NY hospital uses processs, product, education to cut bloodstream infections

Healthcare Purchasing News, Sept, 2003

The central venous catheter is among the most widely used intravascular devices on the market today. In fact, so called central lines are among the most commonly used of all medical products. Estimates are that more than 1,50 million intravascular devices are purchased by healthcare facilities each year for the administration of I.V. fluids, medications, blood products and parenteral nutrition. At the same time, while central lines contribute positively to patient care, there is unquestionably a dark side to the equation: As many as a quarter-million central venous catheter-related bloodstream infections are attributed to central lines, leaving a trail of extensive mortality, excess length of stay and rising costs in their wake.

This dichotomy is well known in the infection control community. So when infection control practitioners at Brookdale University Medical Center, a busy 525-bed teaching facility in Brooklyn, NY, sought a way to stem the tide of patient infections and their associated costs, their detective work led them to eye central lines as a major culprit.

In 1999, reports Robert Garcia, the hospital's lead infection control expert, Brookdale embarked on house-wide surveillance of central line performance at the hospital. It quickly became apparent that compared with established benchmarks, central line infections at Brookdale were both a patient safety hazard and a producer of red ink. Changes had to be made and Garcia and his staff began to chart their intervention strategy.

In January 2000, a yearlong education and awareness program was begun, showing clinicians what central line infections were costing the hospital and harming patients (See Table Two for data on the effect of education on staff). The program consisted of targeting medical residents, surgical residents, anesthesiologists and all nurses involved in the maintenance of the insertion site. Topics covered included the morbidity, mortality, and costs associated with the occurrence of catheter-related bloodstream infections; hospital rates vs. national benchmarks; indications for use of a CVC; risk of infection by insertion site; procedure and timing of handwashing; proper sterile attire to be used during catheter insertion; aseptic techniques during initial catheter insertion and replacement (conducted by an experienced surgical attending); the nature and mechanism of infection prevention when using antimicrobial catheters; proper placement mad maintenance of dressings including the recommended regimen for the application of skin antiseptics; review of the revised process for physician certification (first-year residents are required to successfully complete five insertions under supervision prior to solo attempts).

Physician education also was conducted during new resident orientation sessions as well as monthly for residents covering critical care areas. "We achieved nearly a 60 percent infection rate reduction (more precisely 57.3 percent) simply with education," says Garcia. "But soon after that, the improvement reached a plateau."

In January 2001, the decision was made to start evaluating new products, leading Brookdale to bring in silver-platinum catheters for all adult patients requiring CVCs, items that are about 20 percent less costly and deemed "very promising and very cost effective" by Garcia and a working infection control group, to replace the older silver-chlorhexidine catheter in use at the hospital for years. Through the next nine months, that change dropped the infection rate another 48.4 percent or approximately 78 percent below the January 1999 baseline. But at the same time a disturbing trend was also uncovered: Observation sessions conducted by ICPs at Brookdale revealed that physicians failed to uniformly adhere to a policy of wearing of maximal sterile attire during central line insertion. Physicians were observed either not wearing any gown, not wearing a sterile gown (due to unavailability on specific units), not wearing a mask, as well as using various items such as patient drapes, which were inadequate in size and configuration (obtained from the catheter kit or from other supply). In fact, under the older 1996 CDC guidelines using maximal sterile barriers, between October and December 2001 the number of blood stream infections at Brookdale actually increased by 21.4 percent, proving that there was more work to be done.

A select group of senior medical and surgical residents were gathered in order to solicit information on an ideal kit for use when inserting not only CVCs, but peripherally inserted central catheters (PICCs), arterial, and swan-ganz lines. It was decided that a custom kit to include a 36" x 60" sterile drape, sterile gown (folded in a manner to avoid contamination when donning), a mask, sterile gloves, and enclosed wound dressing kit (Sorbaview transparent dressing, tape strips, 70% isopropyl alcohol-2% chlorhexidine antiseptic applicator, gauze, small drape) would be needed. Central supply ensured distribution to all patient care units, including the operating and emergency departments. The vendor, Tri-State Hospital Supply, Howell, MI, conducted in service on the use of the kit and by September 2001 the practice of using maximal sterile barriers was incorporated in all subsequent educational sessions.