IV bundles: Journey to zero central line associated bloodstream infections (CLABSI)

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Intravenous literature: Exline, M.C., Ali, N.A., Zikri, N., Mangino, J.E., Torrence, K., Vermillion, B., St Clair, J., Lustberg, M., Pancholi, P. and

Sopirala, M.M. (2013) Beyond the bundle – journey of a tertiary care medical intensive care unit to zero central line associated bloodstream infections. Critical Care Forum. 17(2), p.R41. [Epub ahead of print].

Abstract:

INTRODUCTION: We set a goal to reduce the incidence rate of catheter related bloodstream infections to rate of <1 per 1000 central line days in a two-year period.

METHODS: This is an observational cohort study with historical controls in a 25-bed intensive care unit at a tertiary academic hospital. All patients admitted to unit from January 2008 to December 2011 (31931 patient days) were included. Multidisciplinary team consisting of hospital epidemiologist/infectious diseases physician, infection preventionist, unit physician and nursing leadership was convened. Interventions included: central line insertion checklist, demonstration of competencies for line maintenance and access, daily line necessity checklist, and quality rounds by nursing leadership, heightened staff accountability, follow-up surveillance by epidemiology with timely unit feedback and case reviews, and identification of non-compliance with evidence-based guidelines. Molecular epidemiologic investigation of a cluster of Vancomycin-resistant Enterococcus faecium (VRE) was undertaken resulting in staff education for proper acquisition of blood cultures, environmental decontamination and daily chlorhexidine gluconate (CHG) bathing for patients.

RESULTS: Center for disease control/national health safety network (CDC/NHSN) definition was used to measure central line-associated bloodstream infection (CLA-BSI) rates during the following time periods: baseline (January 2008-December 2009), intervention year (IY) 1 (January-December 2010), and IY 2 (January-December 2011). Infection rates were as follows: baseline: 2.65 infections per 1000 catheter-days; IY1: 1.97 per 1000 catheter-days; the incidence-rate ratio (IRR) was 0.74 (95% CI = 0.37-1.65, P=0.398); residual seven CLA-BSIs during IY1 were VRE faecium blood cultures positive from central line alone in the setting of findings explicable by non-infectious conditions. Following staff education, environmental decontamination and CHG bathing (IY2): 0.53 per 1000 catheter-days; the IRR was 0.20 (95% CI = 0.06-0.65, P=0.008) with 80% reduction compared to the baseline. Over the 2-year intervention period, the overall rate decreased by 53% to 1.24 per 1000 catheter-days (IRR of 0.47 (95% CI = 0.25-0.88, P=0.019) with zero CLA-BSI for a total of 15 months.

CONCLUSIONS: Residual CLA-BSIs despite strict adherence to central line bundle may be related to blood culture contamination categorized as CLA-BSIs per CDC/NHSN definition. Efforts to reduce residual CLA-BSIs require a strategic multidisciplinary team approach focused on epidemiologic investigations of practitioner- or unit-specific etiologies.

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