Education to Prevent Nosocomial Infections Works in Community Hospitals, Too
Abstract & Commentary
Warren and colleagues performed a nonrandomized pre- and postobservational trial of an educational intervention to prevent catheter-associated bloodstream infections (CABSIs) in a 500-bed private community hospital in Missouri. During the 16-month initial, noninterventional phase of the study, trained infection control and research nurses collected data on all patients admitted to the hospital’s 2 ICUs (20 total beds). Patients were followed daily, with data collected prospectively on central venous catheters (CVCs), severity of illness, the need for mechanical ventilation, and the occurrence of ventilator-associated pneumonia and CABSIs. An educational intervention for reducing CABSIs was then implemented during a 3-month period, and the same data collected during the succeeding 13 months.
The educational intervention consisted of reporting CABSI rates to all ICU personnel, 45-minute lectures presented to nursing and medical personnel, grand rounds presented to the hospital staff on the prevention of CABSIs, and a series of posters and fact sheets distributed in the ICUs. All physicians and nurses working in the ICUs were required to complete a 10-page self-study module on CABSI prevention, with 20-question pre- and post-tests.
During the study period, 1215 (31%) of 3943 patients admitted to the ICUs had a CVC placed. Patient demographics and severity of illness (as assessed by APACHE II score) were not different before and after the educational intervention. Before the educational intervention, the rate of CABSIs was 4.9 cases per 1000 catheter-days; this fell to 2.1 cases per 1000 catheter-days following the intervention (relative risk, 0.43; 95% CI, 0.22-0.84). The proportion of CVCs inserted at the subclavian site (as opposed to internal jugular or femoral sites) increased during the postintervention period (28% vs 41%, P < 0.001). There were no significant changes in the timing or microbiological characteristics of CABSIs before and after the intervention, and mortality rates and ICU and hospital lengths of stay also did not change (Warren DK, et al. An educational intervention to prevent catheter-associated bloodstream infections in a nonteaching, community medical center. Crit Care Med. 2003;31[7]:1959-1963).
Comment by David J. Pierson, MD
Catheter-associated bloodstream infections are a well-documented and much-studied source of increased morbidity and cost in hospitalized patients. The Centers for Disease Control and Prevention (CDC) have published evidence-based guidelines for the prevention of CABSIs,1 which emphasize measures proven to decrease the risk of acquiring such infections (see Table).
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Table |
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Techniques Proven to Reduce the Incidence of Catheter-Associated Bloodstream Infections |
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Employment of "maximal barrier precautions" during catheter insertion: |
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• Sterile gloves |
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• Gown |
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• Large drapes |
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• Surgical masks |
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Use of subclavian site rather than internal jugular or femoral |
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Avoidance of "routine" catheter changes |
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Prompt removal of insertion site dressing if it becomes: |
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• Soiled |
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• Bloody |
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• Nonocclusive |
More than half of all acute inpatient admissions in the United States occur in nonteaching hospitals, yet the studies used in developing current guidelines were virtually all carried out in large university-affiliated teaching hospitals. As Warren et al point out, there are important differences between teaching and nonteaching hospitals, involving nursing and physician organizational structures, patient mix, and process of care for the management of critically ill patients. This study is important because it confirms the value of currently recommended infection control measures in the nonteaching hospital setting. The incidence of CABSIs fell by 57% during the study period, and this improvement persisted throughout the 13-month postintervention period without evidence of waning.
As emphasized in the editorial accompanying the paper by Warren et al,2 there are several barriers to the successful implementation of institution-wide changes such as those achieved in this study. Healthcare workers must first be aware of published guidelines and their recommendations. Importantly, the leadership of the groups involved (in this instance, nursing and intensivist physicians) must agree with the guidelines and support the proposed changes. Decreasing the incidence of CABSIs involves the use of certain specific products that must be made available to those placing and maintaining the catheters, so that hospital administrative buy-in is an important component of the process. As O’Grady points out in the editorial, "hospital administrators must become active partners to make it easy for healthcare providers to adhere to the guidelines and to make it equally difficult for them not to adhere to the guidelines."2
This study demonstrates that a focused, relatively inexpensive intervention to change ICU processes of care can be successfully implemented outside of academic medical centers and can result in persistent reductions in the incidence of nosocomial CABSIs.
Dr. Pierson is Professor of Medicine University of Washington Medical Director Respiratory Care Harborview Medical Center Seattle.
References
1. O’Grady NP, et al. Guidelines for prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2002;51:1-29.
2. O’Grady NP. On the road to avoiding adverse events: Educational programs pave the way. Crit Care Med. 2003;31(7):2077-2078.
Warren and colleagues performed a nonrandomized pre- and postobservational trial of an educational intervention to prevent catheter-associated bloodstream infections (CABSIs) in a 500-bed private community hospital in Missouri.Subscribe Now for Access
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