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Remington L, Faraklas I, Gauthier K, et al. Assessment of a Central Line–Associated Bloodstream Infection Prevention Program in a Burn-Trauma Intensive Care Unit. JAMA Surg. 2016;151(5):485–486. doi:10.1001/jamasurg.2015.4445
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Although evidence-based strategies have resulted in a sharp decrease in central line–associated bloodstream infection (CLABSI) rates in recent years, including a zero rate in many intensive care unit (ICU) environments,1,2 burn units continue to have the highest pooled mean rate of CLABSIs (2.9 infections per 1000 central line–days) but only a moderate central line utilization rate (0.47 central line–days per 1000 patient-days).3 The objective of our study was to evaluate a multimodal, multidisciplinary quality improvement project to reduce the number of CLABSIs in a dedicated burn-trauma ICU (BTICU).
A multidisciplinary committee in our 15-bed BTICU convened to synthesize evidence-based interventions into a multimodal, multidisciplinary CLABSI bundle (Figure). Hospital epidemiology staff monitored and reported CLABSIs as defined by the Centers for Disease Control and Prevention’s National Healthcare Safety Network.4
A before-after intervention review included patients with central venous access during the period from April 1, 2011, to March 31, 2015. The institutional review board of the University of Utah declared this review exempt, and so informed consent was not obtained because the data were deidentified. The data collected included patient demographics, number of central lines, number of central line–days, and number of CLABSIs. Patients were divided into 2 cohorts: the before-intervention cohort were admitted before October 1, 2013, and the after-intervention cohort were admitted after. The CLABSI rate is reported as the number of CLABSIs per 1000 central line–days and the number of CLABSIs per 1000 patient-days.
The Wilcoxon rank sum test or the t test was used for continuous variables, and the Pearson χ2 test was used for nominal variables. Stata, version 13.0 (StataCorp), was used for all statistical calculations. P = .05 was considered to be statistically significant.
During the 48-month study period, 478 of 1634 possible patients received at least 1 central line during their hospital stay, resulting in 7798 line-days. We found no significant differences in patient demographics between the patients in the before-intervention cohort and the patients in the after-intervention cohort (Table 1). The median number of patient-days increased significantly from before to after intervention (335 vs 390 patient-days per month; P = .002) owing to BTICU expansion from 9 to 15 beds in July 2013. The median number of central line–days decreased significantly from before to after intervention (168 vs 132 central line–days; P = .03), and the median central line utilization rate decreased significantly from before to after intervention (0.57 vs 0.34 central line–days per 1000 patient-days; P < .001). Blood cultures were obtained at a similar rate between the 2 time periods, with a trend toward more blood cultures being obtained after rather than before intervention (56 vs 79 blood cultures per 1000 central line–days; P = .08).
After the intervention, there were no CLABSIs (P = .02), and this has continued beyond the review period for 23 months total. There were a total of 11 CLABSIs (1.2 infections per 1000 central line–days) before the intervention (Table 2). Our analysis showed no significant correlation between central line–days and rate of CLABSIs (P = .95, determined by the Pearson χ2 test).
Burn ICUs have been plagued by higher rates of nosocomial infections and associated complications than other ICUs, and CLABSIs have been an important contributor to those rates.4 Since the implementation of a multidisciplinary and multimodal CLABSI bundle customized to our BTICU, we have had no CLABSIs. We also have significantly reduced the number of central line–days, likely owing to the daily assessment of the need for central access, with a simultaneous increase in the total number of patient-days and no decrease in the frequency of blood cultures. We did not collect data on anatomic site of catheter insertion because our longstanding practice has been to optimize the catheter’s distance from burn wound, and this did not change during the review period.5
Because of the multimodal nature of our intervention, we are unable to isolate a single measure that resulted in our zero CLABSI rate since September 2013. Our CLABSI bundle has been successful for our center and can be used as a foundation for other burn centers and ICUs to develop similar protocols. The implementation of a multimodal, multidisciplinary CLABSI bundle transformed a burn ICU that was performing better than national norms for CLABSI rates to one with a zero CLABSI rate.
Corresponding Author: Amalia Cochran, MD, Burn-Trauma ICU, Department of Surgery, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132 (firstname.lastname@example.org).
Published Online: December 23, 2015. doi:10.1001/jamasurg.2015.4445.
Author Contributions: Ms Faraklas and Dr Cochran had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Remington, Faraklas, Gauthier, Carper, Wiggins, Cochran.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Remington, Faraklas, Gauthier, Wiggins, Lewis, Cochran.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Remington, Faraklas.
Administrative, technical, or material support: All authors.
Study supervision: Remington, Wiggins, Cochran.
Conflict of Interest Disclosures: None reported.
Disclaimer: Dr Cochran is the Web and Social Media Editor for JAMA Surgery but was not involved in the editorial review or decision to accept the manuscript for publication.
Previous Presentation: This paper was presented at the 47th Annual Meeting of the American Burn Association; April 23, 2015; Chicago, Illinois.