Preventing catheter-related bloodstream infections: thinking outside the checklist.

THE MEDICAL CARE SYSTEM IS AT A CROSSROADS IN the control of health care–associated infections. For years, the status quo has been defined by scattered local success stories but an overall failure to protect patients from largely preventable infections. These infections have enormous human and economic costs, with an estimated 100 000 deaths and $6.5 billion in excess expenditure annually in the United States alone and estimates of 1.4 million patients affected daily worldwide. Catheter-related bloodstream infection is a leading contributor to health care–associated infection. Approximately 80 000 catheter-related bloodstream infections occur annually in US intensive care units (ICUs) and are associated with as many as 24 000 patient deaths. Each of these infections is estimated to have a mean attributable cost of $18 000 and an associated excess hospital stay of 12 days per episode. There are many reasons for this global epidemic of health care–associated infections, including payment systems that neither reward best practice nor punish poor performance. However, in many countries, the payment systems reward poor performance by providing additional reimbursement for incident infections. To counteract this, since October 2008, the Centers for Medicare & Medicaid Services will no longer reimburse hospitals for expenses associated with catheter-related bloodstream infections. Similar strategies have been proposed in some countries in Europe and elsewhere. Additional reasons for the fragmented responses to infection include the lack of clinical trials and costeffectiveness analyses to guide best practice at societal as well as individual hospital levels. Without direct reimbursement for specific initiatives for infection prevention, hospitals have been forced to make economic decisions about funding infection control interventions with limited data and an eye on their bottom line, the outcome of which may not be aligned with the greatest societal benefit. Into the breach of these failures have stepped governmental and other bodies that seek to mandate specific practices. For example, the Veterans Health Administration and the State of Illinois have instituted mandatory screening for methicillin-resistant Staphylococcus aureus (MRSA), and starting in January 2010 the Joint Commission’s Hospital Accreditation Program National Patient Safety Goals will require the use of a catheter checklist and a standardized protocol for central venous catheter (CVC) insertion, along with other measures. Given the high incidence and mortality associated with catheter-related bloodstream infection, it is not surprising that numerous strategies including bundled interventions have been studied. Successful approaches have been as varied as 1-day educational programs and a comprehensive multistep policy with targeted education to address the proper insertion and maintenance of CVCs. The most frequently cited bundle of interventions includes appropriate hand hygiene, use of chlorhexidine for skin antisepsis, use of maximal sterile barrier precautions (mask, sterile gown, sterile gloves, and large sterile drapes) during catheter insertion, avoidance of the femoral vein, and prompt removal of unnecessary catheters. Adherence to these basic infection control practices was tracked using a checklist and was associated with a 66% reduction in catheter-related bloodstream infections in a quasi-experimental study. The success of this strategy is evidenced by its adoption by the Institute for Healthcare Improvement and the Joint Commission, although this strategy has not reduced catheter-related bloodstream infections to zero, neither in the aforementioned trial nor in actual practice. The most recent data from the Centers for Disease Control and Prevention’s National Healthcare Surveillance Network showed that even though rates of catheter-related bloodstream infection decreased 54% in the medicalsurgical ICUs of major teaching hospitals, the rate was still approximately 3 infections per 1000 catheter-days. Fortunately, other preventive measures exist. Numerous trials have reported the benefits of antisepticor antimicrobialcoated catheters. However, many of these studies were