Blue Ribbon Abstract Award: Standardization of the central venous catheter insertion process reduces catheter-associated bloodstream infections in a university hospital medical intensive care unit

ISSUE: Use of central venous catheters (CVC) has been associated with increased incidence of bloodstream infections (BSIs). We set out to decrease the rate of CVC-associated BSI (CVC-BSI) by implementing a multifaceted intervention that included provider education, a standardized insertion checklist, and real-time performance feedback. PROJECT: Our institution defines CVC-BSI using National Nosocomial Infections Surveillance (NNIS) system criteria. During the year prior to the intervention (October 2001 to September 2002), our 14-bed medical intensive care unit (MICU) had a CVC-BSI rate of 7.6/1000 central line days. Based upon published guidelines, a multidisciplinary team developed a mandatory online tutorial and examination for medical and nursing staff. At each CVC insertion or guidewire exchange, the bedside nurse completed a standardized checklist that identified evidence-based insertion behaviors. The checklists were scanned into a computerized database, allowing rapid data entry. Real-time performance feedback reports were generated, and the MICU staff and physicians were provided unit specific data at the start of each month and 3 weeks later to allow resident physicians, who rotate monthly, to review their data and adjust their practice as needed. This collaborative intervention was designed to be educational and not punitive in nature. RESULTS: Following implementation in October 2002, the intervention has been used for 701 CVC insertions. The CVC-BSI rate for lines impacted by this study decreased to a 2004 rate of 1.9/1000 central line days. There have been two periods of greater than 200 days each between CVC-BSI. Positive feedback from this intervention has led to its acceptance and continued use for more than 2 years. MICU is proud of the low BSI rate and works to maintain it. LESSONS LEARNED: Using a standardized intervention aimed at CVC insertion reduces CVC-BSI rates. Development of a successful program requires cooperation and buy-in from physicians as well as nursing staff to effect change. Use of a standardized form provides data for process improvement as well as documentation for the medical record. The observation checklist is available in the electronic medical record. Due to the continued success in the MICU, we started implementing the intervention in all critical care areas in 2004.