"Near zero" catheter-related bloodstream infections: turning dreams into reality*.

Crit Care Med 2012 Vol. 40, No. 11 3083 Catheter-related bloodstream infection (CR-BSI) is a frequent complication in the intensive care unit (ICU) setting. Paradoxically, the presence of CR-BSI, which contributes substantially to increase patient’s morbidity, hospital costs, and ICU length of stay, is largely preventable (1). In fact, care bundles on line insertion have been effective to reduce CR-BSI rates. In the Keystone ICU Project, Berenholtz and colleagues (2) showed that implementation of an evidence-based bloodstream infection bundles that involves five well-known Centers of Disease Control and Prevention recommended measures (hand washing, full-barrier precautions during line insertion, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters) together with improving teamwork, communication, and patient safety culture was able to produce a large and sustained reduction of CR-BSI rates over an 18-month study period (3). Furthermore, most of the participating ICUs sustained reduced CR-BSI rates during a further postimplementation period of 18 months (4). Similar results were reported by others (5–7). This quality improvement program originally developed in Michigan has spread to many states in United States and abroad with consistent successful results (8). In Spain, an agreement of the Spanish Ministry of Health and the Patient Safety Programme of the World Health Organization in collaboration with the Spanish Society of Intensive and Critical Care Medicine and Coronary Units and the Johns Hopkins Quality and Safety Research Group was established to assess the applicability and effectiveness of the Keystone ICU Project (9). As a result, a nationwide multifactorial intervention program, named “Bacteremia Zero,” was designed and progressively implemented in 192 Spanish ICUs over an 18-month period between 2008 and 2010. Significant reductions of CRBSI rates as compared with baseline were observed (unpublished data), showing that this multifaceted quality improvement program can be effectively applied to a different health care system, despite varying levels of organizational structure and safety cultures. The study of the Johns Hopkins Quality and Safety Research Group had a cohort design, so that the next logical scientific step was to perform a randomized controlled trial to assess causality between the multifaceted intervention used in the Keystone ICU Project and the reduced CR-BSI rates as well as to evaluate the magnitude of the effectiveness of the intervention. In this issue of Critical Care Medicine, Marsteller and coworkers (10) report the results of a multicenter, phased, clusterrandomized controlled trial in 45 ICUs from 35 hospitals, in two faith-based affiliated health systems, which was designed to determine the causal effects of an intervention to reduce CR-BSIs in the ICU. The multifaceted intervention consisted of the above mentioned evidence-based practices to prevent CRBSI (2) and the Comprehensive Unit– based Safety Program to improve safety, teamwork, and communication (11). Interestingly, the study included a first phase (phase 1) in which the intervention was assessed according to the randomized controlled trial design and a second follow-up period of 1 yr (phase 2) in which the intervention was implemented to all participating ICUs (including those in the control arm), aimed to assess sustainability of the intervention. The intervention group started in March 2007 and the control group in October 2007, and the study period ended in September 2008. Baseline data for both groups were from 2006. The number of primary CR-BSI per 1000 central-line days was collected monthly and reported to the authors through the health systems corporate headquarters. The main primary outcome was the quarterly rate of CR-BSI during the postimplementation period (third quarter, from October to December 2007). By that time, the mean infection rate (CR-BSI per 1,000 central-line days) declined from 4.48 to 1.33 in the intervention group compared to a decline from 2.71 to 2.16 in the control group (adjusted incidence rate ratio 0.19; 95% confidence interval 0.06–0.57; p = .0003). The intervention and the control groups showed sustained CR-BSI rates <1/1,000 central-line days at 19 (81% reduction) and at 12 months (69% reduction), respectively. However, at the end of the study, reductions in CR-BSI rates near to 0.8 per 1,000 line days were observed in both study groups, which was even lower than the rates achieved in the Keystone ICU Project (3). The study shows a casual relationship between the multifaceted intervention and reduced rates of CR-BSI, decreased infection rates in both groups after implementation, and sustained results over time, providing further evidence that CR-BSI is a preventable condition. In addition to the design, other strengths of this study were that the authors decided to incorporate several modifications to optimize the intervention that contributed decisively to the Adventist collaborative success, such as the development of a dressing-change check-list, use of a preplanned educational curriculum, recognition as a nurse-led program, and measurement of the influential elements of the context at each site. However, from a methodological point of view, the authors use the zero-inflated Poisson models to analyze the effect of the intervention on CR-BSI and to identify other associated factors. The model is appropriate for “near zero” catheter-related bloodstream infections: turning dreams into reality*