‘Matching Michigan’: a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England

Background Bloodstream infections from central venous catheters (CVC-BSIs) increase morbidity and costs in intensive care units (ICUs). Substantial reductions in CVC-BSI rates have been reported using a combination of technical and non-technical interventions. Methods We conducted a 2-year, four-cluster, stepped non-randomised study of technical and non-technical (behavioural) interventions to prevent CVC-BSIs in adult and paediatric ICUs in England. Random-effects Poisson regression modelling was used to compare infection rates. A sample of ICUs participated in data verification. Results Of 223 ICUs in England, 215 (196 adult, 19 paediatric) submitted data on 2479 of 2787 possible months and 147 (66%) provided complete data. The exposure rate was 438 887 (404 252 adult and 34 635 paediatric) CVC-patient days. Over 20 months, 1092 CVC-BSIs were reported. Of these, 884 (81%) were ICU acquired. For adult ICUs, the mean CVC-BSI rate decreased over 20 months from 3.7 in the first cluster to 1.48 CVC-BSIs/1000 CVC-patient days (p<0.0001) for all clusters combined, and for paediatric ICUs from 5.65 to 2.89 (p=0.625). The trend for infection rate reduction did not accelerate following interventions training. CVC utilisation rates remained stable. Pre-ICU infections declined in parallel with ICU-acquired infections. Criterion-referenced case note review showed high agreement between adjudicators (κ 0.706) but wide variation in blood culture sampling rates and CVC utilisation. Generic infection control practices varied widely. Conclusions The marked reduction in CVC-BSI rates in English ICUs found in this study is likely part of a wider secular trend for a system-wide improvement in healthcare-associated infections. Opportunities exist for greater harmonisation of infection control practices. Future studies should investigate causal mechanisms and contextual factors influencing the impact of interventions directed at improving patient care.

[1]  B. Hales,et al.  A multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial. , 2011, JAMA.

[2]  Suzette Woodward,et al.  Patient safety first. , 2013, Nursing management.

[3]  Matthew F. Niedner,et al.  The harder you look, the more you find: Catheter-associated bloodstream infection surveillance variability. , 2010, American journal of infection control.

[4]  MS Timothy P. Hofer MD,et al.  Preventing Hospital-Acquired Infections: A National Survey of Practices Reported by U.S. Hospitals in 2005 and 2009 , 2011, Journal of General Internal Medicine.

[5]  Marin H Kollef,et al.  The effect of an education program on the incidence of central venous catheter-associated bloodstream infection in a medical ICU. , 2004, Chest.

[6]  Ruth Thorlby,et al.  High Quality Care For All , 2008 .

[7]  L. Moret,et al.  Should self-assessment methods be used to measure compliance with handwashing recommendations? A study carried out in a French university hospital. , 2004, American journal of infection control.

[8]  Karla Hemming,et al.  Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase , 2011, BMJ : British Medical Journal.

[9]  Sanjay Saint,et al.  Guidelines for the prevention of intravascular catheter-related infections. , 2011, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[10]  D. Anderson,et al.  Current Definitions of Central Line–Associated Bloodstream Infection Is the Emperor Wearing Clothes? , 2010, Infection Control &#x0026; Hospital Epidemiology.

[11]  G. Scott,et al.  Discrepancy between self-reported and observed hand hygiene behaviour in healthcare professionals. , 2006, The Journal of hospital infection.

[12]  Jeanne E. Zack,et al.  Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit , 2002, Critical care medicine.

[13]  L. Backman,et al.  Validation of the surveillance and reporting of central line-associated bloodstream infection data to a state health department. , 2010, American journal of infection control.

[14]  David C. Anderson,et al.  A cluster-randomized trial to improve stroke care in hospitals , 2010, Neurology.

[15]  N. Thomas.  The health foundation. , 2013, Journal of renal care.

[16]  C. Rey,et al.  Intervention to reduce catheter-related bloodstream infections in a pediatric intensive care unit , 2011, Intensive Care Medicine.

[17]  K. Raghunathan.  Checklists, safety, my culture and me , 2012, BMJ quality & safety.

[18]  E. Wong,et al.  Prevalence of the Use of Central Venous Access Devices Within and Outside of the Intensive Care Unit: Results of a Survey Among Hospitals in the Prevention Epicenter Program of the Centers for Disease Control and Prevention , 2003, Infection Control &#x0026; Hospital Epidemiology.

[19]  Joshua A. Doherty,et al.  Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates. , 2010, JAMA.

[20]  Vital signs: central line-associated blood stream infections--United States, 2001, 2008, and 2009. , 2011, MMWR. Morbidity and mortality weekly report.

[21]  E. Wong,et al.  A Multicenter Intervention to Prevent Catheter-Associated Bloodstream Infections , 2006, Infection Control &#x0026; Hospital Epidemiology.

[22]  Peter J Pronovost,et al.  Explaining Michigan: developing an ex post theory of a quality improvement program. , 2011, The Milbank quarterly.

[23]  K. Shojania,et al.  Refocusing quality measurement to best support quality improvement: local ownership of quality measurement by clinicians , 2012, BMJ quality & safety.

[24]  N. Fishman,et al.  Healthcare Infection Control Practices Advisory Committee , 2012 .

[25]  S. Saint,et al.  Preventing Hospital-Acquired Infections: A National Survey of Practices Reported by U.S. Hospitals in 2005 and 2009 , 2012, Journal of general internal medicine.

