Felix, Cassia S.

Giovani, Arlete M.

Lima, Ana Lucia L.

Lorigados, Clara B.

Miranda, Erique P.

Oliveira, Priscila R.

Paula, Adriana P.

English

Cadernos Espinosanos (E-Journal)

RAPID COMMUNICATIONThe long-term impact of a program to prevent centralline-associated bloodstream infections in a surgicalintensive care unitAdriana P. Paula, Priscila R. Oliveira, Erique P. Miranda, Cassia S. Felix, Clara B. Lorigados, Arlete M.Giovani, Ana Lucia L. LimaHospital das Clinicas da Faculdade de Medicina da Universidade de Sa˜o Paulo/SP, Brazil.Email: priscilarosalba@gmail.comTel.: 55 11 2661-6900INTRODUCTIONCentral line-associated bloodstream infections (CLABSIs)are an important type of healthcare-associated infection inintensive care units (ICUs) with high mortality rates andhigh healthcare costs (1). According to the World HealthOrganization (WHO), CLABSIs are also the most commoncause of healthcare-associated infections of the bloodstream(2).In the United States, the median rate ranges from 1.8 to 5.2per 1,000 catheter days, according to the Centers for DiseaseControl and Prevention (CDC) (3). Each year, 100,000 casesand 30,000 deaths occur among patients in ICUs (4).In limited-resource countries, CLABSI rates range from1.6 to 44.6 cases per 1,000 central line days in adult andpediatric ICUs and from 2.6 to 60.0 cases per 1,000 centralline days in neonatal ICUs. CLABSIs are associated withsignificant additional mortality, with an odds ratio rangingfrom 2.8 to 9.5 (5).The optimal intervention method for reducing theincidence of CLABSIs has not been definitively identified,but some studies have proven that many practical, low-cost,low-technology educational measures related to insertingand maintaining central lines not only may be successfuland effective but can also be sustained (3,4,6–11). Withinthis scenario, the CDC has recommended that an educationprogram be implemented for healthcare personnel (6).The objective of this study was to describe the long-termimpact of a program for decreasing CLABSI rates in asurgical ICU in Sa˜o Paulo, Brazil.METHODSFor this interrupted time-series analysis, we compared theCLABSI rates during an 18-month baseline period (fromSeptember 2005 to February 2007), an 18-month interventionperiod (from March 2007 to August 2008) and an 18-monthpost-intervention period (from September 2008 to February2010) in a cohort of patients who received central linecatheterization in a 10-bed surgical ICU located in a tertiaryhospital specializing in orthopedic care in Sa˜o Paulo, Brazil.The intervention consisted of an 18-month program ofweekly visits to the ICU by professionals from an infectioncontrol board. The visits consisted of the inspection of allpatients with central lines and guidance for the ICU team onthe correct techniques for inserting and maintaining thesecatheters, including the following: full-barrier precautionsduring the insertion of central venous catheters; the use of afixation hub with suturing; hand washing before manip-ulating the device (e.g., for blood sampling and druginfusion); cleaning the skin with chlorhexidine; avoidingthe femoral site if possible; and removing unnecessarycatheters or those in poor condition. During these visits, allof the professionals belonging to the medical and nursingstaff were approached individually to ensure that they hadunderstood the instructions.A bloodstream infection was defined according to theCDC criteria [11]. CLABSIs were considered to be ICUrelated if detected at least 48 hours after admission to theunit or less than 48 hours after discharge from the unit. TheCLABSI incidence rates were expressed as the total numberof CLABSI episodes over the number of catheter days. Thestatistical analyses were performed using an ANOVAwith aBonferroni (post-hoc) correction. Statistical significance wasdefined as p,0.05. SPSS 10.0 for Windows (SPSS Statistics,IBM, Chicago, IL, USA) and Microsoft Excel 2007 (MicrosoftInc., Redmond, WA, USA) were used for data collection andstatistical analyses.RESULTSDuring the pre-intervention period (baseline), the meanincidence rate of CLABSI events per 1,000 catheter daysobserved was 15.85 (¡ standard deviation [SD]: 19.44; 95%CI: 6.19–25.52), ranging from 0 to 60.98 events. The medianand interquartile range were 12.66 and 27.24, respectively(Table 1).During the intervention period, the mean incidence ratefell to 4.98¡7.11 (95% CI: 1.45–8.52), and the median reached0 (interquartile range: 12.53), ranging from 0 to 22.30. Thisreduction trend was maintained in the post-interventionperiod, during which 3.91¡8.21 events (95% CI: -0.18–7.99)were observed, ranging from 0 to 31.58. A 68% reduction inthe mean CLABSI rate occurred during the intervention, anda 75% decrease was observed after this period.Copyright  2012 CLINICS – This is an Open Access article distributed underthe terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided theoriginal work is properly cited.No potential conflict of interest was reported.CLINICS 2012;67(8):969-970 DOI:10.6061/clinics/2012(08)19969There were statistically significant differences among allof the periods (p = 0.013) and between the first and secondperiods (p = 0.022) and first and third periods (p = 0.045)(Figure 1). The number of catheter days did not differbetween any of the periods (p= 0.598, ANOVA).DISCUSSIONCLABSIs are associated with high mortality and costs forhealthcare systems around the world, and educationalstrategies are regarded as the cornerstone of infectioncontrol. This strategy has been supported by several studies(2,3,5–9), even in settings