Central-line infection study at UPMC supports return to basic prevention methods

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For seriously ill people, the pain of needles is all too familiar. A proven tool that brings some relief involves the insertion of a central line -- a tiny flexible catheter -- usually through a blood vessel in the arm to an area near the heart. Through that tube flow vital fluids and medications to the body for long-term drug therapy and kidney dialysis.

But while a central line can improve outcomes, it also provides a fast lane for bacteria and viruses to travel body-wide, potentially leading to serious and often deadly central-line-associated bloodstream infections.  

The U.S. Centers for Disease Control and Prevention say such infections lead to death in 12 to 25 percent of patients who become infected, while a recent study published in the Journal of the American Medical Association lists the average treatment cost of $46,000.

Since the turn of the century, medical officials have focused ever greater attention on hospital-based infections, including central-line cases, and that conversation continued last weekend during the 41st Annual Conference of the Association for Professionals in Infection Control and Epidemiology in Anaheim, Calif.

The conference featured an abstract explaining how UPMC St. Margaret in Aspinwall resolved a six- to eight-month problem with elevated central-line-associated infection rates after UPMC discontinued use of alcohol-impregnated caps for the catheter ends outside the body (ports), which were credited with keeping central-line infections at zero.

“When we stopped using alcohol-impregnated line caps as part of a system directive, our [infection] rates doubled, and we saw them go as high as 2.27 line infections per 1,000 patient-days,” states the abstract presented at the conference by Jenny Bender, the former infection-prevention nurse at St. Margaret who now serves the same role at UPMC Presbyterian. 

Central-line-associated infection rates per 1,000 patient-catheter days is how infection rates are gauged nationwide. Current national rates for central-line cases is about 0.5 infections per 1,000 catheter days, said infection-prevention expert Peter J. Pronovost, who heads the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine.

The goal nowadays isn’t to try to limit such infections but to prevent them outright, he said. When an infection occurs, it is treated like an outbreak of a serious disease, with a team mobilized to take action, investigate what went wrong with the well-established procedure to prevent central-line-associated infections and to improve procedures to prevent further infections.

“Now most hospitals have a rate of under one -- about 0.50,” Dr. Pronovost said. “Before they said that was impossible. Years ago clinicians were told a different story and said the infections were inevitable. Afterward they told a new story, that these are preventable with the attitude, ’I can do something about it.’

"It’s quite the success story,“ Dr. Pronovost said.

Hospital alert

St. Margaret officials took action to reverse the trend when infections began occurring at a rate of about one a month, beginning in August 2012, the month after UPMC quit using the caps and continuing for six to eight months.

Ms. Bender’s abstract did not blame the UPMC directive for the problem. Instead, she said, the use of alcohol-impregnated caps may have made nurses and medical personnel lax in following recommended procedures to maintain sterile conditions when central lines were inserted and maintained. 

”Sometimes infection control technology, although helpful, can mask clinical practice problems,” her abstract stated. “When our health system discontinued swab caps, we found an opportunity to improve our nursing practice and decreased CLABSIs with basic line care.”

Supporting continued use of the caps, two other abstracts presented during the conference described how hospitals in Loyola, Ill., and Dallas, initiated use of those selfsame alcohol-impregnated caps to reduce infections significantly.

In an emailed statement to the Post-Gazette, Tami Minnier, chief quality officer at UPMC, said the decision to discontinue use of alcohol-impregnated caps for central lines “was not driven by cost, but rather was made after careful consideration of research guidelines showing that they were not necessary to prevent infections and could create a false sense of security.”

"Also, system-wide, we saw no significant decrease in central-line infections while using the caps,“ she stated. ”Considering all those factors, we chose to go back to good, basic nursing practice with a strong emphasis on proper infection prevention. UPMC’s infection rate has not changed as a result and, as Ms. Bender’s study shows, infections can be prevented through proper infection control procedures.“

Preventing central-line-associated bloodstream infections requires a carefully documented procedure of actions to assure sterile insertion and maintenance of the central line, which allows officials to trace the cause when an infection occurs. 

