Use of Central Venous Catheter‐Associated Bloodstream Infection Prevention Practices by U.S. Hospitals: A National Mixed‐Methods Study

Background:

Catheter‐associated bloodstream infection (CA‐BSI) causes significant morbidity and mortality. Yet there are no national data describing the extent to which American hospitals are using proven strategies to prevent CA‐BSI, nor are there data assessing the facilitators of or barriers to using proven preventive practices. We were also curious how a centralized system of health care delivery, such as the type the Department of Veterans Affairs (VA) has, affects the use of preventive practices.

Methods:

We conducted a national mixed‐methods study employing both quantitative and qualitative evaluations. In the initial phase of the study, with a national random sample of nonfederal hospitals with an intensive care unit and more than 50 hospital beds (n = 600), a written survey was mailed to infection control coordinators at these nonfederal hospitals and at all VA medical centers (n = 119). The survey asked about practices to prevent CA‐BSI and other device‐associated infections and about organizational factors that might be associated with implementing these practices. Analyses were weighted to be nationally representative. The qualitative phase of the study consisted of semi‐structured phone interviews with key personnel and site visits to several of the hospitals in order to elucidate factors that either facilitated or prevented the use of such practices.

Results:

The overall survey response rate was 72%. A significantly higher percentage of VA hospitals than non‐VA hospitals reported using maximal sterile barriers (84% vs. 71%, P = .01), chlorhexidine gluconate for insertion‐site antisepsis (91% vs. 69%, P < .001), and a composite approach (62% vs. 44%, P = .003), indicating concurrent use of maximum sterile barriers and chlorhexidine gluconate and avoidance of routine central line changes. Factors facilitating the use of CA‐BSI prevention practices included having a higher safety culture score, participating in an infection prevention collaborative, and practicing in a hospital environment conducive to change coupled with having a champion (often an intensivist). Barriers included cost silos and the presence of organizational “constipators” (mid‐ to high‐level managers who are resistant to change).

Conclusions:

Most hospitals nationwide are using 2 of the most strongly recommended practices to prevent CA‐BSI: maximal sterile barrier precautions and chlorhexidine gluconate. However, fewer than half of non‐VA hospitals are concurrently using 3 widely recommended practices. We identified both facilitators and barriers; one potentially promising strategy to encourage the use of evidence‐based infection prevention practices is infection prevention collaboratives. Ideally, hospitalists — like intensivists — will take a leading role in coordinating infection prevention and patient safety efforts in hospitals.

Author Disclosure:

S. Saint, None; T. Hofer, None; C. Kowalski, None; R. Olmsted, None; C. Kaufman, None; J. Forman, None; J. Banaszak‐Holl, None; S. Krein, None.