[26]  M. McLaws,et al.  Aseptic insertion of central venous lines to reduce bacteraemia , 2011, The Medical journal of Australia.

[27]  D. Buckeridge,et al.  Epidemiology of central line-associated bloodstream infections in Quebec intensive care units: a 6-year review. , 2012, American journal of infection control.

[28]  Eli N. Perencevich,et al.  Central Line Bundle Implementation in US Intensive Care Units and Impact on Bloodstream Infections , 2011, PloS one.

[29]  Chantal Ferguson,et al.  Aseptic insertion of central venous lines to reduce bacteraemia , 2011, The Medical journal of Australia.

[30]  R J Lilford,et al.  An epistemology of patient safety research: a framework for study design and interpretation. Part 4. One size does not fit all , 2008, Quality & Safety in Health Care.

[31]  P. Pronovost,et al.  Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis , 2011, BMJ : British Medical Journal.

[32]  Sheri Chernetsky Tejedor,et al.  Temporary Central Venous Catheter Utilization Patterns in a Large Tertiary Care Center Tracking the “Idle Central Venous Catheter” , 2012, Infection Control &#x0026; Hospital Epidemiology.

[33]  A. Bhutta,et al.  Reduction of bloodstream infections associated with catheters in paediatric intensive care unit: stepwise approach , 2007, BMJ : British Medical Journal.

[34]  S. Hugonnet,et al.  Long-term reduction of vascular access-associated bloodstream infection. , 2005, Annals of internal medicine.

[35]  J. Bion,et al.  Central venous catheter-related bloodstream infections: improving post-insertion catheter care. , 2009, The Journal of hospital infection.

[36]  V. Rosenthal,et al.  Effect of an infection control program using education and performance feedback on rates of intravascular device-associated bloodstream infections in intensive care units in Argentina. , 2003, American journal of infection control.

[37]  R. Gilbert,et al.  Interventions to reduce central venous catheter-associated infections in children: which ones are beneficial? , 2011, Intensive Care Medicine.

[38]  G. Rubenfeld,et al.  Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial. , 2011, American journal of respiratory and critical care medicine.

[39]  T. Cook,et al.  Quasi-experimentation: Design & analysis issues for field settings , 1979 .

[40]  Ingrid M. Nembhard,et al.  National efforts to improve door-to-balloon time results from the Door-to-Balloon Alliance. , 2009, Journal of the American College of Cardiology.

[41]  Marcelo Park,et al.  Impact of an educational program and policy changes on decreasing catheter-associated bloodstream infections in a medical intensive care unit in Brazil. , 2005, American journal of infection control.

[42]  Peter J Pronovost,et al.  Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study , 2010, BMJ : British Medical Journal.

[43]  Jeanne E. Zack,et al.  The impact of bedside behavior on catheter-related bacteremia in the intensive care unit. , 2004, Archives of surgery.

[44]  R J Lilford,et al.  An epistemology of patient safety research: a framework for study design and interpretation. Part 2. Study design , 2008, Quality & Safety in Health Care.

[45]  U. Bauer,et al.  [Centers for Disease Control and Prevention (CDC)]. , 2000, Annales de dermatologie et de venereologie.

[46]  R. Hyman.  Quasi-Experimentation: Design and Analysis Issues for Field Settings (Book) , 1982 .

[47]  D. Warren,et al.  Catheter-Associated Bloodstream Infections in General Medical Patients Outside the Intensive Care Unit: A Surveillance Study , 2007, Infection Control &#x0026; Hospital Epidemiology.

[48]  P. Pronovost,et al.  Major cultural-compatibility complex: considerations on cross-cultural dissemination of patient safety programmes , 2012, BMJ quality & safety.

[49]  P. Pronovost,et al.  An intervention to decrease catheter-related bloodstream infections in the ICU. , 2006, The New England journal of medicine.

[50]  Stephen E. Muething,et al.  Decreasing PICU Catheter-Associated Bloodstream Infections: NACHRI's Quality Transformation Efforts , 2010, Pediatrics.

[51]  D. Pittet,et al.  Hospital-wide survey of the use of central venous catheters. , 2011, The Journal of hospital infection.

[52]  S J Henly,et al.  Understanding adherence to hand hygiene recommendations: the theory of planned behavior. , 2001, American journal of infection control.

[53]  A. Matlow,et al.  Defining bloodstream infections related to central venous catheters in patients with cancer: a systematic review. , 2011, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[54]  Sanjay Saint,et al.  Guidelines for the prevention of intravascular catheter-related infections. , 2002, American journal of infection control.

[55]  Anne E Sales,et al.  Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement , 2011, Quality and Safety in Health Care.

[56]  Dionne A. Graham,et al.  Systematic Intervention to Reduce Central Line–Associated Bloodstream Infection Rates in a Pediatric Cardiac Intensive Care Unit , 2008, Pediatrics.

[57]  J. Marschall.  Catheter-associated bloodstream infections: looking outside of the ICU. , 2008, American journal of infection control.

[58]  M. Bizzarro,et al.  Prevention of central line associated bloodstream infections in critical care units , 2011, Current opinion in pediatrics.

[59]  D. Warren,et al.  Peripherally Inserted Central Venous Catheter–Associated Bloodstream Infections in Hospitalized Adult Patients , 2011, Infection Control &#x0026; Hospital Epidemiology.