Two billion dollars is a lot of money. It's approximately the amount spent on disaster relief efforts in Haiti and Pakistan last year. It's also, according to some estimates, what the U.S. health care system spends treating catheter-associated bloodstream infections (CA-BSI) every year.
The cost of caring for a single infection ranges from $34,000 to $56,000. Combine that with an average intensive-care infection rate of 5.3 per 1,000 catheter days, and you get a cost of $296 million to $2.3 billion for this potentially avoidable condition, according to Emil P. Paganini, FACP, senior consultant in critical care nephrology for the Cleveland Clinic Foundation.
“This is one of the reasons why CMS and others have focused on catheter-induced nosocomial infections and have, in fact, said that they may not pay for consequences that are related to the infections, which then makes it mandatory for us clinicians to identify the areas that can be improved,” Dr. Paganini told attendees at the annual meeting of the American Society of Nephrology, held in Denver in November.
Dr. Paganini described a number of those areas during the session he led on reducing nosocomial infections in patients with catheters. He particularly focused on central venous catheters, as they have been found to pose the greatest risk. “While peripheral catheters may be a source of infection, central venous catheters are associated with very serious infection,” he said.
The role of the clinician
Another factor strongly associated with infection rates is the clinician who places the catheter. The less experienced the person, the more the infections, said Dr. Paganini, suggesting it might be time to rethink the “See one, do one, teach one” model so that clinicians have more time to hone their technique. Simulator-based training programs can be helpful for refining skills, as long as they stress catheter placement, he added.
To focus staff attention on the issue, some hospitals track infections back to whomever placed the catheter and score physicians and students based on those outcomes, Dr. Paganini said.
Training of nurses, as well as physicians, is also important to good catheter care. Undertrained or overworked nurses will have more catheter infections. “If there are not enough nurses, catheter care will be the first to be let go,” Dr. Paganini said.
If the catheter is to be used for dialysis, even more expertise is required. There's been some debate about whether triple-lumen catheters are appropriate for dialysis patients, or dialysis access should be separated, Dr. Paganini noted. While multiple lumens could reduce the need for central catheters, the other uses of the catheter could increase infection risk. “We, and others, felt that the dialysis catheter should be used only by those who are performing the dialytic interventions, whether it be the dialysis nurse or the ICU nurse,” he concluded.
Location, location, location
Another tough decision and area of debate is the location of the catheter. “You hear much about femorals being avoided and it's probably true. There is a density of skin flora,” said Dr. Paganini. Femoral catheters were associated with more bacteria colonization, but had similar bloodstream infection rates to subclavian catheters, in an August 2001 study published in the Journal of the American Medical Association. However, multivariate analyses in other studies have shown increased bloodstream infections associated with femoral and internal jugular catheters compared to subclavians, Dr. Paganini reported.
Infection-wise, subclavian catheters appear to be the best option, but they pose other concerns, including the risk of subclavian vein stenosis and potential insertion complications. If the choice is between a femoral and internal jugular (IJ) catheter, the patient's body mass should be considered. “The heavier (over 28.4 BMI) or thinner (under 24.2) the patient, the more that IJs are associated with colonization,” said Dr. Paganini.
Another major determinant of whether patients become infected is the hygiene precautions that are taken at insertion. Not only should hands be washed, but maximal sterile precautions should be taken, including cap, mask, sterile gown, gloves and large sterile drapes, Dr. Paganini advised.
Implementing a catheter care protocol
Hygiene precautions can be a component of a hospital's catheter care protocol, the implementation of which research has shown to be an effective means of reducing infections. A study in a Virginia intensive care unit, published in the American Journal of Surgery in December 2009, found that protocol-based care reduced CA-BSI rates to 7.7 per 1,000 days compared to 16.5 in a control group.
“This is just putting a protocol in place and following the protocol—nothing magic about it,” said Dr. Paganini. “There are written protocols which can be developed in your hospital which address catheter insertion: how to prepare the equipment, the type of skin antisepsis, insertion techniques, what to do and what not to do.”
He offered additional advice that could be used in shaping a catheter protocol:
- If you're putting an urgent catheter in, it should come out as soon as the patient stabilizes, and a new catheter should be placed;
- Extraluminal coatings do appear to reduce infection risk, but the second generation of coated catheters with intra- and extraluminal coating don't offer any additional benefit;
- Catheter covers of minocycline/rifampin reduce colonization and infection, but ionic silver doesn't;
- There's no need to routinely replace catheters, because it doesn't reduce infections, and when done over a guidewire may actually increase them;
- However, administration sets should be replaced at 72-hour intervals, or more frequently when fluids that enhance growth, such as lipid emulsions or blood products, are being infused;
- “Needleless systems, which many of our hospitals are going to, are fine except when those entry points are not changed to manufacturers' specifications,” said Dr. Paganini. After multiple uses, the points can become infected;
- Tunneling appears to be worthwhile for non-subclavian catheters that are expected to stay in for a week or longer; and
- Systemic antibiotic prophylaxis only encourages the emergence of resistant organisms, but antibiotic ointments are important, especially for dialysis catheters.
And finally, “The single most important issue for decreasing nosocomial infections is adequate hygiene,” Dr. Paganini reminded his audience. “It's nothing you don't already know.”