Central Venous Lines Pose High Risk for Infection
Abstract & Commentary
By Jacob Ufberg, MD Dr. Ufberg is Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Temple University School of Medicine, Philadelphia Dr. Ufberg reports that he is a researcher for Pfizer Pharmaceuticals.
Source: Centers for Disease Control and Prevention. Reduction in central line-associated bloodstream infections among patients in intensive care units- Pennsylvania, April 2001-March 2005. MMWR 2005;54;1013-1016.
Central line-associated bloodstream infection (BSI) is the third most common nosocomial infection reported from the medical/surgical intensive care unit (ICU) setting (after ventilator-associated pneumonia and catheter-associated urinary tract infection). Approximately 250,000 central line-associated BSIs occur annually in the United States. These lead to an estimated mortality of 12-25% and a marginal cost of $25,000 to the health care system for each infection. In 2001, the Pittsburgh Regional Healthcare Initiative (PRHI) invited the Centers for Disease Control and Prevention (CDC) to assist in a hospital-based program to prevent central line-associated BSIs among ICU patients in the region.
In 2000, PRHI formed a committee of infection-control experts to develop an infection-control intervention, targeting the elimination of central line-associated BSIs in ICUs in the region. The intervention consisted of five components: 1) promotion of evidence-based catheter insertion practices (such as the use of maximum sterile barrier precautions during insertion, use of chlorhexidine for skin preparation, avoidance of femoral catheters, use of recommended dressing practices, and removal of catheters when no longer needed); 2) development of an educational program; 3) development of standardized tools for documenting catheter insertion practices; 4) promotion of a standardized list of contents for insertion kits that included all supplies necessary to follow recommended insertion practices; and 5) measurement of central line-associated BSIs and confidential quarterly reporting of data.
To assess the effect of the intervention on the rate of BSIs, hospitals collected data on central line-associated BSIs using standardized definitions and methods during a four-year period. Thirty-two hospitals in 10 counties participated. The median number of beds in participating hospitals was 215 (range 27-796 beds). A total of 66 ICUs were included in the analysis, of which 48% were medical/surgical, 11% cardiothoracic, 14% coronary, 9% surgical, 6% neurosurgical, 5% trauma, 3% medical, 3% burn, and 3% pediatric. During the four-year period, the pooled mean rate of central line-associated BSIs fell from 4.31 to 1.36 per 1000 central line days, a drop of 68%.
Commentary
As the editorial note accompanying this report states, the infection-control practices used in this study are not new. However, it also is noted that adherence to these guidelines remains poor. While it is clear that ICUs should be using standard practices to prevent central line-associated BSIs, it is unclear how this information translates to the ED.
It would be quite easy to implement some of the recommended practices in the ED, such as the use of chlorhexidine rather than an iodine-based scrub for skin preparation. However, some of these guidelines would be quite difficult to implement in the ED, such as avoidance of the femoral insertion site and the use of maximum sterile barrier precautions. Many patients in the ED present in situations that demand the rapid placement of central lines in the femoral vein or that do not allow the time necessary for the use of maximum sterile barrier precautions. In these cases, it is incumbent upon ICU personnel to replace these dirty lines when circumstances permit.
The way I see it, there are two general scenarios: 1) the somewhat stable patient who requires a central venous line due to poor venous access or for some other problem that is not emergent; and 2) the unstable patient who requires immediate central access. In the first scenario, we should do our best to place central lines using evidence-based recommendations such as chlorhexidine preparation, maximum barrier precautions, and avoidance of the femoral site. In the second scenario, we need to continue to do what is necessary to save lives and stabilize patients.
Central line-associated bloodstream infection (BSI) is the third most common nosocomial infection reported from the medical/surgical intensive care unit (ICU) setting (after ventilator-associated pneumonia and catheter-associated urinary tract infection). Approximately 250,000 central line-associated BSIs occur annually in the United States.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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