Comparison of US and non-US central venous catheter infection rates: evaluation of processes and indicators in infection control study

A Central Line Care Maintenance Bundle for the Prevention of Central Line-Associated Bloodstream Infection in Non-Intensive Care Unit Settings

OBJECTIVE To evaluate a central line care maintenance bundle to reduce central line-associated bloodstream infection (CLABSI) in non-intensive care unit settings. DESIGN Before-after trial with 12-month follow-up period. SETTING A 1,250-bed teaching hospital. PARTICIPANTS Patients with central lines on 8 general medicine wards. Four wards received the intervention and 4 served as controls. INTERVENTION A multifaceted catheter care maintenance bundle consisting of educational programs for nurses, update of hospital policies, visual aids, a competency assessment, process monitoring, regular progress reports, and consolidation of supplies necessary for catheter maintenance. RESULTS Data were collected for 25,542 catheter-days including 43 CLABSI (rate, 1.68 per 1,000 catheter-days) and 4,012 catheter dressing observations. Following the intervention, a 2.5% monthly decrease in the CLABSI incidence density was observed on intervention floors but this was not statistically significant (95% CI, -5.3% to 0.4%). On control floors, there was a smaller but marginally significant decrease in CLABSI incidence during the study (change in monthly rate, -1.1%; 95% CI, -2.1% to -0.1%). Implementation of the bundle was associated with improvement in catheter dressing compliance on intervention wards (78.8% compliance before intervention vs 87.9% during intervention/follow-up; P<.001) but improvement was also observed on control wards (84.9% compliance before intervention vs 90.9% during intervention/follow-up; P=.001). CONCLUSIONS A multifaceted program to improve catheter care was associated with improvement in catheter dressing care but no change in CLABSI rates. Additional study is needed to determine strategies to prevent CLABSI in non-intensive care unit patients. Infect Control Hosp Epidemiol 2016;37:692-698.

Reduction and surveillance of device-associated infections in adult intensive care units at a Saudi Arabian hospital, 2004-2011

BACKGROUND

Device-associated infections (DAI) are recognized as a marker of patient safety. Data regarding DAI rates in Saudi Arabia are sparse.

METHODS

This was a prospective surveillance study of DAI rates conducted in the adult intensive care units of the Saudi Aramco Medical Services Organization, carried out using the DAI definition provided by the Centers for Disease Control and Prevention's National Healthcare Safety Network. DAI prevention bundles were introduced in 2006 for ventilator-associated pneumonia (VAP), in mid-2010 for catheter-associated urinary tract infections (CAUTI), and in 2008 for central line-associated blood stream infections (CLABSI).

RESULTS

DAI rates for VAP, CLABSI, and CAUTI are reported for the study period from 2004 to 2011. CAUTI was the most common DAI (42.2%), followed by CLABSI (38.5%) and VAP (19.3%). The overall rate of each infection type per 1000 device-days was 8.18 for CAUTI, 10 for CLABSI, and 4.52 for VAP. Annual DAI rates showed a significant reduction over time from the beginning of the study to the end of the study for CLABSI (16.3 vs. 6.06), CAUTI (6.75 vs. 3.41), and VAP (9.8 vs. 1.3) (p<0.05).

CONCLUSIONS

CAUTI was the most common infection, and the use of DAI prevention bundles was associated with a significant decrease in DAI rates over time.

Laboratory-confirmed, health care-associated bloodstream infections in Jordan: a matched cost and length of stay study

BACKGROUND

No studies have been carried out in Jordan to examine length of stay (LOS) and extra cost associated with health care-associated bloodstream infections (HCABSIs). This study aims to estimate the extra LOS and cost associated with HCABSIs among adult hospitalized Jordanian patients.

METHODS

Five-year data were retrieved from 1 large university-affiliated hospital in Jordan. Matched case-control design was used in this study. Cases were determined based on confirmed positive blood culture after 48 hours of admission. Matching criteria were age (±5 years), gender, admission diagnosis, and LOS in comparison group equal to the LOS (±5%) before blood culture for the case group.

