Clinical Review

Prevention of Central Line–Associated Bloodstream Infections


 

References

Division of Infectious Diseases, Department of Internal Medicine, VA Ann Arbor Healthcare System and University of Michigan Health System, Ann Arbor, MI.

Abstract

  • Objective: To review prevention of central line–associated bloodstream infection (CLABSI).
  • Method: Review of the literature.
  • Results: Evidence-based prevention practices include ensuring hand hygiene before the procedure, using maximal sterile barrier precautions, cleaning the skin with alcoholic chlorhexidine before central line insertion, avoiding the femoral site for insertion, and removing unneeded catheters.
  • Conclusion: For continued success in CLABSI prevention, best practices should be followed and patient safety should be emphasized.

Health care–associated infections (HAIs) are a preventable cause of morbidity and mortality in the United States and internationally. A Centers for Disease Control and Prevention (CDC) report estimates that in acute care hospitals, 1 in 25 patients end up with at least one HAI during their hospital stay [1]. HAIs can also be costly; in the United States, the indirect and direct cost has been estimated to be between $96 to $147 billion dollars [2]. National initiatives to prevent these types of infections have included efforts from the Department of Health and Human Services (HHS), the Institute of Medicine (IOM), the Institute for Healthcare Improvement (IHI) and the Centers for Medicare and Medicaid Services (CMS). This work has led to particular success in preventing central line–associated bloodstream infection (CLABSI).

CLABSI can lead to considerable mortality, morbidity, and cost. An estimated 250,000 CLABSIs occur in patients yearly, and about 80,000 of those are estimated to occur in the intensive care unit (ICU) setting [3]. Since central venous catheters (CVCs), or central lines, are most often used in the ICU setting, much of the work on prevention and management of CLABSI has been within the ICU population [4,5]. The increased use of peripherally inserted central catheters (PICCs) in the non-ICU setting and recognition of CLABSI in non-ICU settings has led to new efforts to understand the best way to prevent CLABSI in the non-ICU setting [4,6]. Regardless of setting, the annual cost of these infections has been estimated to be as high as $2.3 billion [7]. One episode is estimated to cost a hospital up to $46,485 per episode with components of excess length of stay, antibiotic cost, and cost of care [8]. In this review, selected best practices in CLABSI prevention are identified and described.

Elements of CLABSI Prevention

One of the key papers in the CLABSI literature was the Keystone ICU project in Michigan [9]. This state-wide effort grew out of a successful pilot patient-safety program that was trialed at Johns Hopkins Medical Institutions to reduce CLABSI in the ICU setting. In 2003, the Agency for Healthcare Research and Quality (AHRQ) funded a study to examine the intervention in ICUs in the state of Michigan. A total of 108 ICUs from 67 individual hospitals participated in the pre-intervention/post-intervention study [9]. A combination of technical and socio-adaptive interventions to prevent CLABSI included clinician education on best practices in insertion of central lines, having a central-line cart in each ICU, an insertion checklist of best practices, empowering nursing staff to stop the procedure if best practices were not being followed, discussing removal of catheters daily, and providing feedback to units regarding rates of CLABSI [10]. Executive administration of each hospital was also involved and there were monthly phone calls for hospital teams to share successes and barriers.

In the pre-intervention phase, the median catheter- related bloodstream infection rate was 2.7 infections per 1000 catheter days for the sum of hospitals. After the interventions were put in place, the median rate of catheter related bloodstream infections was down to 0.34 at 18 months. The study showed that results from a relatively inexpensive and straightforward intervention could be effective and could last in the long term. This study led to many other single center and multicenter studies, nationally and internationally, to replicate results in efforts to decrease CLABSI in ICU populations [5]. The CDC and AHRQ have continued to partner with regional, state and national efforts to focus on CLABSI prevention.

The Bundle Approach

A number of interventions have been proven to be effective at preventing CLABSI. Combining more than one intervention can often have additive effects. This effect has been recognized in numerous quality improvement studies on CLABSI and has been termed using the “bundle” approach.

A CVC insertion bundle often uses 3 to 5 interventions together. The Keystone study used a bundled approach and many patient safety interventions employ this approach to improve patient care processes [11]. The IHI’s “central line bundle” is shown in the Table.

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