have become a ubiquitous feature of modern-day patient care; current estimates suggest that as many as 2 million persons in the U.S. have an intravascular device that is used daily or intermittently.1 These devices fulfill a variety of clinical needs, including monitoring acutely ill patients and the administration of critical medications, in a variety of settings, including ICUs, medical and surgical units, and the outpatient setting.
This important therapeutic role comes with associated risks, including the possibility of bloodstream infection, which leads to an increase in morbidity, length of stay, and cost. Each year in the ICU alone, 80,000 catheter-related bloodstream infections (CRBSIs) occur. This figure increases to 250,000 to 500,000 infections per year when all hospitalized patients are considered.1,2
Infections related to intravascular catheters have been targeted by numerous quality-improvement (QI) initiatives, uncovering a number of clinical actions that can impact their rates. Studies have shown that these infections can be avoided and nearly eliminated entirely with close adherence to several evidence-based, infection-control measures.3 Furthermore, these results can be sustained across multiple ICUs over extended periods.4
The majority of data that describe the epidemiology of CRBSIs and the interventions needed to prevent these infections have been generated in the ICU. However, the pervasiveness of these devices in other care settings dictates the need for heightened awareness by the entire care team. As such, it is important for hospitalists to understand and be aware of guidelines outlining the standard of care not only in personal practice, but also in order to ensure that all members of the team are playing their part in preventing this serious complication.
In May 2011, the Society of Critical Care Medicine (SCCM), in collaboration with 14 other professional organizations, published new guidelines for the prevention of intravascular catheter-related infections.5 These guidelines are a revision of guidelines published in 2002 and provide recommendations that apply to all intravascular catheters, as well as specific comments based on the type of device in use.6
Specific recommendations include:
- Responsible staff should be well-versed and assessed on the proper procedures for the care of all intravascular catheters with designated personnel responsible for central venous catheters (CVCs)
- and peripherally inserted central catheters (PICCs).
- Prior to CVC and arterial catheter insertion and during dressing changes, an antiseptic solution containing more than 0.5% chlorhexidine with alcohol should be used to prepare the skin.
- Nontunneled CVCs should be preferentially placed in a subclavian site rather than a jugular or a femoral site, except in hemodialysis or advanced kidney disease patients, for which this may cause subclavian stenosis, with the understanding that the risks of placing a CVC at a site be weighed against its benefits.
- Skilled personnel should use ultrasound guidance during CVC placement, and the minimal essential number of ports or lumens on the CVC should be present. Avoidance of routine placement of CVCs and prompt removal of any nonessential intravascular catheter is recommended.
- Maximal sterile barrier precautions should be taken during the placement of CVCs and PICCs or guidewire exchange, which includes a sterile full-body drape for the patient and use of cap, mask, sterile gown, and gloves for personnel. After the catheter has been placed, it should be secured with a sutureless securement device. In addition, patients with these intravascular catheters should bathe with 2% chlorhexidine daily.
- If rates of CLABSI remain high despite adherence to education/training, appropriate antisepsis, and maximal sterile barrier precautions, the use of antiseptic- or antibiotic-impregnated, short-term CVCs and chlorhexadine-impregnanted sponge dressings might help to further decrease rates.5
No single intervention alone appears to be sufficient to significantly reduce CRBSI rates. Therefore, the guideline recommends “bundling” several of these individual best practices into a streamlined approach—inclusive of feedback to healthcare personnel on infection rates and compliance—thereby promoting quality assurance and performance improvement. This bundling tactic makes best practices a priority and a reality, and offers the largest potential impact on the prevention of intravascular catheter-related infections.5
Practical recommendations to assist clinicians in preventing CLABSI also were put forth in 2008 guidelines by the Society for Healthcare Epidemiology of America (SHEA) and Infectious Disease Society of America (IDSA).7 Compared to the SCCM guidelines, these guidelines are more focused on CVCs and do not directly address other available intravascular devices (PICCs, hemodialysis catheters, etc.). Beyond this, the SCCM guidelines also discuss the microbiology of infection, surveillance measures, and the specifics of the performance improvement measures involved in their implementation, which are not found in the SHEA and IDSA guidelines.
Numerous national initiatives and measures have been established based on these and other clinical practice guidelines. The Joint Commission recently produced the new monograph “Preventing Central Line-Associated Infections: A Global Challenge, A Global Perspective,” listing “Use proven guidelines to prevent infection of the blood from central lines” as one of its National Patient Safety Goals.8 The Institute for Healthcare Improvement (IHI) created its Central Line Bundle along with its “How-To Guide: Prevent CLABSI in 2011,” which has been implemented by many hospitals in the U.S. and United Kingdom. The IHI bundle has resulted in dozens of hospitals achieving more than a year of no CLABSIs in their ICU patients, and many have expanded the program to other areas of the hospital.9
Giving further impetus toward efforts to prevent these complications, the Centers for Medicare & Medicaid Services (CMS) determined that vascular-catheter-associated infections are hospital-acquired conditions that will no longer be reimbursed, as outlined in 2008 in the Acute Inpatient Prospective Payment System.10 Therefore, hospitals will not receive additional payment for these infections acquired during hospitalization (i.e. was not present on admission), and the case is paid as though the costly infection were not present, thus aligning improved patient care and outcomes with the financial bottom line for hospital reimbursement.
Given the significant economic and clinical burden of intravascular-device-related infections, hospital staffs should be aware of and adopt proven interventions to minimize this important complication. No one single intervention can meaningfully impact this infection rate, but a “bundled approach” appears to be the most influential.
Dr. Rohde is a hospitalist and assistant professor of internal medicine and Dr. Hartley is a hospitalist and clinical instructor of internal medicine at the University of Michigan Hospital and Health Systems in Ann Arbor.