May / June 2008
A New Bundle for Preventing CRBSIs
Patients in hospitals have a right to expect that any risks associated with their care are avoided. When it comes to catheter-related bloodstream infections (CRBSIs), those expectations are not being met. Many in the infection control community believe that CRBSIs are preventable. Yet, these infections are the fourth most common hospital-acquired infection and are particularly frequent with central-line catheter placements. Roughly 80,000 CRBSIs associated with central lines in the ICU occur in the United States every year, and these infections are fatal in up to 25% of cases.
Until recently, the notion that these infections could be completely eliminated was considered hypothetical. As noted in Patient Safety & Quality Healthcare, many institutions have dramatically reduced their CRBSI rates but have not been able to make that final push to zero (Abe et al., 2007).
Perhaps the tide is turning. The same article notes that St. Louis' Missouri Baptist Medical Center achieved a zero CRBSI rate in two ICUs for a prolonged period: about 6 months in one ICU and 7 months in the other. The most impressive accomplishment may be at our institution Sutter Roseville Medical Center (SRMC), a 270-bed community hospital in Roseville, California.
Using a central line bundle (evidence-based protocol) that expands on other bundles, SRMC has sustained a zero CRBSI rate for more than 2 years for all lines placed by our PICC team in our medical/surgical and trauma-neuro ICUs. This success is not just a chance occurrence. We believe this is a direct result of the fact that we have taken measures to provide consistent, repetitive attention to each and every central line catheter. We also believe our experience is replicable. Key to this success has been a strong PICC team, optimizing technology, and empowering nurses to work with physicians to identify the right line for the right patient at the right time.
Sutter Roseville Medical Center's CRBSI rate dropped to zero immediately after we implemented the bundle in January 2006. In the previous year that is pre-bundle 11 CRBSIs occurred. The CRBSI rate dropped to zero even as our central line placements were growing tremendously. In 2005, our PICC team placed 767 PICCs. PICC placements grew 103% to 1,558 placements in 2006, and to 2,278 PICCS in 2007, all without incidence of infection in any PICC placed by our PICC team.
The results at SRMC are good news not only for patients but also hospital executives dealing with pressing financial issues. Starting in October 2008, the Center for Medicare and Medicaid Services (CMS) will cease reimbursing hospitals for costs related to several types of HAIs that are largely preventable, including CRBSIs. Private insurers will likely follow CMS's lead. Eliminating CRBSIs can minimize the financial consequences of this momentous change in reimbursement.
Synergy of Bundle and Implementation
Our bundle had its origins in the 100,000 Lives Campaign (now the 5 Million Lives Campaign), a project of the Institute for Healthcare Improvement (IHI) and partner organizations to decrease preventable deaths in hospitals. As part of its involvement in the campaign, SRMC set about designing and implementing a sepsis bundle for the ICU, and the PICC team led the development of the central line component of the bundle.
Many of the steps in our bundle will be familiar to readers from hospitals that have had their own CRBSI initiatives. We built upon evidence-based practices and product technologies that already have been successfully deployed elsewhere or otherwise validated in the literature.
We believe our comprehensive approach produces a cumulative effect. Each step makes its own contribution. Each prevents infection at a different portion of the catheter insertion or line maintenance process. The end product is a multilayered defense against infection that seems to be working as intended.
The elements of the bundle are only part of the story. Many other parts and pieces needed to fall into place. Physician collaboration, PICC team ownership of central lines, a commitment to training all staff in their responsibilities toward the bundle's success, and a common dedication to the end result contributed to our outcomes.
Technological Aspects of the Bundle
We developed the bundle by researching best practices and recommendations from the IHI and the Centers for Disease Control and Prevention (CDC). Most of the elements advocated by those organizations are behavioral for example, appropriate hand hygiene. Our review of the literature also highlighted several technologies known to reduce CRBSI risk. We adopted those that promised to be the most effective and that fit into our overall approach. Since some of those technologies will be less familiar to readers, we will discuss those first.
A key pillar of our bundle is a maximum barrier precaution kit, based on a plank from the IHI central line bundle. Other than appropriate hand hygiene, the use of maximum barrier precautions is also strongly recommended for CRBSI prevention. As infection professionals now widely recognize, it is not enough to have the appropriate items within the organization. They also have to be conveniently available for every placement if you're going to maintain compliance with your bundle. When clinicians fail to comply with a central line bundle, "I couldn't find the..." is a common excuse. Therefore, SRMC followed the example set by many hospitals and created maximum barrier precaution kits containing a drape, gown, hat, mask, and sterile towel and placed them with easy access in all patient care units. By avoiding the need to call a central location and asking clinicians to wait for equipment arrival, compliance with the maximum barrier kits increased.
