VA Hospitals Are Tops in Central Line Infection Control

ANN ARBOR, Mich. June 1 -- Veterans Affairs hospitals are more likely than non-VA facilities to follow recommendations for preventing bloodstream infections from central venous lines.

Of surveyed VA hospitals, 62% regularly used all three major evidence-based infection control recommendations compared with only 44% of non-VA facilities, said Sarah Krein, Ph.D., R.N., of the University of Michigan here and the VA Ann Arbor Healthcare System, and colleagues.

Their findings, reported in the June issue of the Mayo Clinic Proceedings, emerged from a survey of 516 hospitals, including 95 VA hospitals and 421 non-VA facilities with an intensive care unit and 50 or more beds. Questionnaires were mailed March 16 to August 1, 2005.

About 200,000 infections associated with central venous catheters are reported each year in the U.S., the researchers wrote. These infections increase mortality, morbidity, and hospital stays, and cost the U.S. health care system as much as billion a year.

In 2001the Agency for Healthcare Research and Quality published evidence-based recommendations for preventing catheter-related infections. The CDC followed with recommendations in 2002.

In addition to proper hand hygiene, the recommendations for all facilities include:

• Using maximal sterile barrier precautions for inserting a central venous catheter (sterile gloves and gown, mask, cap, and a large sterile drape);
• Using chlorhexidine gluconate (2%) on the skin before insertion, rather than providone iodine or alcohol;
• Replacing catheters only as needed, rather than on a routine basis every four to seven days.

Also recommended are the use of antimicrobial catheters, but only if infection rates are high or when the catheter will remain in place for long periods of time.

Since the recommendations were published, there have been no national studies to determine whether hospitals are actually following them, Dr. Krein said.

Their study establishes that most U.S. hospitals are using maximal sterile barrier precautions and chlorhexidine gluconate, the investigators said. Yet only 44% of non-VA hospitals use all three recommended practices concurrently compared with 62% of the VA institutions (P=0.003), the investigators said.

In the survey, 84% of the VA hospitals and 71% of the non-VA hospitals (P=0.01) reported regular use of maximal sterile barrier precautions to prevent infection.

Of the VA hospitals, 91% regularly used chlorhexidine as an antiseptic, compared with 69% of non-VA hospitals (P

The centralized structure of the VA, particularly its centralized purchasing, may be one reason for the increased adherence to the recommendations, Dr. Krein said. For example, chlorhexidine is part of the VA's blanket purchase agreement, so it would be less expensive for the VA to institute its use than for freestanding nonfederal hospitals. Communication within the VA could also have helped, she added.

The study had several limitations acknowledged by the researchers. First, the measure of regular use of a practice was a global assessment and did not identify whether the practice was adequately implemented.

Second, response bias may have existed with some respondents providing what they perceived to be the preferred answer.

Finally, the infection control coordinator may not be the most knowledgeable person to oversee some of the practices, compared with others at the facility, such as the ICU nurse manager

These results have important implications for enhancing the safety of hospitalized patients, the researchers wrote.

To improve adoption of key infection prevention practices, hospitals can begin by fostering a culture of safety, encouraging certification for the infection-control professional, and participating in an infection-prevention collaborative.

However, additional strategies for promoting proven infection- prevention practices in hospitals will need to be identified if the goal of a safer health care environment is to be achieved, the investigators concluded.

In an accompanying editorial, David R. Syndman, M.D., of Tufts University in Boston, wrote that the recent well-documented furor over care provided to active military personnel at Walter Reed Hospital and at VA hospitals throughout the U.S. "provides an interesting backdrop for the report by Krein et al."

Regrettably, Dr. Snydman wrote, 16% of VA and 29% of non-VA hospitals did not use maximal sterile barrier precautions when inserting central lines. Furthermore, although almost all VA hospitals used chlorhexidine, 31% of the non-VA hospitals failed to do so.

Admittedly, this research was based on a survey rather than direct observation, he said, but the findings were consistent with those of recent studies documenting improvements in health-care quality throughout the VA.

Dr. Syndman called for a standardized technique for reporting central venous catheter bloodstream infections. He suggested reporting central line days as the denominator rather than patient days, along with standardized definitions for the cases and use of severity-of-illness indicators.

Now that the steps necessary to reduce these infections are widely known, "institutions should follow the lead of the VA health care system and adopt the recommended practices so as to reduce this preventable form of infection." Dr. Snydman said.