Reduction of central line infections in Veterans Administration intensive care units: An observational cohort using a central infrastructure to support learning and improvement

Abstract

Background: Elimination of hospital-acquired infections is an important patient safety goal. Setting: All 174 medical, cardiac, surgical and mixed Veterans Administration (VA) intensive care units (ICUs). Intervention: A centralised infrastructure (Inpatient Evaluation Center (IPEC)) supported the practice bundle implementation (handwashing, maximal barriers, chlorhexidinegluconate site disinfection, avoidance of femoral catheterisation and timely removal) to reduce central line-associated bloodstream infections (CLABSI). Support included recruiting leadership, benchmarked feedback, learning tools and selective mentoring. Data collection: Sites recorded the number of CLABSI, line days and audit results of bundle compliance on a secure website. Analysis: CLABSI rates between years were compared with incidence rate ratios (IRRs) from a Poisson regression and with National Healthcare Safety Network referent rates (standardised infection ratio (SIR)). Pearson's correlation coefficient compared bundle adherence with CLABSI rates. Semi-structured interviews with teams struggling to reduce CLABSI identified common themes. Results: From 2006 to 2009, CLABSI rates fell (3.8-1.8/ 1000 line days; p<0.01); as did IRR (2007; 0.83 (95% CI 0.73 to 0.94), 2008; 0.65 (95% CI 0.56 to 0.76), 2009; 0.47 (95% CI 0.40 to 0.55)). Bundle adherence and CLABSI rates showed strong correlation (r=0.81). VA CLABSI SIR, January to June 2009, was 0.76 (95% CI 0.69 to 0.90), and for all FY2009 0.88 (95% CI 0.80 to 0.97). Struggling sites lacked a functional team, forcing functions and feedback systems. Conclusion: Capitalising on a large healthcare system, VA IPEC used strategies applicable to non-federal healthcare systems and communities. Such tactics included measurement through information technology, leadership, learning tools and mentoring.