstream Infections Using Non-Technologic Strategies

AbstractObjective:To evaluate the incidence of nosocomial bacteremias related to the use of non-impregnated central venous catheters (CVCs) when only non-technologic strategies were used to prevent them.Design:This was a prospective study of infectious complications of CVCs placed in intensive care unit (ICU) patients from April 1997 to December 2001.Setting:The medical–surgical ICU of a tertiary-care, university-affiliated hospital in Argentina.Methods:We studied all patients admitted to the ICU using non-impregnated CVCs. Maximal sterile barrier precautions (ie, use of cap, mask, sterile gown, sterile gloves, and large sterile drape), strict handwashing, preparation of the patients' skin with antiseptic solutions, insertion and management of catheters by trained personnel, and continuing quality improvement programs aimed at appropriate insertion and maintenance of catheters were employed.Results:During the study period, 2,525 patients were admitted to the ICU. Eight hundred sixty-eight patients had 1,037 CVCs inserted. The number of CVC-related bloodstream infections (BSIs), acquired in the ICU, was 2.7 per 1,000 CVC-days (13 nosocomial CVC-related BSIs during 4,770 days of CVC use). Microorganisms isolated included methicillin-susceptible Staphylococcus aureus (n = 6), methicillin-resistant S. aureus (n = 2), coagulase-negative methicillin-resistant Staphylococcus (n = 2), Escherichia coli (n = 1), Klebsiella pneumoniae (n = 1), and Enterobacter cloacae (n = 1).Conclusions:A low rate of catheter-related BSI was achieved without antimicrobial-impregnated catheters. The incidence of CVC-associated bacteremias corresponded to the 10th to 20th percentile range of the National Nosocomial Infections Surveillance System hospitals for the same type of ICU.

Using maximal sterile barriers to prevent central venous catheter?related infection: a systematic evidence-based review*1

<h2>Abstract</h2><h3>Background</h3> Catheter-related infections cause increased morbidity, mortality, and health care costs. Infection control experts advocate using maximal sterile barriers to reduce the incidence of these infections. Low compliance rates suggest that clinicians are not convinced or are not aware that available data support adopting this more cumbersome, time-consuming, and relatively more expensive technique. Accordingly, we conducted a systematic, evidence-based review of the medical literature to determine the value of maximal sterile barriers. <h3>Data sources</h3> We used multiple computerized databases, reference lists of identified articles, and queries of prominent investigators. <h3>Study selection</h3> We selected studies comparing infectious outcomes using maximal sterile barriers versus using less stringent sterile barrier techniques during central venous catheter insertion. <h3>Data synthesis</h3> We found only 3 primary research studies. Although each study suggests maximal sterile barriers may reduce infectious complications, the evidence supporting this conclusion is incomplete. The only randomized controlled trial limited enrollment to ambulatory oncology patients. These 3 studies differed notably in their patient populations, research designs, and health care settings. <h3>Conclusion</h3> The medical literature suggests maximal sterile barriers are advantageous in at least one setting and may be useful in others. While we believe the available evidence does support the use of maximal sterile barriers during routine insertion of central venous catheters, prospective studies and economic analyses would better clarify its value.

Interventional Program in Bacteremia in an Adult ICU of Chilean Teaching Hospital, 9-Year Follow-Up

ISSUE: Bacteremia (BAC) associated with central venous catheters (CVCs) is frequent in critical patients and increases costs and risk of death during hospitalization. The objective of this work was to evaluate results of an interventional program in BAC associated to CVCs in an adult ICU. PROJECT: During 1994–2002, an interventional program in bacteremia was established. It was based in three strategies: 1) inform and discuss the ICU rates of CVC-associated BAC, 2) inform the results of supervision, and 3) educational program to health personnel. Surveillance was done according to NNIS definitions. RESULTS: We surveilled 1799 patients with indwelling CVCs during this period (10,721 catheter days), 54 of them developed BAC (5/1000 catheter day). Average catheterization time was 15.9 days in patients with BAC, compared to 5.7 days in patients without infection (p=0.000764). The rate of CVC-associated BAC between 1994 and 1997 was 7.0 cases/1000 CVC days, which was reduced during 1998–2002 to 3.5 (OR 0.51 IC 0.29–0.87, p=0.018). There where 352 observations done, assessing techniques for insertion and care of CVC. Currently, fulfillment of recommended guidelines to prevent CVC-associated bacteremia is almost 100% for maximal sterile barriers precautions, handwashing, protection and care of insertion site, and connections replacement. CONCLUSION: We observed a significative reduction in the risk of CVC-associated bacteremia as improvement of practices dealing with CVC management was completely fulfilled. Catheterization time is significatively higher in patients with bacteremia.

