|
Article Excerpt
Central venous catheters (CVCs) are integral to the care of acutely ill children. CVCs provide vascular access for the administration of fluids, medications, parenteral nutrition, and blood products, and for hemodynamic monitoring and blood sampling. Although CVCs provide reliable vascular access, there are associated risks with their use; the most common is central line-associated blood stream infection (CLABSI) (Institute of Healthcare Improvement [IHI], 2008). According to the IHI (2008), approximately 90% of all CLABSI occur due to CVC use. These infections result in increased lengths of stay, increased costs, and higher mortality rates (IHI, 2008; Yokoe et al., 2008). Costs attributed to CLABSI range from $3,700 to $29,000 per episode, and associated mortality rates range from 4% to 20%. It has been estimated that between 500 to 4000 patients die annually from blood stream infections related to CVC use (IHI, 2008; Marschall et al., 2008). As a result of these findings, the Joint Commission mandated that hospitals implement protocols by January 1, 2010, that meet the requirements of Patient Safety Goal 7, the reduction of CLABSI (IHI, 2008; Joint Commission, 2008; Yokoe et al., 2008).
Background
To facilitate comparison and goal setting of CLABSI rates in healthcare facilities across the nation, the Centers for Disease Control and Prevention (CDC) has indicated that a common definition of CLABSI be utilized and that CLABSI be reported using a universal measure (O'Grady et al., 2002). Members of the CDC suggest that the definition be "blood stream infections associated with central venous catheters when a CVC has been in use 48 hours prior to signs and symptoms of an infection (such as chills, fever, and positive blood cultures) with no apparent source except the CVC." The CDC and the Joint Commission recommend that CLABSI be reported as the rate of CLABSI per 1000 catheter days, which designates the proportion of the total number of days that patients had central venous lines (see Figure 1) (IHI, 2008). These expert groups have set the benchmark or goal rate for CLABSIs for pediatric intensive care units at 1.5 of CLABSI/1000 catheter days. This goal was set after the National Nosocomial Infection Surveillance System, established by the CDC, pooled data from 54 pediatric intensive care units (PICU) across the nation and reported that the current CLABSI rate was 6.6 per 1000 catheter days (IHI, 2008).
In October 2008, a compendium of practice recommendations was sponsored by 5 groups: the Society for Healthcare Epidemiology, the Infectious Disease Society of America, the Association for Professionals in Infection Control and Epidemiology, the Joint Commission, and the American Hospital Association. These practice recommendations focus on five preventable hospital-acquired infections, one of which was CLABSI. Some specific practice recommendations targeting the decrease of CLABSI included the IHI's recommended central line bundle of care to prevent CLABSI (Yokoe et al., 2008). According to the IHI (2008), bundling several individual evidence-based care interventions (such as hand washing and creating a sterile environment) into one process should significantly improve patient outcomes when all components of care for a central venous catheter are done together every time. In order to accomplish this, two things are essential: a) all the care interventions must be based on irrefutable science grounded in high-level research and b) all care interventions must be done together (bundled together) in the same space and time and each time central venous catheter care is completed to ensure excellent patient outcomes occur (IHI, 2008).
Figure 1. Calculation of the Rate of Central Line-Associated Blood Stream Infections per 1,000 Catheter Days In a local 25-bed pediatric intensive care unit (PICU), data were collected for the month of May (31 days) and then reviewed on June 1st. There were 9 patients who had central venous catheters (CVCs) at some point during the month. Five of those patients had catheters inserted during the month of May and kept them for the rest of the month. Four of the 9 patients had CVCs placed the previous month but were discontinued during the month of May. Also during the month of May, there were two central line-associated blood stream infections identified. Below is the number of days each patient had a CVC line in place (catheter days): Patient 1: Central line placed May 1st still in place (31 catheter days). Patient 2: Central line placed May 3rd still in place (29 catheter days). Patient 3: Central line placed May 18th still in place (14 catheter days). Patient 4: Central line placed May 25th still in place (7 catheter days). Patient 5: Central line placed May 29th still in place (3 catheter days). Patient 6: Central line in for 10 days of May but then discontinued (10 catheter days). Patient 7: Central line in for 2 days of May but then discontinued (2 catheter days). Patient 8: Central line in for 5 days of May but then discontinued (5 catheter days). Patient 9: Central line in for 25 days of May but then discontinued (25 catheter days). Total Catheter Days: 126 Catheter Days (31+29+14+7+3+10+2+5+25=126) Calculation formula: Total number of CLABSI divided by Total number of Catheter Days --Or-- 2 (infections) divided by 126 (catheter days) = 0.0158 This number is multiplied by 1,000 to calculate the rate of CLABSI per 1,000 catheter days. 0.0158 x 1,000 = 15.8 infections per 1,000 catheter days Therefore, this 25-bed PICU had 16 CLABSI per 1000 catheter days for the month of May. This is a very high rate of CLABSI, despite the low absolute number of CLASBIs, especially when compared to the national goal rate of 1.5 infections per 1,000 catheter days.
Several studies have looked at the efficacy of introducing bundling care components, such as initiating the IHI bundle for central line care for PICU patients as a way to significantly reduce CLABSI (Bhutta et al., 2007; Child Health Corporation of America, 2006a, b; Costello et al., 2008; Garland, Henrickson, & Maki, 2002; Marschall et al., 2008; McKee et al., 2008; Morgan & Thomas, 2007; National Association of Children's Hospitals and Related Institutions [NACHRI], 2006; O'Grady et al., 2002; Ranji et al., 2008; Yokoe et al., 2008). The IHI committee recommends the following components of care be utilized when inserting centrally placed catheters: hand hygiene, maximum barrier precautions, skin antisepsis, appropriate site selection, daily discussions to determine if the CVC is necessary, and monitoring of protocol adherence to sustain fidelity to the care bundle (see Table 1) (IHI, 2008).
Reducing rates of CLABSI is likely to result in decreased costs, decreased lengths of stay, and most importantly, increased patient comfort and wellness. Therefore, a thorough review of research evidence has been completed to fully appreciate the state of the evidence with regard to CVC care bundle implementation, to appreciate the effects of this intervention, and make practice recommendations. The PICO (P = patient population, I = intervention, C = comparison intervention, O = outcome) question formulated to drive the search of the evidence was, "In patients requiring central venous catheter access (P), does the implementation of central line bundled care (i) as compared to usual central line care (C) reduce the number of CLABSI (O)?"
Search Process
The EBSCO host search engine was utilized to access the Cochrane Library, CINAHL, Medline, and Web of Science databases. Additionally, the databases associated with the CDC, NACHRI, Agency for Healthcare Research and Quality (AHRQ), Child's Health Corporation of America, Joint Commission, and the IHI were accessed via the Internet to execute an exhaustive search and gain the most current evidence. A total of 2587 articles were retrieved from the previously mentioned publication databases. Keywords used included all "age groups," "central line infection," "pediatrics" (inclusive...
|