Hands must be washed thoroughly. Nurses must wear sterile masks, caps and medical gowns, with the patient covered by a sterile drape during the line insertion and maintenance process. The entry point must be disinfected prior to insertion with medical dressings used to protect the line-insertion site labeled by the date of application. 

Ports or hubs on the central line, where fluids or medications are introduced into the line, must be scrubbed with disinfectant for 15 seconds each time they are used.

With caps no longer in use and infection rates rising, Ms. Bender said, she initiated a “house-wide” re-education program at St. Margaret to return infection rates to zero. Staff members were given a central-line tool kit, along with pocket cards and postcards describing proper procedures and full-time access to an Internet-based care manual.

“After the roll-out of the toolkit in May 2013, we have seen zero CLABSIs each month through November 2013,” Ms. Bender’s abstract states. “Getting our nurses ’back to basics when it comes to line care was not easy at first, but the numbers speak for themselves.”

The three abstracts presented at the national infection control conference highlight how the infection-prevention field involves sharing information and extolling the idea that every hospital and health-care facility should work to reduce its infection rate to zero.

“For patients with long lengths of stay, maintenance-related issues become very important,” said APIC president Jennie Mayfield last week before the conference. “As these examples demonstrate, each health system needs to review its own data and work as a team with front-line caregivers to tailor interventions that will be successful at their institution,.” 

Prevention campaign

On a snowy night in February 2001, 18-month-old Josie King died of dehydration after a series of mistakes at Johns Hopkins Hospital in Baltimore, leading Dr. Pronovost and hospital officials to assure her parents of his commitment to reduce illnesses and deaths caused by hospital errors.

At that time, the CDC reported 2 million infections and 90,000 deaths annually from hospital infections, with central-line-associated infections representing the most deadly and the third most common health-care-associated infections (behind ventilator-associated pneumonia and catheter-associated urinary tract infections). At that time, central-line infections were responsible for 30,000 deaths a year, comparable to the death toll of breast or prostate cancers.

Since that snowy night, Dr. Pronovost has led the charge in turning a fairly common infection, thought to be inevitable, into a fairly rare occurrence.

Initially changes were made at Johns Hopkins, then expanded to Baltimore area hospitals and beyond, eventually leading to an initiative to use his Comprehensive Unit-based Safety Program, or CUSP, to improve the culture or prevention in medical facilities and learn from mistakes.

The program included using a checklist to confirm that each procedure was followed, along with a philosophy that infections were wholly preventable. 

Southwestern Pennsylvania played an important role in testing early protocols to help reduce hospital-associated infections nationwide. 

From April 2001 to March 2005, a CDC-initiated program reduced central-line infections by 68 percent -- from 4.31 to 1.36 infections for every 1,000 central-line patient days -- among intensive-care-unit patients in 32 hospitals in 10 counties of southwestern Pennsylvania.

“The results suggest that a coordinated, multi-institutional infection-control initiative might be an effective approach to reducing health-care-associated infections,” the CDC reported in 2005.

Dr. Pronovost eventually tested his program in Michigan hospitals, which provided overwhelming evidence that the program worked, with a median infection rate statewide at zero, meaning that a majority of hospitals recorded no infections. 

“In 2009 alone, an estimated 25,000 fewer CLABSI occurred in U.S. intensive care units than in 2001, a 58-percent reduction,” the CDC stated in a 2011 report, noting up to 6,000 lives saved with up to $1.8 billion in health-care savings since 2001.

A 2011 follow-up report noted that 5 percent of hospitalized patients developed health-care-associated infections, with central-line infection totals nationwide dropping from 43,000 in 2001 to 18,000 in 2009. That reduction meant 6,000 lives were saved along with health-care cost savings of $1.8 billion. 

In 2012, Pennsylvania hospitals reported 1,474 total central-line infections statewide. 

"Pennsylvania did amazingly well in the program and UPMC did great work on its own,” Dr. Pronovost said. “It worked with the whole state, which saw great improvements.”









David Templeton: dtempleton@post-gazette.com or 412-263-1578.

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