RESULTS

Of the total 445 infected patients 125 (28.1%) were matched with uninfected patients. The mean LOS after infection for cases was 12.1 days (standard deviation [SD] = 17.2) compared with 8.3 (SD = 7.9) days for the controls (P = .02). The total mean inflation-adjusted charges for cases was M (mean) = US $7,426, SD = $7,252 compared with M = $3,274, SD = $4,209 for controls, P < .001. Using multiple regression modeling, LOS after acquiring HCABSIs, admission to critical care units, and being infected with HCABSIs were significant predictors of patients' total charges.

CONCLUSION

Figures generated from this can be used to inform health care researchers, policy makers, and professionals about the impact of HCABSIs.

Zero central-line infections in a 550-bedded district general hospital

The dominance of central-line-associated bloodstream infection (CLABSI) prevention has become a powerful far-reaching endeavour in recent years. Surveillance is well established as an infection 'occurrence' reporting mechanism. Unfortunately, surveillance is rarely described in the literature as a component of CLABSI prevention. This changed in 2009 following the introduction of a preventative CLABSI surveillance initiative. Upon completion of the 2011 period of surveillance, the authors were able to demonstrate the insertion of 1012 catheters, which equalled 7522 line days and a 12-month period of zero CLABSI.

History of SHEA-Sponsored Research: Time to Pass the Torch

Since its inception, the Society for Healthcare Epidemiology of America (SHEA) has promoted research into prevention of adverse events in hospitals. In 1995, SHEA made this mission concrete by initiating a collaborative research project with the Joint Commission on the Accreditation of Health Care Organization (now known as the Joint Commission). In the early 1990s, the Joint Commission was implementing its “Agenda for Change” and associated Indicator Monitoring System. At the time, there were numerous competing measurement systems that used different definitions, all aimed at measuring the quality of patient care, and many had indicators measuring the incidence of hospital-acquired infections. Some of these indicators used administrative data, such as International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, to measure adverse events.

Catheter-associated bloodstream infections: looking outside of the ICU

BACKGROUND

Current recommendations for the prevention of central venous catheter-associated bloodstream infections (CA-BSIs) are mostly based on data from intensive care units (ICUs). The rates of CA-BSIs appear to be higher in non-ICU wards. Until this year, no published data were available on non-ICU CA-BSIs in the United States. This article is a summary of a talk given at an industry-sponsored conference on CA-BSIs. It summarizes an original article of ours previously published in a peer-reviewed journal.

OBJECTIVE

The objective of this study was to determine the rate of CA-BSIs in non-ICU medical patients by developing a prospective surveillance program in a major tertiary care hospital. All positive blood cultures electronically detected from April 1, 2002, to April 30, 2003, were reviewed and clinical data collected by chart review.

DEFINITIONS

Catheter utilization ratio = total number of days with a central venous catheter (CVC)/total number of patient-days; catheter-associated BSIs = defined by Centers for Disease Control and Prevention criteria, eg, a patient had to have a catheter at least 48 hours before detection of infection; CA-BSI rate = CA-BSIs/1000 catheter-days.

RESULTS

The 13-month study included 7337 catheter-days and 33,174 patient-days. The overall catheter-utilization ratio was 0.22 (range, 0.19-0.25). Of 42 cases of CA-BSIs, gram-positive organisms were recovered in 24 (57%); gram-negative bacteria in 7 (17%); and Candida spp in 6 (14%). The CA-BSI rate was 5.7 (95% confidence interval: 3.4-8.0) and varied from 4.3 to 8.0. There were no significant differences in CA-BSI rates among the wards (chi(2) for linear trend, 0.42; P = .52). The overall rate of CA-BSIs decreased steadily during the study period, from 7.8 during the first 6 months to 3.9 during the following 7 months, representing a rate ratio of 0.5 (95% confidence interval: 0.27-0.93).

CONCLUSION

Benchmark data for hospital infections in the non-ICU setting are starting to become available and efforts to improve care may have greater impact here than in the ICU. Upon patient transfer out of the ICU, it should be determined whether the catheter can be removed. Educational measures targeted at non-ICU wards are warranted. First results of computer-assisted methods to facilitate surveillance of larger number of patients are promising. The Healthcare Infection Control Practices Advisory Committee recommends that CA-BSIs be publicly reported. CA-BSIs in non-ICU patients could soon be part of a mandatory reporting.

