"...CRBSI are a well recognized problem in the intensive care unit (ICU)," write Walter Zingg, MD, from the University Hospitals of Geneva in Geneva, Switzerland, and colleagues. "A recent study, in the neonatal setting, found hand hygiene successful as a single intervention measure in reducing CRBSI when its promotion was guided by healthcare workers' perceptions and combined with organization at the workplace. On the basis of high incidence rates of CRBSI in previous surveys of the ICUs in our institution, we decided to conduct an interventional study using an educational campaign focusing on hand hygiene and catheter care."
At 5 adult ICUs of a university hospital, CRBSIs were studied in all patients with a central venous catheter (CVC) from September to December 2003 (baseline period) and from March to July 2004 (intervention period). The intervention consisted of an educational program focusing on hand hygiene, catheter care standards, and intravenous drug preparation. The rate of CRBSIs per 1000 catheter days during the 4-month baseline period and the 5-month intervention period was the main endpoint of the study, and the secondary endpoint was compliance with hand hygiene.
The investigators monitored 499 patients with 6200 catheter days in the baseline period and 500 patients with 7279 catheter days in the intervention period. In the baseline period, there were 3.9 CRBSIs per 1000 catheter days, which decreased to 1.1 per 1000 catheter days in the intervention phase (P < .001). Both univariate and multivariate analysis revealed a significantly higher risk for CRBSIs in the baseline period. Hospitalization in the medical ICU and male sex were also independent risk factors.
During the intervention period, time to CRBSI was significantly longer vs baseline (median, 9 days vs 6.5 days, respectively; P = .02). Although compliance with hand hygiene increased only slightly from 59% in the baseline period to 65% in the intervention period, the rate of correct performance of hand hygiene improved from 22.5% to 42.6% (P = .003).
Limitations of this study include lack of randomization and disparity of the study population, with a higher fatal McCabe score, more trauma patients, longer ICU stay, longer median catheter duration, and more blood culture samples obtained in the intervention period.
"Evidence-based catheter-care procedures, guided by healthcare workers' perceptions and including bedside teaching, reduce significantly the CRBSI rate and demonstrate that improving catheter care has a major impact on its prevention," the study authors write. "Infection control efforts to improve the quality of hand hygiene and catheter care are essential elements for patient safety, not only for the reduction of CRBSI but also for other health care-associated infections."
The study authors have disclosed no relevant financial relationships.
Critical Care. Published online May 29, 2009.
Clinical Context
Risk factors for CRBSIs include long duration of CVC use, insertion site other than subclavian, overmanipulation of the CVC system, and heavy cutaneous colonization, as well as patient factors of illness severity and immunodeficiency. Strategies such as handwashing and the use of CVCs coated with antimicrobials have been examined as methods to reduce CRBSIs.
This is a study of the effect of an educational intervention on hand hygiene practice in ICUs and its impact on CRBSI rates and predictors of CRBSIs among patients in the ICU.
Study Highlights
- The study was conducted at 5 ICUs (medical, cardiovascular, trauma, general surgery, and neurosurgery) with a total of 52 beds at 1 hospital.
- All adults hospitalized in any of the ICUs with 1 or more CVCs were included, and there were no exclusion criteria.
- Surveillance of CVCs was conducted by a trained infection control nurse who visited the ICUs daily and recorded information.
- CRBSI was defined by the criteria of the Centers for Disease Control and Prevention and the National Healthcare Safety Network.
- Patients were monitored for CRBSI until 48 hours after discharge from the ICU.
- CRBSI was considered ICU acquired if diagnosed 48 hours or more after admission or within 48 hours of discharge from the ICU.
- Comorbidities were assessed with the Charlson Comorbidity Index, and the McCabe score and severity of illness was assessed with the Simplified Acute Physiology Score during the first 24 hours of ICU stay.
- The educational intervention consisted of training of head nurses and instructors, general teaching to all ICU nurses, bedside small group teaching for all nurses, and teaching of medical staff.
- Teaching phase 1 consisted of 12 interactive training sessions with use of evidence-based CVC procedures.
- Teaching phase 2 consisted of 5 teaching interventions of 45 minutes each in the auditorium.
- Teaching phase 3 consisted of 80 practical bedside teaching workshops on hand hygiene, and teaching phase 4 consisted of a physician teaching program.
- Primary outcomes were compliance with hand rubbing before and after patient contact with use of surveillance forms and monitoring the volume of alcohol-based hand rub used, and CBSRI rate.
- 499 and 500 patients were included in the baseline and the intervention period.
- A total of 6649 ICU days were observed (2944 for baseline and 3705 for intervention).
- The intervention period had more patients with trauma and rapidly fatal McCabe score.
- A total of 974 CVCs representing 6200 catheter days were surveyed during baseline, and 1015 CVCs representing 7279 catheter days during the intervention period.
- Incidence densities of CRBSI were 3.9 per 1000 catheter days in the baseline and 1.0 per 1000 catheter days in the intervention period (P < .001).
- Time to CRBSI was significantly longer in the intervention period (9 days vs 6.5 days; P = .02).
- CRBSI rates in medical ICUs were significantly higher vs other ICUs (9.0 vs 3.0 per 1000 catheter days).
- Patients with CRBSI had a longer stay in ICU by 10.5 days (15.5 vs 5 days).
- The most common pathogens in CRBSI were coagulase-negative staphylococci followed by Escherichia coli, Staphylococcus aureus, and Candida albicans.
- Risk factors for CRBSI were baseline vs the intervention period (hazard ratio [HR], 4.47), hospitalization in a medical ICU vs other ICUs (HR, 3.32), and male sex (HR, 2.54).
- A higher Simplified Acute Physiology Score and a rapidly fatal McCabe score were not independent predictors.
- Patients in medical ICUs had longer stays, more CVCs per patient, and higher Simplified Acute Physiology Score at admission but similar CVC days vs other ICUs.
- Male patients had longer ICU stays, more diabetes, and higher Charlson scores.
- Correctly performed hand hygiene practices before patient contact improved significantly from 26% to 45% (P = .007) and after patient contact from 21% to 56% (P < .001).
- Overall compliance with hand hygiene was improved, but this was not significant.
Clinical Implications
- Predictors of risk for CRBSIs in ICUs are hospitalization in a medical ICU, male sex, and baseline period.
- An educational intervention for ICU nurses and medical staff is associated with improved hand hygiene and reduced CRBSI rates.
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