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Transformation of the ICU
Cost of preventing an infection – priceless
BryanLGH enthusiastically endorses the Institute for Healthcare Improvement’s (IHI) 100,000 Lives Campaign to prevent central line infections. According to the IHI’s How-To Guide, nationwide, 48 percent of intensive care unit (ICU) patients have central venous catheters, accounting for about 15 million central-venous-catheter-days per year in ICUs. Approximately 5.3 central line infections (often termed catheter-related bloodstream infections) occur per 1,000 catheter days in ICUs. The mortality for such central line infections is approximately 18 percent. It is estimated that about 14,000 deaths occur annually due to central line infections. Some studies put this figure as high as 28,000 deaths per year.(1) In addition, nosocomial bloodstream infections prolong hospitalization by a mean of seven days. Estimates of attributed cost per bloodstream infection are estimated to be between $3,700 and $29,000. (2)
To help reduce the incidence of central venous line infections, the IHI promotes the use of the central line bundle, which is a group of evidence-based interventions for patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually.
The central line bundle has five key components:
1. Hand hygiene
2. Maximal barrier precautions
3. Chlorhexidine skin antisepsis
4. Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters
5. Daily review of line necessity, with prompt removal of unnecessary lines
Compliance with the central line bundle can be measured by simple assessment of the completion of each item. This approach is most successful when all elements are executed together, in an “all or none” strategy.
BryanLGH estimated they had 13 central venous line infections per year in their three ICUs with a mortality rate of 28 percent. As part of the initiative to transform the ICU, they adopted this IHI bundle as a way to improve care. One of the first things they did was to empower the entire healthcare team – physicians, nurses, respiratory therapists, and others involved in the patient’s care – to work together to implement the bundle guidelines. There was strong physician support of the initiative with the chief of staff solidly behind the initiative. While they were met with initial resistance, they were able to answer caregivers’ questions about why implementing the changes was necessary, and more importantly, showed the staff how they had the power to make the difference in any individual patient’s outcome. In 2004 they began using chlorhexidine antiseptic for central line insertions and dressing changes. They also started using a larger drape for insertions and during 2004/2005, stressed the need for full sterile barrier technique during insertions. During daily rounds in the ICU, they began to ask whether the patient still needed the central line. In 2006, they added the use of a sterile procedure cart in the ICU.
What were the results?
BryanLGH went from an overall rate in their three ICUs of 1.86 bloodstream infections per 1000 central line days to 0.26 bloodstream infections per 1000 central line days. One ICU went 682 days without a central line associated bacteremia; another went 461 days and the third went 647 days without a central line associated bacteremia. Even using a conservative estimate of $20,000 in added cost as a result of a central venous line infection, this adds up to several hundreds of thousands of dollars in savings and more importantly, better outcomes for the patient.
As a result of their success in reducing the number of central venous line infections, BryanLGH has agreed to serve as one of IHI’s Mentor Hospitals. Contact Larry Krebsbach at
lkrebsback@bryanlgh.org if you have any questions about implementing these measures to reduce central venous line infections at your facility.
Click here for the
IHI’s How-To guide
Information about central line infection prevention, and other quality measures, is available on the
www.ihi.org web site.
(1) Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1994;271:1598-1601.
Saint S. Chapter 16. Prevention of intravascular catheter-related infection. Making health care safer: a critical analysis of patient safety practices. AHRQ evidence report, number 43, July 20, 2001.
Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32:2014-2020.
(2) Soufir L, Timsit JF, Mahe C, Carlet J, Regnier B, Chevret S. Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: a matched, risk-adjusted, cohort study. Infect Control Hosp Epidemiol. 1999;20(6):396-401.
If you have any questions or would like your hospital's quality
initiatives to be featured on the NHA Web site, contact Monica Seeland, Vice
President, Quality Initiatives, (402) 742-8152 or mseeland@nhanet.org.
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