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Reply: Compliance with central line insertion bundles in an intensive care unit

      To the Editor:
      The letter by Liang et al signifies the ongoing efforts to reduce central line-associated blood stream infections (CLABSI) in developing countries. The authors evaluated “insertion” and “maintenance” bundles for central venous catheters, but had problems achieving perfect compliance despite eliminating CLABSI for 8 consecutive months. This is likely because even partial compliance with bundles has shown reductions in CLABSI in previous studies.
      • Jeong I.S.
      • Park S.M.
      • Lee J.M.
      • Song J.Y.
      • Lee S.J.
      Effect of central line bundle on central line-associated bloodstream infections in intensive care units.
      • Apisarnthanarak A.
      • Thongphubeth K.
      • Yuekyen C.
      • Warren D.K.
      • Fraser V.J.
      Effectiveness of a catheter-associated bloodstream infection bundle in a Thai tertiary care center: a 3-year study.
      The authors describe their “insertion bundle” but do not elaborate on the “maintenance bundle” and its compliance rates, which are equally important in reducing CLABSI and could be the predominant factor in eliminating their CLABSIs. It would also be interesting to know if they observed any reduction in the number of total catheter days in their patients.
      The main barriers faced by the authors during insertion were inability to achieve maximal sterile precautions and nonfemoral site selection, whereas they had excellent compliance with hand hygiene. These challenges are different from what we faced.
      • Khalid I.
      • Al Salmi H.
      • Qushmaq I.
      • Al Hroub M.
      • Kadri M.
      • Qabajah M.R.
      Itemizing the bundle: achieving and maintaining “zero” central line-associated bloodstream infection for over a year in a tertiary care hospital in Saudi Arabia.
      Hand hygiene compliance in our study was done from random audits as opposed to the direct observation used by Liang et al. This could explain the difference in hand hygiene compliance and emphasizes the need for a standardized surveillance system.
      • Reisinger H.S.
      • Yin J.
      • Radonovich L.
      • Knighton V.T.
      • Martinello R.A.
      • Hodgson M.J.
      • et al.
      Comprehensive survey of hand hygiene measurement and improvement practices in the Veterans Health Administration.
      Use of full barrier precautions and nonfemoral site selection in our experience can be improved if mandated. Use of a unit-based quality nurse, in addition to education and reinforcement strategies, can also help improve overall bundle compliance.

      Thom KA, Li S, Custer M, Preas MA, Rew CD, Cafeo C, et al. Successful implementation of a unit-based quality nurse to reduce central line-associated bloodstream infections. Am J Infect Control Epub 2013 Dec 17.

      Nonetheless, our study and the results reported by Liang et al should encourage practitioners in developing countries to continue improving infection control practices, regardless of the geographic location of hospitals and demographics of patients. Every little improvement counts in reducing patient morbidity and the financial burden that results from CLABSI.

      References

        • Jeong I.S.
        • Park S.M.
        • Lee J.M.
        • Song J.Y.
        • Lee S.J.
        Effect of central line bundle on central line-associated bloodstream infections in intensive care units.
        Am J Infect Control. 2013; 4: 710-716
        • Apisarnthanarak A.
        • Thongphubeth K.
        • Yuekyen C.
        • Warren D.K.
        • Fraser V.J.
        Effectiveness of a catheter-associated bloodstream infection bundle in a Thai tertiary care center: a 3-year study.
        Am J Infect Control. 2010; 38: 449-455
        • Khalid I.
        • Al Salmi H.
        • Qushmaq I.
        • Al Hroub M.
        • Kadri M.
        • Qabajah M.R.
        Itemizing the bundle: achieving and maintaining “zero” central line-associated bloodstream infection for over a year in a tertiary care hospital in Saudi Arabia.
        Am J Infect Control. 2013; 41: 1209-1213
        • Reisinger H.S.
        • Yin J.
        • Radonovich L.
        • Knighton V.T.
        • Martinello R.A.
        • Hodgson M.J.
        • et al.
        Comprehensive survey of hand hygiene measurement and improvement practices in the Veterans Health Administration.
        Am J Infect Control. 2013; 41: 989-993
      1. Thom KA, Li S, Custer M, Preas MA, Rew CD, Cafeo C, et al. Successful implementation of a unit-based quality nurse to reduce central line-associated bloodstream infections. Am J Infect Control Epub 2013 Dec 17.

      Linked Article

      • Compliance with central line insertion bundles in an intensive care unit
        American Journal of Infection ControlVol. 42Issue 5
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          We read with great interest the article by Khalid et al,1 who demonstrated that a rate of no incidence of central line-associated bloodstream infection (CLABSI) is achievable in 1 developing country in Asia.1 CLABSI is associated with high morbidity and mortality and becomes a life-threatening issue in intensive care units (ICUs).2,3 Our ICU, which is located in southern Taiwan—another Asian country—is no exception.4 Although the incidence of CLABSI declined from 4.5 per 1,000 catheter-days in 2009 to 2.16 per 1,000 catheter-days in 2010 in our intensive care unit,4 we are still eager to improve the situation to achieve the goal of “Zero CLABSI.” Since March 2013, 2 major central line care bundles, including insertion bundles for reducing the risk of infection during the insertion of central venous catheters (CVCs) and maintenance bundles for minimizing the risk of infection while caring for a CVC during use, were implemented in our ICU to prevent CLABSI.
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