At SRMC approximately 95% of central lines are PICC lines, inserted by our RN PICC team. However, like all institutions, patients admitted through the emergency department and a defined population of our critical care patients, require physician inserted central line catheters. We collaborated with our infectious disease physicians and worked with our medical staff committees to get physician buy-in of the maximum barrier kit. Our physician leadership supported empowering nurses to stop central line insertions not following this protocol.
We also created a central line dressing kit. The kit includes a skin prep solution containing CHG, (chlorhexidine gluconate), a protective disk that secretes CHG, and an occlusive dressing.
Evidence has shown that a combination of 2% CHG and 70% isopropyl alcohol provides persistent antimicrobial protection for up to 48 hours. This solution is also one of the five elements in IHI's central line bundle and is described as the preferred approach in the CDC guidelines for preventing CRBSI.
With the literature showing that 60% of CRBSI originate in skin bacteria, every central line dressing kit includes a protective disk, which is placed around the catheter at the insertion site and secretes CHG for 7 days. The 7-day antisepsis supports our current weekly dressing change practice. An occlusive dressing is placed on the insertion site over the protective disk at the time of catheter insertion.
Finally, we changed our connector system by converting to a neutral IV connector system. Our review of the literature had shown that the positive pressure connector system used at SRMC was associated with increased CRBSI rates. We converted to the neutral connector system for two reasons. First, the system reduces blood refluxes in the line. Second, the system supports both our saline-only flushing protocol and our septum disinfection practice, described below.
Other Bundle Elements
The remaining bundle elements are essentially behavioral, beginning with our revised approach to site selection and our use of ultrasound guidance. Our review of the literature showed that there was less bacteria colonization when PICCs were placed in the upper arm, basilic vein of choice. We transitioned from traditional antecubital placement to using 100% ultrasound guidance for all PICC placements. This reduces the number of placement attempts, thereby improving patient comfort, reducing complications, and saving costs.
We also strongly reinforced septum disinfection. The literature showed that disinfecting the catheter septum is critical to preventing CRBSI. We continue to educate nursing staff about this practice and reinforce compliance with it.
Our bundle now includes a saline-only catheter flushing policy supported by our medical staff. The protocol has been standardized such that central lines (except dialysis and ports) are flushed with 10ml normal saline every 8 hours and PRN, using a push-pause technique.
The last behavioral element of the bundle is daily monitoring of PICC lines, performed by the PICC team. To assist the team in this crucial activity, we developed a data collection tool that identifies the patient, unit, type of line, insertion site, and possible complications. The tool enables us to identify any potential problems so we can intervene immediately. This data is easily reported to medical and nursing staff for improvement to practice.
CRBSIs and Culture Change: The Difference at SRMC
Anyone involved in a CRBSI initiative knows that "getting to zero" usually requires a culture change. Many institutions have dramatically improved their CRBSI rates by adding elements such as central line kits, ongoing bundle compliance education for nurses, and various checklists that remind clinicians of the institution's central line policies. But once the rates drop to a certain level, it becomes more difficult to make any further gains that are significant unless the culture truly transforms into a zero tolerance environment.
In our case, a key element of our transformation was development of collaboration and trust with our physicians in the PICC team. Our PICC nurses bring to their work the passion for patient care. They place the lines, monitor them every day, and troubleshoot any problems. If any evidence of a complication appears, they assess, determine an appropriate intervention, and communicate to physicians and staff a management strategy.
CRBSIs constitute a major complication for hospitalized patients with central line catheters. The use of those catheters is increasing, which increases the potential for more widespread bloodstream infections. Many institutions have targeted CRBSIs with ambitious initiatives. While these initiatives have often produced impressive results, few have succeeded in completely eliminating CRBSIs, despite the view of many experts that a zero rate is entirely feasible. Our hospital's success at eliminating CRBSIs for more than 2 years in the ICU may well be because we have hit upon a winning combination of bundle elements and implementation approach. Hospitals with PICC teams are positioned to replicate what we have done. We heartily encourage them to do so.
Walter Martin is a pulmonologist and infectious disease specialist at Sutter Roseville Medical Center in Roseville, California. He can be contacted at 916.786.7498
Sophie Harnage is clinical manager for infusion services at Sutter Roseville Medical Center. She can be contacted at harnagSA@sutterhealth.org.
Abe, C., Zack, J., Lewis, A. R., & Vanderveen, T. (2007). Zero tolerance: Curbing catheter-related blood stream infections. Patient Safety & Quality Healthcare, 4(6), 14‚18.