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.

Associations between hospital occupancy, intensive care unit transfer delay and hospital mortality.

PURPOSE: Hospital occupancy (HospOcc) pressures often lead to longer intensive care unit (ICU) stay after physician recognition of discharge readiness. We evaluated the relationships between HospOcc, extended ICU stay, and patient outcomes. MATERIALS AND METHODS: 7-year retrospective cohort study of 8500 alive discharge encounters from 4 adult ICUs of a tertiary hospital. We estimated associations between i) HospOcc and ICU transfer delay; and ii) ICU transfer delay and hospital mortality. RESULTS: Median (IQR) ICU transfer delay was 4.8 h (1.6-11.7), 1.4% (119) suffered in-hospital death, and 4% (341) were readmitted. HospOcc was non-linearly related with ICU transfer delay, with a spline knot at 80% (mean transfer delay 8.8 h [95% CI: 8.24, 9.38]). Higher HospOcc level above 80% was associated with longer transfer delays, (mean increase 5.4% per % HospOcc increase; 95% CI, 4.7 to 6.1; P < .001). Longer ICU transfer delay was associated with increasing odds of in-hospital death or ICU readmission (odds ratio 1.01 per hour; 95% CI 1.00 to 1.01; P = .04) but not with ICU readmission alone (OR 1.01 per hour; 95% CI 1.00 to 1.01, P = .14). CONCLUSIONS: ICU transfer delay exponentially increased above a threshold hospital occupancy and may be associated with increased hospital mortality.