Maximal barrier precautions, intensivist supervision, and catheter-related bloodstream infections

Introduction

Catheter-related bloodstream infections (CR-BSI) have significant costs. Use of maximal barrier precautions (MBP) may reduce the incidence of CR-BSI. We studied MBP with/without intensivist supervision of residents on CR-BSI incidence.

Methods

We prospectively studied CR-BSI incidence in an ICU following the implementation of MBP (hand washing before line placement, sterile site preparation, draping the entire patient in sterile fashion, use of hat, mask, gloves and gown, maintenance of a sterile field, assistants following the same precautions, and sterile dressing application). The Centers for Disease Control definition of CR-BSI was used. Data were compared with historical controls at the same ICU. Also, independent observers evaluated the procedure for technique break (omitting any conditions listed under MBP). Subsequently, in addition to MBP, all central venous catheters were placed under intensivist supervision. Data analysis included one-tailed z tests for proportions and t tests.

Results

From 1 January 2000 to 31 December 2002 (control period) the CR-BSI incidence was 12.1/1,000 catheter-days. Following implementation of MBP (1 January 2003–31 October 2004) the CR-BSI incidence decreased to 3.5/1,000 catheter-days (19/5,499 catheter-days), P < 0.02; in 85 independently observed line placements using MBP, 7/85 patients had CR-BSI (8.2%). Technique breaks occurred in 34/85 procedures and were associated with six CR-BSI (17.6%); the 51/85 procedures without technique breaks had one infection (1.9%), P < 0.01. Intensivist supervision (11 January 2004 to 30 April 2006), in addition to MBP, further reduced the incidence to 1.5/1,000 catheter-days (7/4,667 catheter-days), P < 0.04.

Conclusion

While MBP can reduce the incidence of CR-BSI, placement of central venous catheters by residents under intensivist supervision can further lower the incidence.