Central line-associated bloodstream infection (CLABSI) is a preventable complication. In the United States, there are more than 20,000 CLABSI per year, resulting in a cost of about $30,000 per infection. A number of interventions have been employed to decrease the risk of CLABSI. Previous studies have documented the importance of simulation-based training. There is a paucity of literature differentiating insertion- vs maintenance-related infections. Interventions targeted at reducing CLABSI rates could be focused based on this information. We report the impact of a formal curriculum, blending simulation-based training with procedural performance at the bedside, on incidence rates.
Methods:
This is a retrospective study which includes all temporary central venous catheters (CVC), including hemodialysis (HD) catheters, inserted by the procedure team at Jackson Memorial Hospital (JMH), from July 2010 through June 2015. Our blended curricular approach to invasive bedside procedural education encompasses four pillars: simulation-based training; instruction on and the use of real-time ultrasound guidance; a bedside critical skills checklist; and direct trainee supervision by a hospital medicine attending physician. Based on CDC guidelines, the CLABSI rate per 1000 catheter-days was calculated. This was further subdivided by insertion site, patient location (ICU or non-ICU), and catheter type (standard CVC or HD). In an effort to discriminate insertion- from maintenance-related events, a 3 calendar day cutoff was employed. All CLABSIs were determined by infectious disease physicians uninvolved with the study.
Results:
781 catheters were inserted in 673 patients with an overall CLABSI rate of 2.28 per 1000 catheter-days. The incidence trended toward significant difference according to insertion site, (0.71 femoral, 3.99 jugular, 0 subclavian, per 1000 catheter-days; p=0.052), however catheters in the jugular and subclavian veins remained in place longer (femoral, 5 days; jugular and subclavian, 7 days). The difference in catheter type was significant (0 standard CVC, 2.98 HD, per 1000 catheter-days; p=0.048). No difference was seen according to location. Based on our cutoff, the incidence of insertion-related CLABSI was 1 (0.16 per 1000 catheter-days).
Conclusions:
A blended curricular approach (simulation, ultrasound, checklist, supervision) to central venous catheter insertion resulted in a very low rate of CLABSI. All infections noted in our study occurred in hemodialysis catheters. Whether or not the patient was in a critical care setting or not made no difference. Contrary to popular opinion, jugular catheters tended to be more infected, although this may have been confounded by the longer dwell time. Standardized training programs may reduce the overall CLABSI rates, while differentiating insertion from maintenance-related infections can help focus interventions to reduce rates even further, thereby leading to safer patient care.