Low Compliance Rates Reported With Central Line Bundle Policies in ICUs

Emma Hitt, PhD

March 25, 2010

March 25, 2010 (Atlanta, Georgia) — Compliance with central line bundle policies in intensive care units (ICUs) across the nation appears to be low, although complete compliance is not needed to see a reduction in central-line-associated bloodstream infections (CLABSIs), a new analysis shows.

E. Yoko Furuya, MD, MS, from Columbia University in New York City, presented the findings at an oral session here at the Fifth Decennial International Conference on Healthcare-Associated Infections 2010.

"Just having a bundle policy was not enough to reduce CLABSI rates; it was also necessary to monitor and maintain compliance," Dr. Furuya told Medscape Infectious Disease. With the new Joint Commission mandate for central line insertion checklists, bundle use will increase but, she emphasized, "we may or may not see a decrease in infection rates if people fail to maintain high compliance with the bundle, not just in terms of documentation, but also in actual practice."

Dr. Furuya and colleagues hypothesized that high compliance rates were needed to decrease CLABSI rates.

They conducted a cross-sectional survey of ICUs in National Healthcare Safety Network (NHSN) hospitals and assessed the central line bundle with respect to 4 components: the use of maximal barrier precautions, optimal catheter site selection, daily review of line necessity, and chlorhexidine skin antisepsis.

A total of 312 ICUs in 250 hospitals were included in the analysis. About half of the ICUs reported having a central line bundle policy, but only 38% of those with a policy reported full, defined as at least 95%, compliance.

The researchers evaluated the impact of central line bundle elements on CLABSI rates using 4 models. Model 1 examined the impact of individual bundle elements, model 2 determined the additive value of complying with 1 or more elements, model 3 evaluated the effect of compliance with any 1 element, and model 4 tested whether compliance with all bundle elements was necessary to reduce CLABSI rates.

Mean CLABSI rate was 2.1/1000 line-days.

According to the researchers, "maximal barrier precautions" was the component most often implemented; "daily line checks" and "optimal site selection" were the components least commonly implemented.

Simply having a bundle policy was not associated with lower CLABSI rates. CLABSI rates decreased only when an ICU had a policy, monitored compliance, and had at least 95% compliance.

In addition, no individual bundle element was associated with decreased CLABSI rates, but complying with any 1 of 3 bundle elements resulted in decreased CLABSI rates (P = .015). Model 4 showed that compliance with all 4 bundle elements was not necessary to show a significant decrease in infections.

According to Dr. Furuya, only limited information exists regarding the efficacy of implemented bundle policies, and they had few expectations going into the study.

"Why chlorhexidine use appeared to be less effective in reducing CLABSIs was unclear," she said, "but it is perhaps due to a greater prevalence of Gram-negative and fungal pathogens against which chlorhexidine is less effective, or potentially less-than-optimal use of chlorhexidine in the real-world setting, but this finding was surprising."

"This is an important study and its results support the current approach of bundling several preventive elements to reduce the incidence of central-line-related bloodstream infections," said Luke F. Chen, MBBS, FRACP, from the Duke University Medical Center in Durham, North Carolina. "Effective implementation of such prevention bundles are essential for success and remains the major challenge," he added.

According to Dr. Chen, these data showed poor compliance with some elements in NHSN hospitals and suggest that improvement in adherence to many of the recommended practices is needed to reduce bloodstream infection.

"The study also confirmed what many experts suspected — that the central line bundle is effective," he told Medscape Infectious Diseases. "Although each individual element or combination of interventions appeared to have differential impact on rates of CLABSIs, there are no robust data to conclude which element or combination of elements was the most efficacious, and we should still aim to comply with the entire bundle."

The study received no commercial funding. Dr. Furuya and Dr. Chen have disclosed no relevant financial relationships.

Fifth Decennial International Conference on Healthcare-Associated Infections (ICHAI) 2010: Abstract 387, presented March 20, 2010.