with a low baseline incidence ofCLABSIs (6), although some studies have shown that non-educational measures have been confounders (4,9,10,11). Asingle study in Brazil found no statistically significantreduction in the incidence of CLABSIs despite goodcompliance with educational measures, most likely due tothe use of an open-infusion system (7).In this study, we achieved lower CLABSI rates througheducational measures without increasing costs to thehospital. In this approach, every health professional wasapproached individually regarding the insertion techniqueand maintenance of central venous catheters. Thus, eachprofessional felt valued and motivated, which contributedtoward the success of the intervention. Importantly, evenafter the intervention, the rates remained lower than thebaseline.Provonost et al. (3) found a sustained reduction of up to66% in CLABSI rates after 18 months of follow-up in a largerstudy with an educational intervention based on a similarapproach, although their baseline incidence was lower thanin the present study.The present study has limitations. The absence ofrandomization, the involvement of just one service and theabsence of detailed statistical intervention analyses make itdifficult to establish a causal connection between theintervention and the reduced CLABSI rates, although thelong-term follow-up reduced any effect from seasonaltrends. The possibility of CLABSI underreporting wasminimized through the active surveillance of signs andsymptoms, microbiological data and the prescribing ofantibiotics in the ICU, although the microorganismsidentified were not reported in this study. Furthermore,staff compliance was not evaluated, either by a written testor by statistical analysis, because the infection control teamwas actively monitoring the ICU to ensure the accomplish-ment of the educational approach.Our program produced sustained long-term decreases inthe CLABSI rate. This success shows the importance ofinteractions between infection control and ICU profes-sionals for achieving the goal of reducing infections in thissetting.REFERENCES1. Weber DJ, Rutala WA. Central line-associated bloodstream infections:prevention and management. Infect Dis Clin North Am. 2011;25(1):77-102, http://dx.doi.org/10.1016/j.idc.2010.11.012.2. World Health Organization. Preventing bloodstream infections fromcentral line venous catheters. 2012. Avaiable in: http://www.who.int/patientsafety/implementation/bsi/en/index.html.3. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S,et al. An intervention to decrease catheter-related bloodstream infectionsin the ICU. N Engl J Med. 2006;355(26):2725-32.4. Weber DJ, Brown VM, Sickbert-Bennett EE, Rutala WA. Sustained andProlonged Reduction in Central Line–Associated Bloodstream Infectionsas a Result of Multiple Interventions. Infect Control Hosp Epidemiol2010;31(8):875-7, http://dx.doi.org/10.1086/655438.5. Rosenthal VD. Central line-associated bloodstream infections in limited-resource countries: a review of the literature. Clin Infect Dis.2009;49(12):1899-907, http://dx.doi.org/10.1086/648439.6. Parra AP, Mena´rguez MC, Granda MJP, Tomey MJ, Padilla B, Bouza E. ASimple Educational Intervention to Decrease Incidence of Central Line–Associated Bloodstream Infection (CLABSI) in Intensive Care Units withLow Baseline Incidence of CLABSI. Infect Control Hosp Epidemiol.2010;31(9):964-7, http://dx.doi.org/10.1086/655841.7. Santana SL, Furtado GH, Wey SB, Medeiros EA. Impact of an educationprogram on the incidence of central line-associated bloodstreaminfection in 2 medical-surgical intensive care units in Brazil. InfectControl Hosp Epidemiol. 2008;29(12):1171-3, http://dx.doi.org/10.1086/591862.8. Marra AR, Cal RG, Dura˜o MS, Correa L, Guastelli LR, Moura DF Jr, et al.Impact of a program to prevent central line-associated bloodstreaminfection in the zero tolerance era. Am J Infect Control. 2010;38(6):434-9,http://dx.doi.org/10.1016/j.ajic.2009.11.012.9. Guerin K, Wagner J, Rains K, Bessesen M. Reduction in central line-associated bloodstream infections by implementation of a postinsertioncare bundle. Am J Infect Control. 2010;38(6):430-3, http://dx.doi.org/10.1016/j.ajic.2010.03.007.10. Ong A, Dysert K, Herbert C, Laux L, Granato J, Crawford J, et al. Trendsin central line-associated bloodstream infections in a trauma-surgicalintensive care unit. Arch Surg. 2011;146(3):302-7, http://dx.doi.org/10.1001/archsurg.2011.9.11. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitionsfor nosocomial infections, 1988. Am J Infect Control. 1988;16(3):128-40,http://dx.doi.org/10.1016/0196-6553(88)90053-3.Table 1 - A comparison of the incidence rate and catheter days among the study periods.Baseline Intervention period Period after interventionPeriod 18 months 18 months 18 monthsCatheter daysMean (¡ standard deviation) 98.44¡ 41.03 99.78¡37.05 87.72¡38.46Median (¡ interquartile range) 107¡77.75 95¡56.75 84¡49.5Range 36–156 44–186 34–163Incidence rate (per 1,000 catheter days)Mean (¡ standard deviation) 15.85¡19.44 4.98¡7.11 3.91¡8.21Median (¡ interquartile range) 12.66¡27.24 0¡12.53 0¡31.58Range 0–60.98 0–22.30 0–31.58The impact of a program to prevent CLABSIPaula AP et al.CLINICS 2012;67(8):969-970970

The long-term impact of a program to prevent central line-associated bloodstream infections in a surgical intensive care unit

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The long-term impact of a program to prevent central line-associated bloodstream infections in a surgical intensive care unit

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