March 3, 2011

Efforts to reduce central-line infections show positive results

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A multi-phased approach has helped VUMC reduce central-line associated bloodstream infections.

Efforts to reduce central-line infections show positive results

Hospital patient care teams at Vanderbilt University Medical Center are succeeding in reducing central-line associated blood stream infections (CLABSI), a frequent cause of prolonged hospital stays and increased mortality in both intensive care and general care units.

• From July through January, CLABSI rates among Vanderbilt's eight intensive care units (ICUs) have been 32 percent below the latest national average.

• During the same period, CLABSI rates among non-ICU areas of the Monroe Carell Jr. Children's Hospital at Vanderbilt have been 38 percent below the latest national average.

• CLABSI rates among non-ICU areas at Vanderbilt University Hospital have dropped 36 percent over the past year.

• Over the past year, five ICUs surpassed their own previous records for successive CLABSI-free days — pediatric critical care with 113 days, neonatal intensive care with 153 days, cardio-vascular intensive care with 132 days, neurosurgical intensive care with 184 days and surgical intensive care with 109 days.

• In December Children's Hospital entered new territory for CLABSI prevention, reporting zero cases for the month among all units.

CLABSI is highly dangerous. According to a December 2006 editorial in the New England Journal of Medicine, in intensive care units alone, the number of preventable deaths in the United States per year from CLABSI was approximately 17,000.

That same editorial put the nation's overall CLABSI rate at five infections per every 1,000 central-line days.

Central lines (also called central venous catheters) are flexible tubes placed in a large vein in the neck, chest or groin for an extended period to allow repeated administration of medication or fluids or repeated blood testing.

All such devices present routes into the blood stream for various pathogens. Bacteria on the outside surface of tubes can enter the blood stream around the insertion site. Also, as lines are accessed, bacteria on a caregiver's hands can get inside the tubes.

CLABSI is increasingly seen as preventable, with studies having shown that rates can be reduced to somewhere near zero. In 2009 Tennessee began public reporting of CLABSI rates, prompting hospitals across the state to step up prevention.

There apparently is no magic bullet for prevention: only broad-based strategies will serve.

According to Chief Hospital Epidemiologist Tom Talbot, M.D., MPH, and Quality Consultant Barbara Martin, R.N., MBA, infection reduction begins with committed clinical leadership and with the concerted promotion of prevention standards among front-line staff.

“The key is we had leadership who said this needs to be done and they empowered the right people to get it done and to enforce correct practices,” Talbot said.

• VUMC infection control experts and a broad sample of clinical leaders agreed on a set of prevention standards and received backing for the implementation of standards from the Medical Center Medical Board.

• According to Martin, the key prevention standards enforced at VUMC include daily evaluations with an eye to discontinuing any unneeded lines, attention to aseptic technique when accessing the lines, and, for insertion of lines, hand washing, placing a full body drape over the patient, and wearing a cap, mask, gown and gloves.

• Annual training is required for anyone who places lines at VUMC.

• Posters on each unit publically display running totals of CLABSI-free days; new staff receive handy laminated cards outlining central line placement and maintenance standards; unit-based patient safety rounds include special attention to removing any unneeded central lines.

“The medical and nursing staffs are really committed to getting lines out without delay and to not using them in the first place if possible,” Martin said. “We've found a lot of champions for CLABSI prevention in units all across VUMC.”

Talbot agrees. “You sense people are really owning this effort. They get mad when you tell them there's an infection, which I think is a positive sign because it shows they realize the infection may have been preventable.

“We want zero preventable cases. Some mystery remains regarding how many are truly preventable,” he said.

Related infection control programs at Vanderbilt, such as the hand hygiene campaign, may have attributed to the recent drop in CLABSI.