Multistate programme to reduce catheter-associated infections in intensive care units with elevated infection rates

Abstract

BackgroundPreventing central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) remains challenging in intensive care units (ICUs).ObjectiveThe Agency for Healthcare Research and Quality Safety Program for ICUs aimed to reduce CLABSI and CAUTI in units with elevated rates.MethodsInvited hospitals had at least one adult ICU with elevated CLABSI or CAUTI rates, defined by a positive cumulative attributable difference metric (CAD >0) in the Centers for Disease Control and Prevention’s Targeted Assessment for Prevention strategy. This externally facilitated programme implemented by a national project team and state hospital associations included on-demand video modules and live webinars reviewing a two-tiered approach for implementing key technical and socioadaptive factors to prevent catheter infections, using principles and tools based on the Comprehensive Unit-based Safety Program. CLABSI, CAUTI and catheter use data were collected (preintervention 13 months, intervention 12 months). Multilevel negative binomial models assessed changes in catheter-associated infection rates and catheter use.ResultsOf 366 recruited ICUs from 220 hospitals in 16 states and Puerto Rico for two cohorts, 280 ICUs completed the programme including infection outcome reporting; 274 ICUs had complete outcome data for analyses. Statistically significant reductions in adjusted infection rates were not observed (CLABSI incidence rate ratio (IRR)=0.75, 95% CI 0.52 to 1.08, p=0.13; CAUTI IRR=0.79, 95% CI 0.59 to 1.06, p=0.12). Adjusted central line utilisation (IRR=0.97, 95% CI 0.93 to 1.00, p=0.09) and adjusted urinary catheter utilisation were unchanged (IRR=0.98, 95% CI 0.95 to 1.01, p=0.14).ConclusionThis multistate programme targeted ICUs with elevated catheter infection rates, but yielded no statistically significant reduction in CLABSI, CAUTI or catheter utilisation in the first two of six planned cohorts. Improvements in the interventions based on lessons learnt from these initial cohorts are being applied to subsequent cohorts.

Beyond CLABSI and CAUTI: broadening our vision of patient safety

“…For CLABSI, the incidence rate ratio (IRR) was 0.75, but the 95% CI extended up to an increase of 1.08 (p=0.13). CAUTI showed a similar result: IRR=0.79 but with a CI extending up to 1.06 1. Moreover utilisation for both catheters decreased only marginally and non-significantly.…”

“…Less frequent culturing of blood and urine would give rise to surveillance bias as a cause for some of the reductions in CLABSI and CAUTI reported in past studies, as well as the apparent secular improvements invoked as the basis for ceiling effects in the study by Meddings et al 1. Various studies have identified important differences in the detection, documentation and reporting of CLABSIs between centres 14–16.…”

“…Why would an intervention for CAUTI modelled after one which has apparently worked so well for CLABSI in ICUs2 6 work only outside ICUs? This unexpected result, along with the fact that, even in the seemingly more successful CLABSI project2 a substantial proportion of ICUs did not improve, led to the national collaborative now reported by Meddings et al 1…”

“…In this issue of BMJ Quality & Safety , Meddings et al 1 report the evaluation of a national effort to reduce two well-known safety targets, central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). The paper’s introduction helpfully informs readers of the context.…”

Identifying adverse events: reflections on an imperfect gold standard after 20 years of patient safety research

“…Computerised provider order entry may prevent some adverse drug events at the ordering stage, but it will do little to reduce harms arising at the stages of dispensing or medication administration. Similarly, hospital acquired infections include central line associated bloodstream infections,38 39 catheter-associated urinary tract infections,40–42 C. difficile 42 and so on, each with different interventions to reduce these events. So, the AE rate at a given hospital at a given time represents a composite comprising a very long list of distinct event types, ranging from common to very infrequent harms, and with very different potentials for improvement from a given safety intervention or even multiple interventions.…”