Nearly half of all hospital patients brought to intensive care units (ICUs) each year need plastic catheters inserted in a major vein to deliver vital medicine or to replenish fluids. These so-called central lines are meant to help save the lives of the critically ill and, in most instances, they do. Yet, catheter-related bloodstream infections (CRBSIs) cause as many as 28,000 deaths per year when lethal pathogens are introduced during insertion or when a septic patient’s own bacteria are able to grow on the catheter line.

Despite a decade of infection surveillance and best-practice guidelines published by the Centers for Disease Control and Prevention (CDC), the incidence of CRBSIs has not diminished. In fact, it’s poised to rise, as increasingly older and sicker people survive illness and injury to recover in ICUs and a growing number of cancer-fighting drugs are infused via central lines.

As part of its 100,000 Lives Campaign aimed at preventing avoidable deaths, the Institute for Healthcare Improvement (IHI) has targeted CRBSIs and five other avoidable problems with proven interventions that reduce mortality and morbidity. 

“CRBSIs are completely preventable when the right procedures are followed,” says Thomas G. Rainey, Director of Critical Care at Suburban Hospital in Bethesda, Maryland, and Chair of IHI’s Collaborative on Reducing Complications from Ventilators and Central Lines in the ICU.  And, says Rainey, “We know exactly what those procedures are.” The problem is that many medical professionals think they are following proper protocols when they really are not. “Our job is to close that gap,” says Rainey.

To do that, the ICU Collaborative advocates the Central Line Bundle, a protocol comprising five essential elements of central line management based on the latest clinical evidence. When implemented as a set of interdependent steps, the Central Line Bundle has been proven to improve clinical outcomes. Thomas Rainey breaks it down:

• Hand Hygiene:  Before inserting a line, practitioners must wash their hands, following prescribed sterilization procedures. “A quick scrub won’t do,” explains Rainey.  “We need the operating-room version.”
• Maximal Barrier Precautions:  Caregivers must wear sterile gloves, gown, and mask and the patient must be completely draped with a sterile sheet. “A few dish-towel sized drapes around the site aren’t enough,” says Rainey. “Two-foot catheters can easily pick up bacteria if they touch a non-sterile surface.”
• Chlorhexidine as Antiseptic:  Because bacteria are killed only in the drying process, chlorhexidine rather than iodine-based solutions must be used to disinfect the site. Because chlorhexidine dries much faster, it reduces the likelihood that the catheter will be inserted before bacteria have died off.
• Appropriate Catheter Site Selection and Post Placement Care:  Placement of the catheter must be carefully considered. Though many physicians have a preferred site for central lines, placement should never be rote, says Rainey. “Head movements can dislodge a line placed in the jugular, yet the femoral vein in the groin can be a pretty dirty area.” Physicians must weigh risks and benefits site by site, patient by patient, to figure out the safest location. Then, once a line has been placed, caregivers must be “scrupulous, even compulsive,” says Rainey, in adhering to the hospital’s standards for site care — for  example, maintaining the cleanliness of all catheter-related parts, such as stopcocks on fluid bags and ports on intravenous tubing.
• Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines:  Patient needs must be reviewed daily, says Rainey and “as soon as you don’t need the line any more, get it out.”

Since the elements of the Central Line Bundle were first formulated in the mid-1990s, they have become the standard in dozens of independent initiatives to reduce central line infections, including state-sponsored efforts in Michigan, New Jersey, and Maryland, and one run by the Veterans Health Administration.

One of the most stunning successes has been at Allegheny General Hospital, a 530-bed tertiary-care teaching hospital in Pittsburgh, Pennsylvania.  In mid-2003, the hospital adopted the goal of completely eradicating central line infections in its medical intensive care and coronary care units. Although CDC guidelines for the placement and management of central lines were already in place, an in-house team of physicians, nurses, and infection-control specialists, plus staff from the Pittsburgh Regional Healthcare Initiative, observed and documented variations in the prescribed process. To investigate infections in real time — rather than retrospectively — a team of physicians was notified of any positive blood culture in a patient with a central line in place who developed a fever, convening at the bedside within hours for intensive analysis of root causes.

Armed with documented data on practice variations as well as detailed first-hand observations on the circumstances of individual infections — data that might not emerge in a later review of medical records — the team was able to formulate a set of precisely-targeted preventative measures. They included a prohibition against rewiring dysfunctional catheters, and removal of all catheters already in place on patients transferred from other hospitals. To support staff members who observed any departures from prescribed procedures, the team empowered nurses to stop the process at any point and, if needed, invoke the support of a “help chain” of superiors, all the way up to the Chair of Medicine.

Results have been impressive. Between July 15, 2003, and June 30, 2004, the rate of central line infections in the Allegheny General intensive care and coronary care units plunged from 10.5 percent to 1.2 percent and the death rate plummeted from 51 percent to 16 percent. In September 2004 the protocol was extended to all five ICUs in the hospital and, as of mid-February 2005, central line infections are down 78 percent hospital-wide.

The key, says Richard Shannon, MD, who directed the effort, and is Chairman of the Department of Medicine at Allegheny General, is “immediate feedback on variance and continuous monitoring.” To produce the best outcomes, he says, the right tools, the right education, and the right expectations have to be built into daily practice. Constant vigilance may sound time-consuming, says Shannon, but once everyone — physicians, nurses, lab workers — knows their responsibilities, “It takes only an extra five or 10 minutes a day.” Despite the staff turnover characteristic of all teaching hospitals, Shannon says the learning curve has been surprisingly flat. “When we first began, I would get at least one call a day asking for advice or intervention. Now it’s barely one a week.”

Encouraged by efforts like Allegheny’s, IHI launched its ICU Collaborative in September 2004. Twenty-five hospitals have committed to a nine-month program aimed at reducing central line infections by at least 50 percent. To help them achieve that goal, IHI is providing three formal Learning Sessions on infection control, periodic conference calls, and a dedicated extranet site for mutual support and information sharing. Interim progress reports help team members identify their strengths and weaknesses, says Kelly McCutcheon Adams, the Collaborative’s Director. “These organizations made a strategic planning decision to eliminate central line infections. We give them extra support to do it.” 

Substantial progress has already been made at Our Lady of Lourdes, an 80-year-old Catholic hospital serving greater Binghamton, New York, with a 300-bed main campus, a primary-care physician network, and two mobile vans for primary care and cancer screenings. The hospital, which has committed to all six interventions in the 100,000 Lives Campaign, created a checklist on which each element of the central line bundle must be ticked off. To encourage compliance, everything needed to successfully insert a central line is packaged together, and nurses are required to observe — and enforce — strict adherence to the guidelines.

It’s working, says Jill Patak, RN, the hospital’s Quality Engineering Specialist. “Our immediate goal was to go at least 90 days without a single infection. We went 166 days until mid-January when we did have one infection in an extremely sick patient. We’re disappointed, but we’ve started the clock again and we expect to beat our previous record.” Patak adds, “Our health system, Ascension Health, is committed to eliminating preventable patient injury and death by 2008. This is the overriding strategy that we are committed to in our continuous effort to keep our patients free from harm in our hospital.”