Few Clinicians Adhere to ICU Infection Control Practices

Norra MacReady

January 30, 2014

Infection prevention and control programs in intensive care units (ICUs) vary widely in structure, organization, and adherence across the United States, a new study shows.

Large differences were seen between hospitals in terms of prevention policies for central line‐associated bloodstream infections (CLABSIs), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infections (CAUTIs), write Patricia W. Stone, PhD, and colleagues in an article published in the February issue of the American Journal of Infection Control.

Even when policies were in place, however, clinician adherence rates were low, the authors found.

Other troubling findings included no certified infection preventionist (IP) on staff in more than one third of the hospitals surveyed, an omission that "is not consistent with the Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control and Epidemiology guidelines," the authors write. In addition, half of the hospitals had no physician hospital epidemiologist (HE) on staff, which also is "not in keeping with current recommendations."

Dr. Stone, from the Center for Health Policy, Columbia University School of Nursing, New York City, and coauthors conducted a mixed-methods study that blended qualitative and quantitative approaches.

They invited all hospitals enrolled in the National Healthcare Safety Network to participate. Of 3374 eligible hospitals, 975 responded with information on 1653 adult ICUs, for a response rate of 29%. HEs were employed in 489 hospitals (50%), and the average number of full-time IPs per 100 beds was 1.2 (standard deviation, 1.2). Of 739 hospitals that provided information on certified IP staffing, 284 (38.4%) had no certified IP on staff.

The presence of specific, evidence-based infection control policies varied according to the type of ICU. CLABSI prevention policies were most common overall, with maximal barrier precautions and chlorhexidine use at insertion practiced in 96% and 97%, respectively, of the ICUs surveyed. Daily line checks were performed in 87% of the ICUs. VAP prevention policies were less frequent, ranging from raising the head of the patient's bed, performed in 91% of the ICUs overall, to chlorhexidine mouth care, performed in 69% of the ICUs. Least common were CAUTI prevention policies, with portable bladder ultrasound conducted in 68% of ICUs but nurse-initiated catheterization performed in only 27%.

Guideline Adherence Variable

Effective policies require clinician adherence, the authors point out. "Unfortunately, the hospitals that monitored clinician adherence reported relatively low rates of adherence. Furthermore, we found little time spent on prevention process education and some hospitals without feedback mechanisms." Overall adherence to CLABSI prevention policies ranged from 37% to 71%; for VAP, overall adherence ranged from 45% to 55%; and adherence to CAUTI prevention policies ranged from 6% to 27%.

The authors also found that only 334 of the responding hospitals (34.3%) were using electronic surveillance systems, which "shows a slow trend of uptake."

"This study provides the most comprehensive examination to date of the structures and support of infection prevention and control programs in the US since the [Study on the Effectiveness of Nosocomial Infection Control]," which was conducted in the 1970s, the authors write.

Study limitations include the moderate response rate, but the authors point out that this is still the largest survey of its kind to date. The information was self-reported by infection control department personnel, but the variability of the responses and the use of standardized definitions make systematic bias unlikely. In addition, CLABSI rates between responding and nonresponding hospitals were similar, "giving us some confidence in the generalizability of our data. Finally, we previously found high a test-retest reliability of our survey." The findings are descriptive and are not linked to actual rates of healthcare-associated infections.

"Based on our findings, IP staffing in acute care hospitals is not consistent with published guidelines," the authors conclude. CLABSI rates in the United States have decreased in recent years, which may reflect implementation of evidence-based infection prevention programs. Perhaps because the Centers for Disease Control and Prevention did not publish CAUTI prevention guidelines until 2009, many hospitals still appear to be in the earlier stages of implementing CAUTI control programs. "Clearly, more focus on CAUTIs is needed, and dissemination and implementation studies to inform how best to improve evidence based practices should be helpful."

This study was funded by the National Institute of Nursing Research. The authors have disclosed no relevant financial relationships.

Am J Infect Control. 2014;42:94-99. Abstract


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