Can hospitals drive their rates of central-line bloodstream infections to zero? Although the goal sounds like a pipe dream, new research has found that multidisciplinary team approaches are making great strides in dramatically reducing rates.

At the University of Massachusetts Memorial Medical Center in Worcester, for example, a team of clinicians dedicated to preventing central-line infections in eight of the hospital’s intensive care units (ICUs) cut the rate by almost 90% over a seven-year period. Similarly, a team effort at the Ohio State University Medical Center in Columbus, decreased infection rates in a 25-bed ICU by roughly 33% in one year. Researchers presented details of the two approaches at the 2012 annual meeting of the Society of Critical Care Medicine (abstracts 583 and 584).

Involving caregivers at all levels and providing frequent, regular feedback on infection rates to hospital staff are two key elements that have made these programs a success, experts said.

Matthias Walz, MD, chief of vascular anesthesiology at UMASS Medical Center, said the guidelines at his facility were developed by a small task force and then approved by the institution’s Critical Care Operations Committee prior to implementation. “From the ICU physicians to the ICU nurses, respiratory therapists, pharmacy team, occupational therapists—everybody is at the table.” Because all disciplines were involved in creating the guidelines, all caregivers feel they have a stake in the process, he said.

Although the landmark study by Peter Pronovost, MD, and colleagues is an example of a success story—a reduction in central-line infection rates of 66% in 18 months (N Engl J Med 2006;355:2725-2732)—the UMASS project is unique for its long follow-up, Dr. Walz said.

Infection rates declined steadily throughout the study period, from 5.86 per 1,000 catheter-days in 2004 to 0.6 per 1,000 in 2011. Studies have shown that although programs can be successful in reducing the number of central-line infections, compliance can drop off over time (Arch Surg 2004;139:131-136). The new study demonstrates a program with stamina.

In the UMASS program, ICUs receive data on their infection rates on a monthly basis, allowing for timely reaction. The program includes elements of the Pronovost study, such as the use of a dedicated catheter cart for supplies, checklists to ensure adherence to infection-control procedures, empowering nurses to halt a procedure if checklist elements are not followed and removal of unnecessary catheters.

Clinicians also rely on a preprocedural time-out, and they use chlorhexidine sponges and catheters impregnated with antibiotics. Re-education is key. “If you don’t continue to re-educate your staff and monitor progress, rates will creep back up again,” Dr. Walz said. In both the UMASS and Ohio State approaches, researchers investigate any identified infections to determine if opportunities to prevent them were missed. At Ohio State, infection rates fell from 2.9 per 1,000 catheter-days in 2009 to 1.95 per 1,000 in 2010. The researchers noted that their data for 2011 were incomplete but appeared to indicate further reductions in infections.

The Ohio State approach includes weekly surveillance of infection rates from its clinical epidemiology unit.“Previously, we would get quarterly data and you would hear that you had three central-line infections, but you wouldn’t hear who the patients were, and you were so far removed from the events that no one could remember what actually happened,” said Mathew Exline, MD, associate director of the ICU at the institution. “Now, you can go to the nurse who drew the blood culture and you can go to the physician who put in the line and ask them questions about the event, because it is still fresh in everyone’s mind.”

Ohio State also incorporates components of the Pronovost study with an emphasis on re-education regarding line insertion and maintenance, the use of daily checklists to increase adherence to guidelines and identifying noncompliance with evidence-based guidelines. “Unless you really have someone who is a champion who says, ‘This is really important, we need to focus on it,’ there are so many things going on in the ICU, that it is easy for the checklist to fall by the wayside,” Dr. Exline said.

Trish Perl, MD, professor of medicine, pathology and epidemiology at Johns Hopkins University, in Baltimore, said the two studies add to the growing evidence that teamwork can reduce central line–related blood infections.“I think the use of teams works so well because there is a lot of wisdom that you can get from individuals with different experiences. For example, my perspective may be very different from somebody who is in the trenches,” Dr. Perl said. And she echoed the importance of having a strong advocate.

“If you have a really good and engaged champion, it makes a lot of difference,” Dr. Perl said. “If people really believe low rates are achievable and it is an expectation and the institution and employees have accountability and hence really facilitate the interventions, it makes a lot of difference.”