Infection control for the Reduction of Catheter Related Blood Stream Infection ( CRBSI )

The Centers for Disease Control and Prevention (CDC) of the United States of America has provided evidence-based guidelines for catheter care to reduce Blood Stream Infections (BSI). They refer to recommendations for hand hygiene,5 maximal sterile personnel protection equipment (PPE),6, 7 preferred antiseptics for skin preparation,8, 9 catheter site dressing regimens,10 the site chosen for catheter placement,11, 12 etc. In 2004, our Infection Control Committee set up a project aimed at reducing CRBSI at Bangkok Hospital by using the aforementioned 2002 CDC evidence-based guidelines as a preventive of CRBSI.1


Results
The CRBSI rate is best determined by analyzing rate of infection by BSIs per 1000 catheter-day. 1These rates can be used as benchmarks by individual hospitals to estimate how their rates compare with other institutions.
During January to August 2004, the incidence of CRBSI at the Bangkok Hospital was an average 12 per 1000 catheter-day.
Before the implementation of the new guidelines for prevention of CRBSI, more than 90% of physicians did not use all appropriate personnel protective equipment during central line catheter insertion, for example, only 20% of them used sterile gowns, usually because equipment was not readily available (Table 1).The drapes provided in the central line insertion kit were too small.The disinfectant commonly used was 10% providone-iodine solution and there was no specific system set up to remind nurses when to change dressings or intravenous solution on a timely basis.
After making new central line kits available (Figure 1) and educating physicians on the new protocol, giving nurses the new instructions for aseptic techniques for looking after CVCs and demonstrating how to use a 7 day-color-coded-color sticker (Figure 2) to ensure timely changes of specific intravenous sets and dressings, the incidence rate of CRBSI had reduced to an average 5.9 per 1000 catheter-days during September to December 2004 (Figure 3). Figure 4 shows surveillance compliance for the CVCs project.The performance improved year by year.
The reduction of CRBSI incidence was observed to be sustainable after the new guidelines were implemented in October 2004.Figure 5 shows the surveillance rate of CRBSI from 2004-2010.The rate of CRBSI incidence reduced gradually especially in 2010.It approached to zero per 1000 catheter-day.
-A positive semiquantitative (>15 Colony forming unit (CFU)/catheter segment) or quantitative (>103 CFU/catheter segment) -Culture whereby the same organism is isolated both from the catheter segment and peripheral blood; differential period of CVC culture versus peripheral blood culture positively of > 2 hours.
Target surveillance on CRBSI was conducted in all 4 adult intensive care units at our hospital.The objective was to evaluate the incidence of CRBSI and observe how physicians performed central line insertion, their use of antiseptics, the contents in the central line insertion kit and what the daily care routine for the central line was.Then, the findings were compared with the CDC recommendations.
We set up a multidisciplinary patient-care project team working towards the reduction of CRBSI's.The team's job was in working out how to apply the CDC guidelines to prevent CRBSI in our hospital.For example, Central Supply Service Department (CSSD) was requested to provide ready to use kits for central venous catheter (CVCs) insertion, which included a sterile grown and sterile gloves, a mask, a cap, a large sized sterile drape and a bottle of 2% chlorhexidine gluconate in 70% alcohol for skin preparation, instead of 10% providone iodine solution.
The team also gave workshops on these new implementation regulations to the physicians who were privileged to perform central line insertion.
Instructions were issued to nurses on how to care for CVCs and how to use a 7 day-color-coded-sticker to ensure timely dressing and intravenous solution kits changes.
During follow up, the team also used quality improvement tools such as GAP analysis or Cause and Effect diagrams in order to improve performance in accordance with the new CDC recommendations for CRSBI prevention.

Discussion
Nosocomial infection associated with CRBSI is now a major concern in Modern Medicine.[3] In the USA, there are an estimated 250,000 cases of CRBSI annually; attributed mortality is estimated to be 12-15% for each infection, with a cost to the health-care system $25,000 cases per episode. 1 Danchaivijitr et al 13 showed that in Thailand, about 10% of primary blood stream infections were found to be nosocomial.The CRBSI percentage was shown to be higher in university hospitals (4%) as opposed to general hospitals (0.8%)However, that study didn't analyze BSIs per 1000 catheter-day, (as per official formula for CRBSI rate) so we could not directly compare the prevalence at our medical center to other institutions in Thailand.
The key issues which are so different from previous practices of CVCs insertion and post insertion care include more stringent hand hygiene and aseptic technique during CVCs insertion, with maximal personal protective equipment (PEE), using a larger drape and skin antiseptic with 2% chlorhexidine gluconate in 70% alcohol.
[9] The benefit of using 2% chlohexidine glutconate in 70% Alcohol instead of providone-iodine in preventing catheter-related infections is its superior and rapid skin decontamination. 8,9 ce our project to apply these recommendations from the CDC to reduce CRBSI reduction began in 2004, due to good cooperation from our multidisciplinary team, by 2010 we had succeeded in controlling CRBSI rate to zero rate per 1000 catheter-day.CDC revised their guidelines yet again in 2011. 14he major differences from their 2004 guideline are; 1) Using antiseptic/antibiotic impregnated short-term central venous catheters and chlohexidine impregnated sponge dressing.2) An emphasis on performance improvement by implementing bundled strategies.3) Definition of CRBSI that requires specific laboratory testing.
Since it is often problematic to establish a diagnosis, a simple definition used for surveillance purposes is CRBSI / 1000 catheter-day Mean

CLABSI (Central Line Associated Blood Stream Infection).
A CLABSI is a primary BSI in a patient that had a central line within a 48-hour period and is not blood stream related to an infection at another site.
This year, 2012, our Infection Control Committee will revise the case definition of CRBSI to CLABSI to be in line with CDC's latest guidelines.

Conclusion
Nowadays, all healthcare personnel must take responsibility for preventing nosocomial infections.Our Team has demonstrated that a multidisciplinary team following the CDC guidelines could indeed reduce the infection.In the near future CRBSI may be the first nosocomial infection that can be eliminated from all patient-care areas.

Figure 1 :Figure 2 :
Figure 1: Guideline of the new standard of central venous insertion kit

Figure 3 :
Figure 3: Graph shows Catheter Related Blood Stream Infection Rate of Bangkok Hospital in the year of 2004.

Figure 4 :
Figure 4: Graph shows surveillance compliance for caring central venous catheter project.The performance improved yearly as can be seen.

Table 1 :
Summarized physician's performance during central venous catheter (CVC) insertion compared to the CDC new guidelines for CRBSI prevention.
PPE* = Personnel Protection Equipment