Reducing Blood Stream Infections BSI

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Reducing Blood Stream Infections (BSI)

• Peter Pronovost, MD, PhD

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The Problem is Large

• 16,000 CR-BSI in U.S. ICUs annually
• Mortality 18 (0-35)
• Annual deaths 500 - 4,000
• Cost per episode 28,690-56,000
• Annual cost 60 - 460 million
• CDC. MMWR 2002 Heiselman JAMA 1994 Dimick Arch
  Surg 2001

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What is the Evidence?

• Guidelines for the Prevention of Intravascular
  Catheter-Related Infections August 2002.
  www.cdc.gov
• Mermel LA. Prevention of Intravascular
  Catheter-related Infections. Ann Intern Med
  2000132391-402.

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Strategies for Prevention 5 Key Best Practices

• Remove Unnecessary Lines
• Hand Hygiene
• Use of Maximal Barrier Precautions
• Chlorhexidine for Skin Antisepsis
• Avoid femoral lines

MMWR. 200251RR-10
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Hand Hygiene The Evidence

• Since 1977, 7 prospective studies have shown
  that improvement in hand hygiene significantly
  decreases a variety of infectious complications

Larsen. Clin Infect Dis 1999291287-94 Lancet
20003561307-1312
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What are Maximal Barrier Precautions?

• For Provider
• Hands hygiene
• Non-sterile cap and mask
• All hair should be under cap
• Mask should cover nose and mouth tightly
• Sterile gown and gloves
• For the Patient
• Cover patients head and body with a large
  sterile drape

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Maximal Barrier Precautions
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Maximal Barrier Precautions The Evidence
Am J Med 199191(3B)197S-205S Infect Control
Hosp Epidemiol 199415231-8
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Skin Prep Chlorhexidine
Ann Intern Med. 2002136792-801
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Skin Prep Chlorhexidine
Ann Int Med 2002136792-801
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What Site is Best?

• RCT of femoral and SC lines in the ICU
• 145 pts femoral/144 pts SC
• Outcomes
• Higher rate of infectious complications in
  femoral grp 19.8 vs 4.5 (p lt .001)
• Higher rate of thrombotic complications in
  femoral grp 21.5 vs. 1.9 (p lt .001) complete
  thrombosis 6 vs 0
• Similar rates of mechanical complication 17.3
  vs 18.8 (p NS)

JAMA 2001,286700-7
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Our Baseline Compliance With Best Practice

• Two-week observation period
• Physicians unaware of study
• 26 line insertions
• 8 (31) new central venous access
• 18 (69) for catheter exchanges over a wire
• None were emergent

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Our Baseline Compliance With Best Practice

• Providers were compliant with best practice
  during 62 of the observed procedures

National compliance estimated to be 30
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To prevent mistakes

• Create culture of safety
• Improve Processes
• Reduce complexity
• Create independent checks for key processes
• Automate

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Culture

• Training by Hospital epidemiology staff
• Web-based training
• Nurses assist with lines
• Empower nurses to stop line placement

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Improve Process

• Complexity
• Line cart store all equipment in one place
• Redundancy
• Check list

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CR-BSI Checklist

• Before the procedure, did they
• Wash hands
• Sterilize procedure site
• Drape entire patient in a sterile fashion
• During the procedure, did they
• Use sterile gloves, mask and sterile gown
• Maintain a sterile field
• Did all personnel assisting with procedure follow
  the above precautions

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CR-BSI Rate
VAD Policy
Checklist
Line Cart
Daily goals
Empower Nursing
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240 days without a CR-BSIpresent as weeks
without infection
We can eliminate healthcare acquired infections
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Outcome and Cost Impact

• Rate of CR-BSIs fell from 11.3 to 0 /1000
  catheter days.
• Prevented annually (estimated)
• 43 CR-BSIs
• 8 deaths
• 559 ICU days
• Estimated savings to hospital 1,824,447

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Summary

• Re-defining benchmarks
• Ensure patients receive evidence-based
  intervention
• Culture
• Complexity
• Redundancy

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Conclusions

• 5 Evidence-Based Best Practices
• Remove Unnecessary Lines
• Practice Hand Hygiene
• Use Maximal Barrier Precautions
• Apply Chlorhexidine for Skin Antisepsis
• Avoid Femoral Lines

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Interventions to ensure patient receive evidence

• Education partner with HEIC
• Ask Daily if line needed
• Checklist, nurse must be present
• Empower nurses
• Line cart