In your recent article Sebelius talks infections (May 11, p. 10), HHS Secretary Kathleen Sebelius is cited as challenging hospitals to reduce their rates of central-line-associated bloodstream infections, or CLABs, by 75%. While a 75% reduction would certainly represent dramatic improvement, many vascular access experts believe that these infections can be dramatically reduced, close to zero, not just reducedbut only if hospitals take steps beyond the standard protocols.
Essentially, the bacteria that cause CLABs must be stopped at every conceivable entry point, and in every phase of the catheter-line placement, from insertion to line maintenance to removal. The post-insertion phases are particularly crucial because many institutions focus their preventive efforts primarily on catheter insertion, ignoring the fact that antiseptic skin preparation for insertion only reduces the bacteria population without eradicating it.
For instance, research has shown that some 20% of skin bacteria hide out in the skin that lines the hair follicles and sebaceous glands, untouched by surface antisepsis. Within 48 hours after initial skin prep, bacteria can already be repopulating the skin surface.
There is a lack of a foundation of evidence-based knowledge on the part of many healthcare clinicians about how to best maintain and prevent catheter-related complications.
Here are three examples of important evidence-based, but insufficiently deployed, measures that help eliminate CLABs:
- Septum disinfection. Before every catheter access, intravenous connector ports should be cleansed with 70% isopropyl alcohol as recommended by the Centers for Disease Control and Prevention and the recent Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America. Both time and friction are important factors to prevent intraluminal microbial colonization.
- Catheter flushing. All central lines other than dialysis and implanted ports should be flushed with normal saline at least daily and as needed.
- Use of a chlorhexidine-containing sponge dressing. This protective disk secretes chlorhexidine gluconate, the same antiseptic recommended by the CDC for initial skin prep, for seven days and effectively addresses bacteria recolonization. A study published in the March issue of the Journal of the American Medical Association found that the dressing reduced CLABs by 76% in intensive-care-unit patients.
The article also questioned whether the $50 million being provided by HHS for quality improvements in hospitals would buy much improvement in CLAB infection rates. In fact, CLAB prevention is quite cost-effective, given the low cost of prevention and the estimated $34,508 to $56,000 it costs to treat a CLAB. In a report by the Association for Professionals in Infection Control & Epidemiology, Allegheny General Hospital in Pittsburgh was cited as losing an average of $26,839 per CLAB until it undertook a program in 2003 to prevent the infections. The initiative cost $35,000 and ultimately saved $2.2 million.
Nadine NakazawaPresident Association for Vascular Access Herriman, Utah