Low-Tech Measures Slash Catheter-Related ICU Infections

BALTIMORE, Dec. 27 -- There is an easy route to many fewer potentially lethal blood-stream infections, according to researchers at two institutions.

They employed cheap common-sense measures like hand washing, removal of unneeded catheters, and the use of safer catheter sites. These mundane approaches paid off in dramatic fashion.

In an 18-month cohort study of 103 Michigan ICUs, the interventions reduced catheter-related infections by as much as 66%, Peter Pronovost, M.D., Ph.D., of Johns Hopkins here and colleagues at the University of Michigan reported in the Dec. 28 issue of the New England Journal of Medicine.

The estimated costs associated with catheter-related bloodstream infections vary, ranging from ,971 to ,000 per infection, with a mean ,000 per patient, the investigators said.

Given the results of this study, many of the estimated 80,000 infections, up to 28,000 deaths, and .3 billion in costs attributed annually to these infections in the U.S. could be reduced, they said.

In the pioneering pilot study, which included 1,981 ICU-months of data and 375,757 catheter-days, physicians and nurses were trained about infection control, according to the guidelines of the National Nosocomial Infections Surveillance System.

Infection rates per 1,000 catheter days were measured at three-month intervals up to 18 months. The intervention was part of a statewide safety initiative known as the Michigan Health and Hospital Association (MHA) Keystone ICU project.

The so-called "culture of safety" included ongoing surveillance by trained infection-control personnel, and a supportive central education program. Providers were stopped (in nonemergency situations) if these practices were not being followed, the researchers said.

The interventions included using special standardized central-line supply carts controlled for one-time use; a checklist to ensure adherence to infection-control practices such as hand-washing; use of full-barrier precautions during insertion of central venous catheters, avoiding catheter placement through the femoral artery in the groin, an area difficult to keep sterile, and use of the subclavian vein instead; using and changing gloves, gown, and masks for each procedure; cleaning patients' skin with chlorhexidine; and removing catheters as soon as possible, even if they might be needed again.

When these steps were implemented, the results were dramatic, Dr. Pronovost said. The median rate of catheter-related bloodstream infection per 1,000 catheter-days decreased from 2.7 infections at baseline to zero at three months after implementation of the study intervention (P ? 0.002).

The mean rate per 1,000 catheter-days decreased from, 7.7 at baseline to 1.4 at 16 to 18 months of follow-up (P

Given that the participating ICUs had reported 695 catheter-related bloodstream infections annually before the study, this intervention offers a strategy to improve clinical outcomes and reduce costs. "Broad use of this intervention could significantly reduce morbidity and the costs of care associated with catheter-related bloodstream infection," Dr. Pronovost's team concluded.

In an accompanying editorial, Richard Wenzel, M.D., and Michael Edmond, M.D., of Virginia Commonwealth University in Richmond, wrote that this quasi-experimental study would warrant designation of level B evidence by the U.S. Preventive Services Task Force and the Centre for Evidence-Based Medicine.

"We would like to have known the validity of the institutional surveillance systems, the frequency of use of chemically bonded (with antimicrobial agents) vascular catheters during the study period, the rate of compliance with specific recommendations, and the influence on mortality," they said.

Yet the real-world efficiency- in Cochrane's lexicon - of the team-based intervention, they said, was extraordinary, an "A" according to most standards.

"The story is compelling and the costs and efforts so relatively minor that the five components of the intervention should be widely adopted," they concluded.

Dr. Wenzel reported serving on advisory boards for Pfizer and Replidyne and receiving research support from Pfizer.