A Performance Improvement Initiative to Determine the Impact of Increasing the Time Interval Between Changing Centrally Placed Intravascular Catheters

Abstract

Existing practice guidelines designed to minimize invasive catheter infections and insertion-related complications in general intensive care unit patients are difficult to apply to the burn population. Burn-specific guidelines for optimal frequency for catheter exchange do not exist, and great variation exists among institutions. Previously, the authors' practice was to follow a new site insertion at 48 hours by an exchange over a guidewire, which was followed 48 hours later by a second guidewire exchange (48h group). As a performance improvement initiative, the authors attempted to determine whether there would be any advantage or disadvantage to extending these intervals to 72 hours (72h). All patients with centrally placed intravascular catheters from October 2007 to August 2008 were included in the 48h group, and all patients with catheters placed from September 2008 to December 2009 comprised the 72h group. Catheter infection rates were determined using the National Healthcare Safety Network definition for central line-associated bloodstream infections (CLABSIs) and calculated as CLABSIs/1000 catheter days. The two groups were not significantly different for age, sex, burn etiology, total burn size, or percent third-degree burn. There were 3.1 CLABSIs/1000 catheter days for the 48h group and 2.8 CLABSIs/1000 catheter days for the 72h group (NS). The authors conclude that increasing the central catheter change interval from 48 to 72 hours did not result in any increase in their CLABSI rate. Implementation of this change in practice is expected to decrease supply costs by $28,000 annually in addition to reducing clinical support services needed to perform these procedures.

Update on Severe Burn Management for the Intensivist

“…Kagan and colleagues demonstrated no increase in CRBSI with an increase in exchange interval from 48 to 72 hours in a pediatric population. 44 This contrasts King et al’s findings showing an increase in bacteremia rate from 4% to 12%, with an increase in exchange interval from 3 to 4 days. 47 In an abstract presented at the 2006 ABA, Lozano and colleagues reported that in burns, the application of Centers for Disease Control Guidelines recommending against routine catheter exchange except in the setting of suspected infection resulted in a significantly higher rate of CRBSI compared to routine exchange every 5 days (9.36 CRBSI compared to 3.23 CRBSI/1000 catheter days; P = .017).…”

“…[27][28][29] The incidence of bacteremia in critically ill, adult patients with burn was 4% (99 of 2364 admissions) in an 11-year retrospective review. 44 Staphylococcus aureus is the most frequently identified organism in patients with bacteremia followed by Pseudomonas aeruginosa in North American burn centers. 45,46 Other common organisms include Klebsiella, Escherichia coli, Enterococcus, and Acinetobacter species.…”

Economic Evaluation of Quality Improvement Interventions for Bloodstream Infections Related to Central Catheters

“…We identified 505 records, selecting 63 for full-text review; 16 articles met all eligibility criteria, reflecting 15 unique studies. [27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42] Eleven articles focused on CLABSI [27][28][29]32,33,36,37,[39][40][41][42] , and 5 on CRBSI. 30,31,34,35,38 Two articles drew from a study on CLABSI and ventilator-associated pneumonia; we focused on a cost analysis from the hospital perspective, 40 rather than a cost-effectiveness analysis from the societal perspective.…”

Bacterial Infections After Burn Injuries: Impact of Multidrug Resistance

“…The number of catheter-related bloodstream infections (defined as those bacteremias in which the causative organism was also grown from a catheter segment culture) increased from 0.18 per patient in the every 3rd day historical control group to 1.18 per patient in the every 4th day group [28]. Another study looked at increasing time between line exchanges from every 48 hours to every 72 hours and found no increase in rates of line-related infections [29]. Based on these limited studies, many burn units perform routine line exchanges every 72 hours.…”