CLABSI prevention success pressures hospitals to adopt similar programs

National 58% reduction means prevention "expected"

A recently reported dramatic national reduction in central line associated blood stream infections (CLABSIs) puts a harsh light on hospitals that have not adopted a "checklist" protocol and other proven measures to fight infections that are both expensive and deadly.

CLABSIs — which have mortality rates in the 12% to 25% range — were decreased by 58% in intensive care unit patients from 2001 to 2009 in national surveillance data reported by the Centers for Disease Control and Prevention.1The striking decrease translates to some 27,000 lives spared and $1.8 billion saved in excess health care costs.

After the celebratory reactions, this is the new normal: Hospitals that have not adopted similar CLABSI prevention measures — particularly in ICUs — risk being perceived in violation of a standard of care that has now been widely proven in clinical practice.

Arjun Srinivasan"The message from CDC and everybody in this field is that compliance with these best practices for catheter insertion should be 100%," says Arjun Srinivasan, MD, associate director for Healthcare Associated Infection Prevention Programs at the CDC. "Each and every time a catheter is put in it should be done in the best way. We know what that best way is and we want hospitals to do it that way."

Srinivasan's boss — CDC Director Tom Frieden, MD, MPH — was likewise unequivocal: "Preventing bloodstream infections is not only possible — it should be expected," he says.

That may certainly be the position of patients who take the CDC's advice to "ask which infection prevention methods will be used, why a central line is needed, and how long it will be in." Patients with central lines and their caregivers can prevent bloodstream infections by asking their doctors and nurses to clean their hands before and after touching patients, the CDC urged in releasing the CLABSI findings.

From this growing awareness among patients it is only a short leap to liability, as those with CLABSIs may conclude that their infection — given the national "getting to zero" hubbub — was completely preventable. Plaintiffs' attorneys are increasingly taking that view with healthcare associated infections (HAIs) in general, a medical liability attorney warns.

"From a legal standpoint [people] are looking at this and saying if they can do it in `Hospital A,' then we should be able to do it in `Hospital B,'" says Russell Nassof, JD, health care liability attorney and national practice leader of TRC Companies Inc. in Phoenix.

A single CLABSI costs $16,550

Thus, health care systems ignore this CLABSI success story at their peril. However, infection preventionists are not alone in this fight. The CDC credited at least part of the success to "increased financial and leadership support for CLABSI prevention." While preventing these infections does require some time and money, the bang for the buck is considerable. The CDC estimates that preventing a single CLABSI saves a health care facility $16,550 in excess costs.

"[But success] takes an investment in the types of resources that people need to prevent and monitor these infections," Srinivasan says.

The CDC did not have any estimates of the number of hospital ICUs that have still not adopted the checklist and other bundle measures, but a pioneer behind the CLABSI protocol says it appears to be way too many.

Peter Pronovost"Nationally, our program now has about 1500 [intensive care] units in it," says Peter Pronovost, MD, PhD, medical director of the Center for Innovations in Quality Patient Care at Johns Hopkins Hospital in Baltimore. "But there are still a large number of hospitals who have infection rates that are unacceptably high. There is no reason for that if they would do these programs. In our peer-review work hundreds and hundreds of hospitals of all types have nearly eliminated these infections. If any hospital's [CLABSI] infection rate is anywhere other than zero they should start looking into these programs."

Though the CDC surveillance report did not collect the specific practices at each ICU, the main infection prevention focus has been on the key moments before the catheter needle pierces the skin (i.e., of the neck, chest or groin), when it could possibly take the patient's endogenous bacteria deep into the blood stream. To prevent seeding infection that way or via cross transmission during catheter placement, the CDC recommends using an insertion checklist that includes hand hygiene, maximal barrier precautions and use of a skin prep agent (preferably chlorhexidine). (See CDC recommendations, below.)

CDC urges action by hospitals, patients

To prevent bloodstream infections in patients with central lines, the Centers for Disease Control and Prevention recommends the following for caregivers and patients at hospitals, dialysis centers, and other medical care settings:

  • Make sure CDC infection control guidelines are followed every time a central line is put in and used.
  • Encourage staff members to speak up when guidelines aren't followed.
  • Use data for action. Track infection rates and germ types with CDC's National Healthcare Safety Network (NHSN) to learn where and why infections are happening, target actions to stop them, and track progress.
  • Recognize staff members or units that work hard to prevent central line infections or that solve issues with infection control.
  • Join state-based prevention programs such as the Agency for Healthcare Research and Quality's expansion of "On the CUSP: Stop BSIs." On the web at: http://bit.ly/dVuCS3
  • Patients with central lines and their caregivers can prevent bloodstream infections by asking their doctors and nurses to clean their hands before and after touching patients.
  • Patients should ask which infection prevention methods will be used, why a central line is needed, and how long it will be in. Tell a nurse or doctor if the area around the central line becomes sore or red, or if the bandage falls off or looks wet or dirty.

"It gives you a tool for how you can monitor and measure how well people are doing in following those recommendations," Srinivasan says. "The [national] interventions are all very similar — they are focused on the correct placement or insertion of central catheter lines. All the bundles and checklists in their various forms distill the CDC recommendations surrounding how to best insert catheters."