Catheter-Specific Rates of Central Line–Associated Bloodstream Infections in Critically Ill Children

BACKGROUND: Central line-associated bloodstream infections (CLA-BSI) are the most common healthcare-associated infection among hospitalized children. Active surveillance for CLA-BSI among critically ill children at our hospital has revealed a rate of infection that is above the median rate reported by NNIS for patients in pediatric intensive care units (PICUs). In response to these data, we conducted intensive education about the use of maximal sterile barriers, introduction of chlorhexidine/alcohol for skin preparation and care, and strategies to reduce line utilization. To date, we have not detected a significant change in our rate of CLA-BSI. OBJECTIVES: To understand how central venous catheter (CVC) type influences the risk of CLA-BSI in a population of critically children. METHODS: We perform unit-based surveillance for CLA-BSI in our 38-bed PICU. CDC definitions are used to determine CLA-BSI. For 12 months, a daily tally of the type of catheter used was recorded on every patient hospitalized in the PICU with a CVC. The total and catheter-specific rates of CLA-BSI were determined. RESULTS: During the study period, the median rate for total CLA-BSI was 12.6 (9.5–16.4, 95%CI) per 1000 catheter days; the mean CVC utilization ratio was 0.38 line days per patient day. Despite greater than 4200 line days, we did not measure a significant difference in catheter-specific rates of CLA-BSI: for patients with non-tunneled CVC the rate of CLA-BSI was 12.7 (8.6–17.9) as compared to 14.3 (7.8–23.9) per 1000 catheter days for patients with tunneled CVC. Among patients with peripheral intravenous central catheters (PICC), the rate of CLA-BSI was 10.2 (4.4–20.0) per 1000 catheter days. CONCLUSIONS: These findings suggest that there may be little difference in catheter-specific CLA-BSI rates among critically ill children. However, additional study with data from multiple institutions is needed to detect small differences in the catheter-specific rate of CLA-BSI in this patient population. In addition, strategies to reduce the rate of CLA-BSI among children with long-term CVC (PICC or tunneled catheters) may be needed. Strategies we are considering include 1) reducing the frequency of CVC access; 2) modifying the protocol for CVC hub preparation prior to access; and 3) establishing a dedicated catheter-care team.

The impact of bedside behavior on catheter-related bacteremia in the intensive care unit.

The success of an educational program in July 1999 that lowered the catheter-related bloodstream infection (CRBSI) rate in our intensive care unit (ICU) 3-fold is correlated with compliance with "best-practice" behaviors. Before-after trial. Surgical ICU in a referral hospital. A random sample underwent bedside audits of central venous catheter care (n = 187). All ICU admissions during a 39-month period (N = 4489) were prospectively followed for bacteremia. On the basis of audit results in December 2000, a behavioral intervention was designed to improve compliance with evidenced-based guidelines of central venous catheter management. Compliance with practices known to decrease CRBSI. Secondary outcome was CRBSI rate on all ICU patients. Multiple deficiencies were identified on bedside audits 18 months after the previous educational program. After the implementation of a separate behavioral intervention in July 2001, a second set of bedside audits in December 2001 demonstrated improvements in documenting the dressing date (11% to 21%; P<.001) and stopcock use (70% to 24%; P<.001), whereas nonsignificant trends were observed in hand hygiene (17% to 30%; P>.99) and maximal sterile barrier precautions (50% to 80%; P =.29). Appropriate practice was observed before and after the behavioral intervention in catheter site placement, dressing type, absence of antibiotic ointment, and proper securing of central venous catheters. Thirty-two CRBSIs occurred in 9353 catheter-days 24 months before the behavioral intervention compared with 17 CRBSIs in 6152 catheter-days during the 15 months after the intervention (3.4/1000 to 2.8/1000 catheter-days; P =.40). Although a previous educational program decreased the CRBSI rate, this was associated with only modest compliance with best practice principles when bedside audits were performed 18 months later. A behavioral intervention improved all identified deficiencies, leading to a nonsignificant decrease in CRBSIs.

Guidelines for the Prevention of Intravascular Catheter-related Infections: Recommendations Relevant to Interventional Radiology

THE revised version of the Centers for Disease Control Guidelines for the Prevention of Intravascular Catheterrelated Infections was published on August 9, 2002, in the Morbidity and Mortality Weekly Report Reports and Recommendations series (1). It replaces the previous guideline published in 1996. The goal of the new guidelines is to provide evidencebased recommendations for preventing catheter-related infections. The new document was prepared by a working group led by the Society of Critical Care Medicine, in collaboration with the Infectious Disease Society of America, Society for Healthcare Epidemiology of America, Surgical Infection Society, American College of Chest Physicians, American Thoracic Society, American Society of Critical Care Anesthesiologists, Association for Professionals in Infection Control and Epidemiology, Infusion Nurses Society, Oncology Nursing Society, Society of Interventional Radiology, American Academy of Pediatrics, and the Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control. Major areas of emphasis in the new guidelines include (i) education and training of health-care providers who insert and maintain catheters, (ii) use of maximal sterile barrier precautions during central venous catheter (CVC) insertion, (iii) use of a 2% chlorhexidine preparation for skin antisepsis, (iv) avoidance of routine replacement of CVCs as a strategy to prevent infection, and (v) use of antisepticor antibiotic-impregnated short-term CVCs if the rate of infection is high despite adherence to other strategies (ie, education and training, maximum sterile barrier precautions, and 2% chlorhexidine for skin antisepsis). The full guideline, available without charge at http:// www.cdc.gov/mmwr/PDF/RR/RR5110.pdf, is lengthy and includes numerous other recommendations (1). Portions of the new guideline are of particular interest to interventional radiologists, particularly those dealing with CVCs, peripherally inserted central catheters (PICCs), and hemodialysis catheters. Selected recommendations are presented verbatim here, along with selected supporting data, background information, and references.