Central-line infections declining, CDC reports
■ Hospitals showed 18% fewer infections than expected. This comes as more than 600 hospitals joined a checklist initiative.
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More than 1,500 hospitals in 17 states reported 18% fewer central-line associated bloodstream infections than projected, according to a first-ever state-specific infection report released in May by the Centers for Disease Control and Prevention.
Infection-control professionals said the CDC data suggest that physicians and nurses at hospitals are using checklists to better implement guideline-based care and prevent bloodstream infections that kill an estimated 31,000 Americans each year.
"This progress is being led by that process of using checklists; I think it deserves a lot of credit," said Stephen A. Streed, a board member of the Assn. for Professionals in Infection Control and Epidemiology Inc., representing more than 13,000 members who run infection-control programs.
"When you have a checklist that you follow every single day, every member of the care team is responsible for compliance and meeting those checklists," said Streed, system director of epidemiology and infection prevention at Lee Memorial Health System in Fort Myers, Fla. "The checklist has demonstrated that if you do these things that are evidence-based and do them consistently, you'll have lower infection rates."
This report comes as 33 states and more than 600 hospitals are actively participating in a federally funded quality initiative called On the CUSP: Stop BSI. The project seeks to build on the success in Michigan, where intensive care units at more than 100 hospitals cut their median central-line infection rate to zero, compared with a national average of 5.2 per 1,000 catheter days.
Evidence on how to prevent bloodstream infections has long been established. The challenge has been to consistently apply that evidence. The guidelines urge physicians and nurses to wash their hands, use full-barrier precautions when inserting central venous catheters, clean the skin with chlorhexidine, avoid the femoral site for insertion and remove any unnecessary catheters.
The new CDC report compares data from hospitals in 17 states that are required by state law to share their infection rates with the agency's National Healthcare Safety Network. The CDC used reports from 2006 to 2008 to project a case-mix-adjusted infection rate.
In the first six months of 2009, hospital intensive care units saw 17% fewer bloodstream infections than projected. Hospital surgical wards experienced a 50% rate reduction. In total, hospitals tallied 1,003 fewer bloodstream infections than had been predicted.
Of the states tracked by the CDC, Vermont's eight hospitals saw the biggest bloodstream infection rate drop of 73% from projections, while Maryland's 48 hospitals experienced a 30% increase.
The CDC said states should not be compared with each other because not all of the state health departments have double-checked, or validated, the data that hospitals report to the agency to ensure that all infections are counted. Rates may "appear elevated" in states such as Maryland, where the validation process has been implemented, the report said.
"The bottom line here is that this 18% reduction shows that care in hospitals is getting safer, but we know there is more work to be done," said Arjun Srinivasan, MD, associate director for Healthcare Associated Infection Prevention Programs in the CDC's Division of Healthcare Quality Promotion.
Aiming for zero
Experts agreed the targeted rate for bloodstream infections should be zero.
"Providing this data is a great first step, and I'm very encouraged that it does demonstrate an 18% reduction," said Neil Fishman, MD, president of the Society for Healthcare Epidemiology of America Inc., which represents more than 1,800 physicians and infection-control specialists. "The goal is elimination of these infections. Can all central-line bloodstream infections be eliminated? I don't know, but I think we need to keep trying."
Dr. Fishman and his colleagues at the Hospital of the University of Pennsylvania in Philadelphia had set a goal to achieve a zero bloodstream infection rate by January 2010. It was a tall order, given that the hospital saw more than 50 central-line infections during each of several months in 2006, said Dr. Fishman, director of the Dept. of Healthcare Epidemiology, Infection Prevention and Control at the University of Pennsylvania Health System.
By January of this year, the hospital recorded one or two bloodstream infections a month. One key was to make it easier for doctors, nurses and other staff to implement evidence-based care, Dr. Fishman said.
"A big barrier to implementing the checklist is if the staff has to go to one place in the hospital to get the chlorhexidine, another place to get the gowns, another place for the drapes and yet another place for sterile kits," he said. "You can't just say, 'Here's a checklist; do it.' You have to make it possible to do it. That takes the support of the administration, and it takes resources to do it."
The CDC said future reports will be issued every six months to track progress at the state level. Twenty-seven states mandate some kind of public reporting of infection rates, but at the time the data were compiled, only 17 required participation in the CDC's surveillance system. Four additional states -- California, Nevada, Texas and West Virginia -- have since enacted laws that mandate reporting to the CDC.
The CDC data are useful because they are derived using scientific methodology, as opposed to imprecise claims data, said Rachel L. Stricof, PhD, director of the Hospital-Acquired Infection Reporting Program at the New York State Dept. of Health.
New York was the first state to require that its hospitals participate in the CDC's National Healthcare Safety Network. Stricof said making infection data public is only the first step to spurring collaborative prevention efforts among physicians, nurses, hospitals and states across the nation.
"It is not enough to count infections," Stricof said. "There is so much more that needs to be done to address the full spectrum of health care-associated infection."
Future reports may include state-specific data on catheter-associated urinary tract infections, surgical-site infections and cases of ventilator-associated pneumonia, the CDC said.
APIC's Streed said hospitals are making progress to reduce infections in these areas, using checklists to make evidence-based care routine.
"We are taking care that may have been fragmented in the past and providing a framework for that care," Streed said. "If that framework is based on science, we have more highly predictable outcomes, and that means less infections."