Catheter-associated bloodstream infections in general medical patients outside the intensive care unit: a surveillance study

OBJECTIVE

To determine the incidence of central venous catheter (CVC)-associated bloodstream infection (CA-BSI) among patients admitted to general medical wards outside the intensive care unit (ICU).

DESIGN

Prospective cohort study performed over a 13-month period, from April 1, 2002, through April 30, 2003.

SETTING

Four selected general medical wards at Barnes-Jewish Hospital, a 1,250-bed teaching hospital in Saint Louis, Missouri. PATIENTS; All patients admitted to 4 general medical wards.

RESULTS

A total of 7,337 catheter-days were observed during 33,174 patient-days. The device utilization ratio (defined as the number of catheter-days divided by the number of patient-days) was 0.22 overall and was similar among the 4 wards (0.21, 0.25, 0.19, and 0.24). Forty-two episodes of CA-BSI were identified (rate, 5.7 infections per 1,000 catheter-days). Twenty-four (57%) of the 42 cases of CA-BSI were caused by gram-positive bacteria: 10 isolates (24%) were coagulase-negative staphylococci, 10 (24%) were Enterococcus species, and 3 (7%) were Staphylococcus aureus. Gram-negative bacteria caused 7 infections (17%). Five CA-BSIs (12%) were caused by Candida albicans, and 5 infections (12%) had a polymicrobial etiology. Thirty-five patients (83%) with CA-BSI had nontunneled CVCs in place.

CONCLUSIONS

Non-ICU medical wards in the study hospital had device utilization rates that were considerably lower than those of medical ICUs, but CA-BSI rates were similar to CA-BSI rates in medical ICUs in the United States. Studies of catheter utilization and on CVC insertion and care should be performed on medical wards. CA-BSI prevention strategies that have been used in ICUs should be studied on medical wards.

Hospital- and community-acquired infections: a point prevalence and risk factors survey in a tertiary care center in Saudi Arabia

BACKGROUND

Point prevalence studies are useful in revealing the prevalence of hospital-acquired infections (HAIs) and community-acquired infections (CAIs). Such information allows prioritization of infection control resources and aids in overall hospital expenditure cut-backs.

METHODS

A one-day point prevalence survey was conducted on May 19, 2003 at the King Fahad National Guard Hospital in Riyadh. Since the survey included HAIs and CAIs all patients were included. Data were collected on the underlying diagnosis, infection if present and whether it was hospital-acquired or community-acquired. We identified the presence of a line-associated blood stream infection (BSI), ventilator-associated pneumonia (VAP), catheter-associated urinary tract infection (UTI) or a surgical site infection (SSI) based on the United States National Nosocomial Infection Surveillance (NNIS) definitions.

RESULTS

Five hundred and sixty-two inpatients were included in the survey. There were 38 patients with 45 (8.0%) HAIs and 76 (13.5%) patients with a CAI. Of the HAIs, 31.1% had a line-related BSI, while 28.9% and 24.4% had a VAP and catheter-related UTI, respectively. Most of the HAIs took place in the intensive care units (ICU) (21 (46.7%)), followed by the medical and surgical wards with six (13.3%) cases in each ward. For all HAIs there was a 12.7-fold increased risk with a hospital stay exceeding eight days (OR: 12.7, CI 3.2-50.6). Most of the 76 CAIs were admitted to the medical ward with community-acquired pneumonia (34.9%) as the most common diagnosis. Among the 89 pathogens isolated, Pseudomonas aeruginosa was the most common (21.3%) followed by Enterococcus spp (16.9%).

CONCLUSIONS

The overall rate of HAIs in our hospital was 8%, with significant risk factors including a hospital stay exceeding eight days. A device-related infection was more likely in a patient with a venous or bladder catheter in place for more than eight days, or a patient mechanically ventilated for more than eight days. Catheter-related UTIs were identified as an important source of infection, requiring ongoing surveillance.