Advertisement

Compliance with central line insertion bundles in an intensive care unit

      To the Editor:
      We read with great interest the article by Khalid et al,
      • Khalid I.
      • Al Salmi H.
      • Qushmag 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.
      who demonstrated that a rate of no incidence of central line-associated bloodstream infection (CLABSI) is achievable in 1 developing country in Asia.
      • Khalid I.
      • Al Salmi H.
      • Qushmag 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.
      CLABSI is associated with high morbidity and mortality and becomes a life-threatening issue in intensive care units (ICUs).
      Centers for Disease Control and Prevention
      Vital signs: central line-associated bloodstream infection – United States, 2001, 2008, and 2009.
      • Fagan R.P.
      • Edwards J.R.
      • Park B.J.
      • Fridkin S.K.
      • Magill S.S.
      Incidence trends in pathogen-specific central line-associated bloodstream infections in US intensive care units.
      Our ICU, which is located in southern Taiwan—another Asian country—is no exception.
      • Liu W.L.
      • Chen H.T.
      • Lin H.L.
      • Lai C.C.
      • Hsueh P.R.
      Intervention to reduce catheter-related bloodstream infections in an intensive care unit at a regional hospital in southern Taiwan.
      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,
      • Liu W.L.
      • Chen H.T.
      • Lin H.L.
      • Lai C.C.
      • Hsueh P.R.
      Intervention to reduce catheter-related bloodstream infections in an intensive care unit at a regional hospital in southern Taiwan.
      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. Because studies about CVC insertion bundle compliance in ICUs is scarce, our study was conducted to investigate the adherence to a CVC insertion bundle during an improving quality-of-care process in our ICU.
      Our study was carried out at a regional teaching hospital. Our ICU has 23 beds and 3 intensivists, and most of the admissions are attributed to medical conditions, including shock, acute respiratory failure, cancer, and sepsis. The insertion of a CVC is preferably performed by an intensivist; however, it is rarely performed by nonintensivists such as cardiologists, surgeons, and trained resident physicians. Since March 2013, a CVC insertion bundle, including 4 components—hand hygiene, ensuring maximal sterile barriers upon insertion, use of chlorhexidine gluconate (CHG) for skin preparation, and avoidance of the femoral vein as an access site—were implemented in our ICU. Compliance to the bundle was defined as the frequency of the number of performed actions to the number of CVC insertions.
      During March-October 2013, a total of 205 CVC insertions were observed and 202 (98.5%) insertions were done by intensivists (the other insertions were performed 1 each by a cardiologist, surgeon, and trained resident physician). The overall compliance with all 4 components of the bundle was 70.7%. The compliance with each component was 100% for hand hygiene, 82.9% for ensuring maximal sterile barrier, 100.0% for the use of CHG, and 83.4% for optimal site selection (Fig 1). No case of CLABSI developed during this 8-month period.
      Figure thumbnail gr1
      Fig 1The trend of compliance with each central line insertion bundle component between March and October 2013.
      Despite the fact that the goal of “Zero CLABSI” was reached during this observational study of 205 CVC insertions, the overall compliance with all components of the CVC insertion bundle was only about 70% in our ICU, especially during the initial and late stages of our project. This compliance is much lower than the 96%-99% experienced by Khalid et al.
      • Khalid I.
      • Al Salmi H.
      • Qushmag 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.
      The low compliance could be explained by lack of experience during the early stage and lack of maintenance during the late stage. It suggests that we should work harder to find out the deficit of this project and further enhance compliance.
      When we investigated adherence to each component of the CVC insertion bundle, we found that in contrast to 100% compliance with hand hygiene and use of CHG, compliance was lower for avoidance of femoral venous access site and ensuring a maximal sterile barrier. This reveals that adherence with each component of a bundle may be different, and this kind of improving the quality of care process warrants more detailed investigation so each institution providing care can find out which specific areas have low compliance. In our ICU, it reminds us that our first priority is to enhance the compliance of 2 specific components of the CVC insertion bundle: ensuring maximal sterile barrier and optimal site selection.

      References

        • Khalid I.
        • Al Salmi H.
        • Qushmag 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
        • Centers for Disease Control and Prevention
        Vital signs: central line-associated bloodstream infection – United States, 2001, 2008, and 2009.
        MMWR Morb Mortal Wkly Rep. 2011; 60: 243-248
        • Fagan R.P.
        • Edwards J.R.
        • Park B.J.
        • Fridkin S.K.
        • Magill S.S.
        Incidence trends in pathogen-specific central line-associated bloodstream infections in US intensive care units.
        Infect Control Hospital Epidemiol. 2013; 36: 893-899
        • Liu W.L.
        • Chen H.T.
        • Lin H.L.
        • Lai C.C.
        • Hsueh P.R.
        Intervention to reduce catheter-related bloodstream infections in an intensive care unit at a regional hospital in southern Taiwan.
        J Microbiol Immunol Infect. 2013; 46: 243-244

      Linked Article

      • Reply: Compliance with central line insertion bundles in an intensive care unit
        American Journal of Infection ControlVol. 42Issue 5
        • Preview
          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.1,2 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.
        • Full-Text
        • PDF