By Megan Brooks
NEW YORK (Reuters Health) Aug 31 - In a recent trial, central line-associated bloodstream infections (CLABSIs) were dramatically reduced with a nurse-led intervention involving evidence-based prevention tactics and a program to improve patient safety, communication and teamwork.
Results of the multicenter, phased cluster-randomized controlled trial, reported online in Critical Care Medicine, add to a growing body of evidence that these infections can be prevented.
The intervention included five evidence-based prevention measures: hand washing before line placement; full barrier precautions (full-body drape, hat, gloves, mask and gown); avoiding femoral site line placement; chlorhexidine to cleanse the site; and removing unnecessary lines.
It also included the validated Comprehensive Unit-based Safety Program, or CUSP, which has staff evaluate their culture of safety; undergo "science of safety" training; identify how patients are or could be harmed and suggest solutions; partner with a hospital executive to support safety efforts; learn from identified safety defects, and implement tools to improve teamwork and communication.
The program is very doable but takes some effort, the researchers say.
"It is critical that ICU teams realize that the intervention requires work on both the technical side and the cultural, or adaptive side," Dr. Jill Marsteller, of Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, noted in an email to Reuters Health.
"The technical changes to procedures are important, but the teams that get the most out of this intervention really work hard on improving communication across professions, using teamwork tools, partnering with executives and developing a system for identifying and addressing patient safety hazards proactively, before they reach patients," she said.
In 2006 in the New England Journal of Medicine, the Johns Hopkins team reported that together these interventions reduced the overall CLABSI rate by 66% in a before-and-after study involving 103 ICUs. (See Reuters Health story of Dec. 27, 2006).
Yet the cohort study, with no concurrent control group, couldn't establish a causal relationship between the intervention and the reduced CLABSI rate. Their latest study accomplishes this, they say.
The trial was conducted in 45 ICUs from 35 hospitals in two Adventist health care systems.
The researchers used a phased design, which allowed them to offer the intervention to the control group after the randomized controlled period and to evaluate sustainability beyond one year in the intervention group.
The intervention group started in March 2007 and the control group converted to the intervention starting in October 2007. The study period ended September 2008. Baseline data for both groups are from 2006.
They report that the average CLABSI rate in the intervention group fell from 4.5 per 1000 central line days at baseline to 1.3 in the third quarter after implementation (adjusted incidence rate ratio 0.19; p=0.003).
During the same period, the control group also saw a decrease from 2.7 per 1000 line days at baseline to 2.2.
The intervention group achieved an 81% reduction in CLABSI rates at 19 months post-implementation and the control group, after undertaking the intervention, achieved a 69% reduction 12 months after implementation, the authors note.
"Both groups reduced CLABSIs to approximately 0.8 per 1000 line days by the end of the study," they report.
"Many clinicians I know look for randomized trials as the strongest test of whether an intervention works, and this study provides that higher level of evidence for this intervention," Dr. Marsteller told Reuters Health.
"In addition, I think clinicians will be interested to see how much the infection rates improved... and the very low level they ultimately reached--below one per thousand line days. So an important take-away for clinicians is what's possible in a varied group of faith-based, mostly community hospitals, locate in 12 different states," she said.
Can this approach be implemented elsewhere? "Most certainly," Dr. Marsteller said. Right now, "an ongoing national project is working in almost every state of the US to reduce bloodstream infections," she added.
Nearly 250,000 health care-associated infections occur every year in patients with central lines. Roughly a quarter of ICU patients with CLABSIs die, totaling 31,000 deaths annually in the US. These infections have been estimated to cost $9 billion annually to the US health care system.
Dr. Allison Lipitz-Snyderman, an outcomes research scientist at the Center for Health Policy and Outcomes, Department of Epidemiology and Biostatistics at Memorial Sloan-Kettering Cancer Center in New York City, said the findings of this study "support the added benefit of a structured initiative on reducing infections."
"These results provide further evidence of the potential for quality improvement interventions to have a positive impact on important issues affecting the safety and quality of patient care," added Dr. Lipitz-Snyderman, who was not involved in the study.
Dr. Marsteller's group says the fact that the intervention was nurse-led "confirms the logical role for nurses in quality improvement interventions."
The study was supported by a grant from the Robert Wood Johnson Foundation's Interdisciplinary Nursing Quality Research Initiative.
Crit Care Med 2012.
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