Abstract & Commentary

Standardized teaching lowers infection rates

Avoiding see one done badly, do one badly’

Synopsis: Institution of a standardized procedural instruction course for physicians-in-training resulted in a sustained 28% decrease in vascular catheter infection.

Source: Sherertz RJ, et al. Education of physicians-in-training can decrease the risk for vascular catheter infection. Ann Intern Med 2000;132: 641-648.

Despite adoption of a policy mandating maximum sterile barriers for central venous catheter (CVC) insertion, Sherertz and colleagues noted that compliance by trainees was poor. They therefore instituted a standardized one-day infection control and procedure course for third-year medical students and physicians completing their first year of training. The course included didactic instruction as well as "hands-on" training by faculty. Line insertion was taught by faculty and fellows in critical care medicine and trauma. The course was repeated one year later.

In the first six-month period after the course, the rate of vascular catheter infection (primary bacteremia and local infection) in the critical care and step-down units declined from a baseline of 4.51 per 1,000 patient days to 3.53 per 1,000 patient days. By the third three-month period, the rate had declined further to 2.92 per 1,000 patient days. The average decrease in infections was 28%. The results were similar when expressed as infections per 1,000 device days. During the same period, the number of full-size sterile drapes used per CVC insertion increased by 50%, indicating significantly improved compliance with infection control policies. Depending on the assumptions used in the cost-benefit analysis, the net savings ranged from a low of $60,000 to a high of $800,000.

Comment by Robert Muder, MD, hospital epidemiologist, Pittsburgh VA Medical Center:

Approximately 16,000 CVC-associated bacteremias occur in ICUs in the United States annually, resulting in 500 to 4,000 deaths.1 Use of full-barrier precautions during insertion, including sterile drapes, gowns, gloves, and masks, is effective in reducing the rate of infection. Sherertz et al noted that physicians-in-training complied with these guidelines approximately 20% of the time, and instituted a formal program to try to change this behavior. The result was a significant and sustained decrease in vascular catheter infection. The effectiveness of the behavior change was demonstrated by a 50% increase in the use of full-size sterile drapes.

Although this was a pre/post-observational study rather than a randomized trial, there were no changes in policy during the study periods, and antibiotic/antiseptic-impregnated catheters were not used. Sherertz et al state that there were no changes in the number of admissions or severity of illness over the study, but the actual data to confirm this are not provided.

Nevertheless, this study has several important lessons for infection control programs. The first is that a well-written policy may bear little relationship to what actually goes on in practice. It takes some degree of effort to ensure that personnel actually do things the way they’re supposed to. The second is that physicians-in-training need specific instruction for invasive procedures. This instruction should be provided by senior physicians and not by residents with a year or two of additional training.

In the absence of formal training, deviations from optimal practice can be passed along from one class of residents to the next ("See one done badly, do one badly, teach others how to do one badly"). In the case of CVC insertion, standardized instruction results in improved patient outcomes and lower cost.

Finally, this study adds further support to prior observations that catheter insertion and care by properly trained personnel led to a reduction in catheter-related complications, including bacteremia,2-4 for both peripheral and central catheters.

References

1. Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med 2000; 132:391-402.

2. Miller JM, et al. Reduction in nosocomial intravenous device-related bacteremias after institution of an intravenous therapy team. J Intraven Nurs 1996; 19:103-106.

3. Keohane PP, et al. Effect of catheter tunneling and a nutrition nurse on catheter sepsis during parenteral nutrition: A controlled trial. Lancet 1983; 2:1,388-1,390.

4. Soifer NE, et al. Prevention of peripheral venous catheter complications with an intravenous therapy team: A randomized controlled trial. Arch Intern Med 1998; 158:473-477.