Just for the record, even when patients are admitted with pathogens on their on own skin flora, keeping the bugs out of their bloodstreams is the responsibility of the health care workers who are placing the central line.

"If it is on your skin, it should stay on your skin," he says. "The act of placing the catheter is what creates the risk of infection. It may be their own bacteria, but we gave them the infection because we put the catheter in without, [for example], cleaning the skin properly."

Going beyond the ICU

To estimate the total number of CLABSIs among patients in the United States, the CDC multiplied central-line utilization and CLABSI rates by estimates of the total number of patient-days in each of three settings: ICUs, inpatient wards, and outpatient hemodialysis facilities. In 2001, an estimated 43,000 CLABSIs occurred among patients hospitalized in ICUs in the United States. In 2009, the estimated number of ICU CLABSIs had decreased to 18,000.

Looking at just one year, 2009, the reductions represent some 3,000—6,000 lives saved and $414 million in prevented excess costs in ICUs. Going beyond the ICU may reap similar success.

"This is one of the areas where we know we can simultaneously improve the quality of care that is delivered, save money and most importantly save lives," Srinivasan says. "When you do the right thing, these other factors fall into place."

ICUs have been the prime target for intervention, but the CDC is now making it a high priority to prevent CLABSIs in hospital wards and hemodialysis settings. About 23,000 CLABSIs occurred in non-ICU patients in 2009 and about 37,000 infections occurred in dialysis clinic patients in 2008, the CDC estimated. The substantial number of CLABSIs among hemodialysis patients is also a problem for hospitals, as the infections are a major cause of admissions and readmissions. A primary prevention measure is the avoidance of central lines in favor of arteriovenous fistulas for dialysis patients. Though dialysis interventions pose a whole different set of problems, preventing infections in hospital wards could be done by essentially expanding the ICU interventions. Of course that's easier said than done, as CLABSI prevention requires meticulous insertion and care of the central line by all members of the clinical care team.

"There is empowerment of everybody on the health care team to feel responsible for making sure that everything is being followed correctly, Srinivasan says.

Such an approach may be more conducive to an ICU than a ward bed, but the opportunity for infection prevention is clear.

"It's easy to know which practices work; it is much harder to make sure that everybody is doing those practices," Srinivasan concedes. "But there is now support for [the infection preventionist] saying 'It is not acceptable to us that you don't do these things. And it is a uniform message from the very highest levels of our health care facility.'"

While the checklist has drawn widespread attention, just as crucial to the overall success has been broad collaborations necessary to get CLABSI prevention programs implemented nationwide. For example, CLABSI prevention campaigns are in full stride at both the Association for Professionals in Infection Control & Prevention and the Agency for Healthcare Research and Quality. The forward thinking in all of this is that the CLABSI prevention model may be successfully extended to other infections, which is already happening with ventilator associated pneumonia (VAP).2 Perhaps VAP and other HAIs will eventually become the target of national campaigns a la CLABSIs.

"It's important to recognize why we made progress [with CLABSIs]," Pronovost says. "One reason is that we kept score with a valid measure — that is really important. Two, we were guided by science — there were good studies about what to do and how to do it. And three — and maybe most importantly — is that we committed to work together. This was a collaborative effort of many different groups aligned with a common purpose and common measure. There are very few examples right now where those three things are happening in patient safety."

CMS brings the fiscal pressure

Indeed, the CDC shared its success with a nod to the Centers for Medicare and Medicaid Services (CMS), which has taken a keen interest in preventing health care associated infections (HAIs) to lower health care costs. "The collaborative efforts with CMS have been very important in drawing attention to this problem — drawing attention to the preventability of CLABSIs," Srinivasan says. "Their mandates spur a lot of action."

Donald BerwickThe 58% reduction of CLABSIs is a "remarkable achievement" that underscores the role of infection prevention in health care reform, says CMS Administrator Donald Berwick. "We can't afford the human and financial costs of [HAIs]," he noted at a recent forum on HAIs. "We understand the causes of these problems, and I think we are moving away, happily — from a culture of blame — where we just keep pointing fingers at everybody when things go wrong — into a culture of science."

HAIs are known to be a prime target of Berwick, who remains politically embattled as Republicans in Congress threaten to leave his recess appointment unconfirmed. In any case, even as CMS provides incentives and pressure, evolving health care reform should not rely solely on cutting reimbursements, Provonost emphasizes.

"The reality is that real health care reform isn't going to come from paying doctors and nurses and hospitals less — they are already working hard," he says. "It's going to come from preventing complications and infections. It's these kinds of things we should be doing for health care reform. Yet so much of the work is just ratcheting down — cutting staff at hospitals because they are paying them less. That may actually make the quality problem worse. These kinds of programs — especially this CDC data — should be celebrated and become the main driver of how we are going to improve quality and reduce costs of care."

[Editor's note: IPs looking to start or improve a CLABSI prevention program in their hospital can find a wealth of CDC materials at: http://1.usa.gov/htz1Ib].

References

  1. Centers for Disease Control and Prevention. Vital Signs: Central Line-Associated Blood Stream Infections — United States, 2001, 2008, 2009. MMWR2011;60(08):243-248.
  2. Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol 2011;32:305-314.