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Nosocomial bloodstream infection surveillance in trauma centers: The lack of uniform standards

      To the Editor:
      Critically ill trauma patients have a unique case presentation characterized by depressed immune responses and extensive use of invasive devices, and thus are at increased risk of nosocomial bloodstream infections (NBSI).
      • Saini M.S.
      • Liberati D.M.
      • Diebel L.N.
      Sequential changes in mucosal immunity after hemorrhagic shock.
      • Boddie D.E.
      • Currie D.G.
      • Eremin O.
      • Heys S.D.
      Immune suppression and isolated severe head injury: a significant clinical problem.
      Our clinical observations through data surveillance suggested that the rate of NBSI among trauma patients was almost 3 times higher than that of intensive care patients. However, our review of the literature revealed a lack of data specific to trauma patients except for one report by Wallace et al.,
      • Wallace W.C.
      • Cinat M.
      • Gornick W.B.
      • Lekawa M.E.
      • Wilson S.E.
      Nosocomial infections in the surgical intensive care unit: a difference between trauma and surgical patients.
      who suggested that rates of NBSI in critical care trauma units was higher than that of intensive care units. Therefore, we decided to conduct a survey of the rates and surveillance practices of NBSI across multiple trauma centers to establish unique benchmarking criteria and provide better understanding of NBSI rates among trauma patients. A 30-item survey questionnaire was developed for this purpose and distributed to 17 self-designated trauma centers around the United States. The centers were selected from a directory of trauma and intensive care facilities. Each of the 17 centers was mailed a copy of the survey questionnaire along with a copy of the internal review board approval of the study, an invitation letter for voluntary participation, a confirmation letter, and a fact sheet stating the “terms and conditions” for participation. In order to protect the confidentiality of responses, recipient sites were instructed to mail the confirmation sheet indicating whether the site would participate in a separate self-addressed envelope from the completed questionnaire, which contained no site identifiers. Despite 3 separate contacts with nonresponding sites over a period of 6 weeks, only 6 of 17 trauma centers actually participated in the survey. The low response rate limited our ability to obtain meaningful data concerning surveillance procedures and the rates of NBSI across trauma centers. Nonetheless, the data we did receive revealed a lack of uniformity among trauma centers concerning surveillance procedures. Only one site was able to provide comprehensive data on NBSI rates classified by type of NBSI (primary vs secondary) and unit (critical care vs step-down). The poor response rate may reflect lack of interest, but might also indicate a desire to conceal possibly high rates of NBSI. While this concern is understandable, it prevents an accurate assessment of the problem, and limits development of interventions that might minimize the risk of NBSI in the acute trauma patient population.
      Despite a reluctance of most centers to participate in our survey, several important points can be made from this experience. First, we demonstrated that not all trauma centers are restricted to trauma cases or share the same benchmarking NBSI criteria. In addition, some centers differentiate NBSI rates between strictly critical care trauma units and subacute units, while others did not. Therefore, in spite of the fact that clinical observations and previous reports suggest that the incidence of NBSI is higher among critically ill trauma patients than surgical intensive care patients, it is not surprising that NBSI reports across various trauma centers are not uniform. For this reason, it is essential to establish benchmarking of NBSI in the critically ill trauma population based on the case presentation of a critically ill trauma patient rather than the unit or center where the patient is treated.
      While most of the participating centers indicated having standard guidelines for central venous catheter (CVC) practices, these guidelines varied widely. Guidelines for change of CVC dressing, change of CVC, change of CVC tubings, and personnel inserting CVC also varied across the sites. This lack of uniformity in standards may have an impact in the rate of NBSI among the various centers, and thus may be the subject of future studies.
      In conclusion, lack of uniformity in surveillance procedures and benchmarking of NBSI in critical care trauma centers may be an impediment to better understanding of the true rates of NBSI in the critical care trauma population and development of improved prevention strategies. To enable valid comparisons of NBSI rates between trauma and other patient populations, it would be necessary to develop case presentation methods of tracking, rather than unit-based statistics. Such changes in reporting methods are not likely to occur unless they are adapted as practice guidelines by health care entities such as the Centers for Disease Control and Prevention, the Joint Commission on Accreditation of Healthcare Organizations, and the American College of Surgeons.

      References

        • Saini M.S.
        • Liberati D.M.
        • Diebel L.N.
        Sequential changes in mucosal immunity after hemorrhagic shock.
        Am Surg. 2001; 67: 797-801
        • Boddie D.E.
        • Currie D.G.
        • Eremin O.
        • Heys S.D.
        Immune suppression and isolated severe head injury: a significant clinical problem.
        Br J Neurosurg. 2003; 17: 405-417
        • Wallace W.C.
        • Cinat M.
        • Gornick W.B.
        • Lekawa M.E.
        • Wilson S.E.
        Nosocomial infections in the surgical intensive care unit: a difference between trauma and surgical patients.
        Am Surg. 1999; 65: 987-990