Physician's Weekly Article - Preventing Central Line-Associated Bloodstream Infections

       New recommendations from infection control experts aim to help clinicians prevent common healthcare-associated infections. Practical recommendations are provided to assist acute care hospitals in central line–associated bloodstream infection prevention efforts.

      According to recent estimates, about 80,000 central line-associated bloodstream infections (CLABSIs) occur each year in the United States. According to outcomes data, hospital-acquired CLABSIs are associated with increased length of hospital stays and higher costs. “These infections are associated with significant morbidity and, in older patients, higher mortality,” says Leonard A. Mermel, DO, ScM, AM (Hon), FACP, FIDSA, FSHEA. “Research has shown that risk–adjusted in-hospital mortality in Medicare fee-for-service inpatients is higher for those with CLABSIs than for those who do not get these infections.” Additional studies have also demonstrated that the non–inflation-adjusted attributable cost of CLABSIs varies from $3,700 to $29,000 per episode. Between $300 million and $2.3 billion in costs per year have been attributable to CLABSIs.

      The Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America appointed a task force to create a concise compendium of recommendations for the prevention of common healthcare-associated infections (HAIs) in 2008. The resulting recommendations can help acute care hospitals focus and prioritize efforts to implement evidence-based practices for the prevention of HAIs. Published in the October 2008 supplement to Infection Control and Hospital Epidemiology and available online at www.preventingHAIs.com, the document concisely highlights practical recommendations to assist acute care hospitals in implementing and prioritizing prevention efforts for CLABSIs, among other infections.

      “Considering the broad impact of CLABSIs,” says Dr. Mermel, “clinicians and hospitals must identify strategies and protocols that mitigate risk of these infections. Increased awareness of the problem is important because the scope and magnitude of these infections is not always understood. Greater attention should be paid to the credentialing of those who are involved with insertion and maintenance of central lines, as well as enhancing their understanding of infection control practices. CLABSIs are a problem that must be addressed by the entire team of healthcare providers caring for patients with intravascular catheters.”

      Identify Patients At Risk

      According to the compendium recommendations, several risk factors have been associated with the development of CLABSIs in acute care facilities (Table 1). “The risk of CLABSIs in ICU patients is high,” says Dr. Mermel, who was on the panel that generated the compendium recommendations for preventing these infections. “There are several reasons for this, including the frequent insertion of multiple catheters and the use of specific types of catheters that are almost exclusively inserted in ICU patients and associated with additional risk of infection (eg, arterial catheters). These patients are also at heightened risk of infection because catheters are frequently placed in emergent circumstances, repeatedly accessed each day, and often needed for extended periods.” Although much of the attention has focused on ICU settings over the past 20 years, recent data suggest that the greatest numbers of patients with central lines are in hospital units outside the ICU. These settings are also associated with a substantial risk of CLABSIs.

      Recognize Opportunities

      “Clinicians have opportunities to prevent and detect CLABSIs by breaking down processes into pre- and post-insertion of these central lines,” Dr. Mermel says (Table 2). “During insertion, many institutions have catheter carts or kits with all of the components necessary to insert these devices. However, not all institutions use a checklist to be certain that there are no breaches in technique. Checklists are important to ensure that policies are being followed for central-line insertions.” The compendium recommendations also provide guidance for specific scenarios in which antimicrobial catheters or other prophylactic measures may be considered.

      In addition to checklists, Dr. Mermel says that other important actions are needed when inserting central lines. “Clinicians should be savvy to the needs for a maximal sterile barrier and should use the recommended chlorhexidine-based antiseptics. When inserting venous catheters, it’s also important to discourage femoral access in adults.”

      With regard to maintenance of central lines, Dr. Mermel says that more attention should be paid to aseptic techniques when catheters are being manipulated. “In busy ICU settings, some catheter hubs may be manipulated numerous times a day for various reasons. Healthcare providers may not pay enough attention to the care of catheters once they’re inserted. This can impose increased risk to patients.” He adds that the compendium recommendations provide guidance for cleaning catheter hubs.

      Getting “Buy In”

      To bring about change in reducing the risk of CLABSIs, Dr. Mermel says that educating all physicians, nurses, and administrators is important. “It’s imperative to get ‘buy in’ from the entire hospital team to prevent CLABSIs. Designating local champions and leaders to guide processes and outcome measures is instrumental to quality improvement. A decree must be set and followed, and all constituents should be informed that processes and outcomes will be monitored and measured. If there’s institutional will to improve quality of care, then there is a greater likelihood that all hospital staff will make efforts to accomplish established goals.”

      Leonard A. Mermel, DO, ScM, AM (Hon), FACP, FIDSA, FSHEA, has indicated to Physician’s Weekly that he has worked as a consultant for CorMedix, Cadence Pharmaceuticals, Ash Access Technology, and Sage. He has also received grants/research aid from Angiotech.