One-Day Course for Residents Reduces ICU Vascular Catheter Infections

Abstract & Commentary

Synopsis: After a one-day "hands on" course on infection control practices was integrated into the yearly training provided for house staff, the rate of catheter-related infection in ICUs decreased from 4.51 infections per 1000 patient days to 2.92 infections.

Source: Sherertz RJ, et al. Ann Intern Med 2000; 132:641-648.

This study was conducted in response to the observation that, despite conventional bedside and didactic instruction, physicians-in-training were not using optimal infection control practices. Consequently, Sherertz and associates developed a one-day course that included lectures on basic infection control principles (1 hour) and blood and body fluid precautions (1 hour) and a series of one-hour stations at which participants received 5-15 minutes of didactic instruction followed by hands-on instruction and practice.

Training received during the hands-on portion of the course included: 1) blood draws through vascular lines (taught by oncology nurses); 2) arterial punctures for ABGs (taught by RRTs); 3) insertion of arterial catheters and central venous catheters (CVCs) (taught by critical care faculty and fellows; 4) urinary catheter insertion (taught by nurse instructors); 5) lumbar puncture (taught by an oncologist); 6) peripheral venous catheter insertion (taught by nurse instructors); and 7) phlebotomy (taught by physician faculty). All participants practiced phlebotomy on each other and participants started peripheral IV lines first on mannequins and then on another participant. The course was taught several times so that groups were relatively small (~ 50 per group).

Pre- and post-course outcomes were assessed in several ways. The hospital’s purchasing department recorded requests for CVCs and full-size sterile drapes. Sherertz et al determined the number of catheter-related infections and primary bloodstream infections in six general medical-surgical ICUs and the associated stepdown ICU. Employee health recorded the number of injuries that involved blood and body fluid exposure.

The perceived need for full-size sterile drapes during CVC insertion (an intervention proven to reduce the risk for CVC-related infection) was 22% in the year before the course and 73% six months after the course (P < 0.001). The perceived need for small sterile towels at the insertion site decreased reciprocally (P < 0.001). Documented use of full-size sterile drapes increased from 44% to 65% (P < 0.001). The rate of catheter-related infection decreased from 4.51 infections per 1000 patients days before the first course, to 2.92 infections per 1000 patient days 18 months after the first course (mean decrease, 3.23 infection per 1000 patient days; P < 0.01). There was no change in the number of blood and body fluid exposures (15% pre; 19.3% post).

Over the study period, it was estimated that 39 primary bloodstream infections were prevented. Course costs were estimated to be $74,081 for supplies and faculty time. Cost savings were determined in two ways. Based on CDC data for the cost of a primary bloodstream infection ($3517), cost savings were $63,082 after expenditures. Based on a higher-end estimate ($28,690 per ICU survivor) and an estimated 80% survival, attributable cost savings were $815,309 after expenditures.

COMMENT BY LESLIE A. HOFFMAN, PhD, RN

Vascular catheter infections are a substantial cause of morbidity and mortality in hospitalized patients, with an attributable cost as high as $29,000 per episode. As many as 90% of these infections are believed to originate from CVCs. In teaching institutions, physicians-in-training insert essentially all CVCs and arterial catheters. In addition, they perform numerous other invasive procedures that place patients at risk for infection.

Prompted by the observation that optimal infection control practices were not being used, Sherertz et al developed a course that combined didactic and hands on instruction. The benefits were impressive. There were changes in participant practice and patient outcomes, reflected in a significant decrease in the rate of catheter-related infections per 1000 patient days. Cost savings for the 18-month observation period ranged from $63,000 to $800,000 depending on the method used to estimate the cost of each infection.

There were several unique aspects of the course that may have facilitated change in practice. Skills were taught by experienced practitioners using a small group, hands-on format. These practitioners included nursing instructors, attending physicians, fellows, and respiratory therapists, dependent on the skill station. Course participants had little prior experience performing these skills and were likely receptive to learning. The course was included as part of house staff orientation, a time when participants expected to learn new skills.

A total of 92 physicians took the course the second year. Prior to taking the course, the median number of procedures performed in medical school was five arterial punctures, one blood draw through a line, one CVC insertion, five peripheral line insertions. Thus, participants had limited prior experience performing these skills. In this institution, as in many teaching institutions, training in infection control practices was not standardized prior to course implementation. Findings suggest that failure to provide standardized instruction may predispose patients to increased risk of infection. If findings of this study can be replicated in other institutions, this instructional program should be adopted as a model for teaching infection control practices.