Central line-associated bloodstream infections, called CLABSIs, are associated with serious complications. Simple interventions, such as hand washing, and technologic interventions, such as use of chlorhexidine-impregnated dressings, are associated with reduced infection rates. Dr. J. Matthias Walz, MD, Departments of Anesthesiology and Surgery, University of Massachusetts Medical School and UMass Memorial Medical Center, Worcester, MA and coauthors showed how a multidisciplinary approach toward reducing infection rates resulted in a very significant reduction in the rate of CLABIs, and how the reduction was maintained. Their work, now available online in the article titled “The Bundle ‘Plus’: The Effect of a Multidisciplinary Team Approach to Eradicate Central Line-Associated Bloodstream Infections,” will be published in a future issue of Anesthesia & Analgesia.
At the authors’ hospital, a multidisciplinary committee of physicians, nurses, pharmacists, occupational and physical therapists, hospital administrators, and patient representatives was formed almost ten years ago to develop guidelines for patients in the ICU based on the best published medical evidence. A subcommittee was later developed to help minimize CLABSIs. Interventions included hand washing, use of a dedicated catheter insertion cart, maximal barrier protection precautions, time out before the start of the procedure, use of a catheter insertion checklist, chlorhexidine solutions for skin preparation, chlorhexidine sponges for catheter dressings, use of the subclavian vein as the preferred site of catheter insertion, and use of a standardized procedure note to document catheter insertion. Further interventions included empowering nurses to stop a procedure if the checklist was not properly followed, tracking the use of high-risk catheters, e.g., those inserted for emergencies, treating infection as a critical event that demanded holding a root cause analysis (RCA) to determine cause after each CLABSI, creation of a best practice atlas of dressings for internal jugular catheters, and a daily determination assessing the need to use a catheter. Also, reduction of infection rates became a pay-for-performance measure for senior ICU leadership, medical directors and nurse managers. CLABSI rates in ICUs are publicly reported in Massachusetts.
CLABSI rates decreased from 5.86 per 1000 catheter-days in 2004 to 0.33 per 1000 catheter-days in 2012. From 2008 to 2012, use of central venous catheters decreased significantly whereas use of peripherally inserted central catheters increased. In several ICUs, there were no CLABSIs for more than 2 years.
Is it one or several interventions that lead to success? Can something be accomplished only if there is a financial incentive attached? Should those who actually inserted the lines also receive an incentive? What is clear, though, is that such efforts require the input and cooperation of a team.