Set a goal of zero central line and VAP infections

Determining what is really preventable

A movement toward "zero tolerance" for hospital-acquired infections is gathering steam. "I am a true supporter of that goal, but we have to figure out if that is a realistic goal," says Thomas Talbot, MD, MPH, chief hospital epidemiologist at Vanderbilt University Medical Center in Nashville, TN.

The challenge is to determine what percentage of infections are totally preventable. "The pendulum has really shifted nationally that any infection is a bad infection, and we all agree with that," says Talbot. "But the question is whether any infection is a preventable infection. We don't know what that threshold of percentage is — can we prevent 75% or 80%?"

An overweight smoking diabetic who comes in for cardiac surgery is clearly at higher risk, even if everything is done correctly. "But we want to be able to reassure ourselves that we have eliminated preventable infections for every patient who comes in," Talbot says.

Oakland, CA-based Kaiser Permanente set an organizational goal to reduce hospital-acquired infections to zero, says Alide L. Chase, senior vice president for quality and service. "Our northwest region has already reached and sustained that goal, with zero central line infections for 500+ days and zero bloodstream infections in the last four quarters," she reports.

Best practices are shared through a national infection control steering committee. "We work on national projects focused on reducing infection transmission, facilitate standardization of surveillance methodologies, and improve patient health outcomes through identification and implementation of evidence-based practices," says Chase.

At Vanderbilt, a central line initiative was implemented in one of the hospital's intensive care units, after problems with catheter-associated bloodstream infections were identified. "Like any successful initiative, we started in one area that was really vested in this. They agreed there was a problem and agreed on the process to solve it," says Talbot.

A checklist was developed, but more importantly, everyone at the bedside was empowered to stop the procedure if things aren't happening as they are supposed to.

'Pilot-copilot checklist'

For example, if a nurse sees a resident wearing gloves without full barrier precautions, team members expect that the nurse will stop the procedure. "This isn't a confrontation, but a pilot-copilot checklist," says Talbot. "Creating collaborative accountability is key."

After central line infections were dramatically reduced in the ICU, the same process was rolled out in other ICUs. "Our challenge is that we still have better performers than others," says Talbot. "Early on, a couple of the ICUs began using the checklist, but they did this without any education or culture change. It didn't work, which is not surprising."

To reduce central line-associated bloodstream infections, University of California Irvine Medical Center implemented the Institute for Healthcare Improvement's Central Line Bundle in all adult critical care units and the OR. Practices include:

  • hand hygiene by inserter prior to line insertion;
  • cap/gown/sterile gloves/mask worn by inserter prior to line insertion;
  • full sterile drape used to cover patient prior to line insertion;
  • avoidance of the femoral site;
  • selection of optimal site for insertion.

"Compliance with each of these measures is monitored at the time of insertion," says Linda L. Dickey, RN, MPH, CIC, manager of epidemiology and infection prevention. "Data are collected and fed back to physicians, staff, and administration."

At Vanderbilt, an initiative to reduce ventilator-associated pneumonia (VAP) was the topic at a meeting with key leaders, ICU directors, bedside nurses, and administrators. "Our goal was to get it up and running in six weeks," says Talbot. "We had a couple of roadbumps, but after implementation, we had a dramatic reduction in infection rates."

For some of the units that didn't show reductions, reasons for poor compliance are being pinpointed. For instance, one of the recommendations is to wean the patient off the ventilator more quickly to reduce risk. It was discovered that an attending physician was concerned about stroke patients being weaned off too soon, and as a result of this concern, the unit was resistant to the whole initiative.

At University of California Irvine, the following interventions were implemented to reduce VAP:

  • Improved mouth care for patients on ventilators, including increased frequency of cleaning and use of chlorhexadine;
  • All the measures included in the IHI "VAP Bundle" (elevation of the head of the bed, peptic ulcer disease, and deep venous thrombosis prophylaxis, daily "sedation vacations," and assessment of readiness to extubate);
  • Participation in the California Assessment and Reporting Taskforce, which measures compliance with these VAP prevention processes;
  • Measuring rates of VAP in all critical care units, with data fed back to clinicians and administration.

As an active participant in the Surgical Care Improvement Project initiative, Asheville, NC-based Mission Hospitals is now moving beyond the recommended smaller subpopulations to a housewide approach. "We are actively applying preoperative glucose and hypertension screening, normothermia management, and hair removal using clippers and venous thromboembolism prophylaxis," says Tom Knoebber, director of performance." After implementing VAP and central line protocols, one of the hospital's ICUs has had zero VAPs for 190 days.

OSF Saint Francis Medical Center implemented a VAP bundle, which includes frequent oral hygiene, in-line suctioning, and elevation of the head of the bed unless medically contraindicated. Additionally, a "wean team" was created, staffed with two nurse practitioners and a respiratory therapist. "This team can be consulted by the attending physician to oversee the weaning and respiratory management of complex respiratory patients," says Patricia Ham, RN, MS, CIC, manager of epidemiology and infection prevention and control. "During daily rounds, the need for the central line is assessed, and the catheter is discontinued at the earliest opportunity."