The bundle "plus": the effect of a multidisciplinary team approach to eradicate central line-associated bloodstream infections.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) have decreased significantly over the last decade. Further reductions in CLABSI rates should be possible. We describe a multidisciplinary approach to the reduction of CLABSIs. METHODS: This was an observational study of critically ill patients requiring central venous catheters in 8 intensive care units in a tertiary medical center. We implemented a catheter bundle that included hand hygiene, education of providers, chlorhexidine skin preparation, use of maximum barrier precautions, a dedicated line cart, checklist, avoidance of the femoral vein for catheter insertion, chlorhexidine-impregnated dressings, use of anti-infective catheters, and daily consideration of the need for the catheter. Additional measures included root cause analyses of all CLABSIs, creation of a best practice atlas for internal jugular catheters, and enhanced education on blood culture collection. Data were analyzed using the Poisson test and regression. RESULTS: CLABSI, catheter use, and microbiology were tracked from 2004 to 2012. There was a 92% reduction in CLABSIs (95% lower confidence limit: 67.4% reduction, P < 0.0001). Central venous catheter use decreased significantly from 2008 to 2012 (P = 0.032, -151 catheters per year, 95% confidence limits: -277 to -25), whereas peripherally inserted central catheter use increased (P = 0.005, 89 catheters per year, 95% confidence limits: 50 to 127). There was no apparent association between unit-specific Acute Physiology And Chronic Health Evaluation III/IV scores and CLABSI. Three units have not had a CLABSI in more than a year. The most common organism isolated was coagulase-negative staphylococcus. Since the implementation of minocycline/rifampin catheters, no cases of methicillin-resistant Staphylococcus aureus CLABSI have occurred. CONCLUSIONS: The implementation of a standard catheter bundle combined with chlorhexidine dressings, minocycline/rifampin catheters, and other behavioral changes was associated with a sustained reduction in CLABSIs.

Interdisciplinary collaboration: the slogan that must be achieved for models of delivering critical care to be successful.

There is wide acceptance of the concept that interdisciplinary collaboration is an essential building block for successful health-care teams. This belief is grounded in our understanding of how teams function to address complex care needs that change with acute illness or injury. This general agreement has been validated in studies that have reported favorable outcomes associated with successfully implementing interdisciplinary models of health-care delivery in non-critical care settings. The very short time frames over which the care needs of critically ill or injured adults change and the team approach taken by nearly all ICUs strongly suggest that interdisciplinary collaboration is also beneficial in this setting. In this commentary, we define interdisciplinary collaboration and share the story of how we successfully redesigned and transformed our system-wide, interdisciplinary collaborative model for delivering critical care in order to share the lessons we learned as the process evolved with those who are about to embark on a similar challenge. We anticipate that those health-care systems that successfully implement interdisciplinary collaboration will be ahead of the curve in providing high-quality care at as low a cost as possible. Such institutions will also potentially be better positioned for improving teaching and providing a better foundation for critical care research in their institutions.