Staff Training

The purpose of the study was to introduce prospective surveillance for nosocomial infections to improve prevention measures and reduce central line-associated blood stream infections (CLABSIs) in patients with hematologic malignancies.

Surveillance was performed for 18 months, after which the incidence rates for CLABSIs were calculated. Ward staff were then presented with the data and trained on measures to reduce CLABSIs according to national and international guidelines. During this time, they also implemented the use of chlorhexidine silver sufadiazine-coated catheters. Surveillance was then conducted for an additional 18 months.

• In total, 268 patients (57% male, 43% female) were included.
• All patients were 18 years or older.
• Patients were undergoing hematopoietic stem cell transplantation (HSCT).
• Patients were studied during neutropenic periods (defined as an absolute white blood count <1x10⁹ cells/L for at least two days).

• Twenty-bed HSCT unit
• The unit had 17 adult beds and 3 pediatric beds, although only adults were included in this study.
• Data from approximately 24 participating national and international centers for bone marrow transplantation from Germany, Switzerland, and Austria were used as a comparator for CLABSI incidence rates.

Active treatment

This was a prospective surveillance (pre/post design) study.

• Incidences (episodes per 100 patients) and incident densities (CLABSIs per 1,000 neutropenic days) were calculated.    
• Incidence densities were compared using the exponential maximum likelihood estimation test.
• Categorical variables were compared using chi-square or Fisher exact test, as appropriate.
• Risk factors were identified using a multivariate analysis with sequential backward stepwise elimination.
   

During the first study period (prior to intervention), CLABSIs occurred at a rate of 24.3 per 1,000 neutropenic days. This rate was notably higher than the median of the comparator group (17.7 per 1,000 neutropenic days) during the same study period. Following intervention, the CLABSI incidence rate dropped to 16.2 per 1,000 neutropenic days, which was below the median of the comparator group (17.7 per 1,000 neutropenic days). The reduction was significant (odds ratio = 0.58; 95% confidence interal [0.34-0.99]).

Strict adherence to hand hygiene and other preventive guidelines when handling central lines in neutropenic patients can have a positive impact on lowering the incidence of CLABSIs.

• The intervention involved educating clinical staff regarding improved preventive measures in handling central lines. The study did not monitor compliance with the new practices, which were multifaceted.  
• The outcome measure of 1,000 neutropenic days did not account for catheter dwell time as the usual CLABSI rate of patient catheter days. In addition to staff training, they also implemented the use of an antimicrobial-impregnated catheter, so it was difficult to determine which of these interventions was truly responsible for the change in results.
   

As part of the intervention, staff education included demonstrating that CLABSI incidence rates at the facility were higher than at comparable centers. This approach provides motivation for changes in nursing practice.

To provide evidence-based recommendations for the prevention of intravascular catheter-related infections for healthcare personnel who insert and care for intravascular catheters and for those responsible for surveillance and infection control in hospital, outpatient, and home health settings. Patients addressed in the guidelines were adult and pediatric patients with intravascular catheters.

The resource is comprised of evidence-based guidelines. For the development process, evidence was categorized as category 1A to category 2 based on strength of recommendation and support from clinical or epidemiological studies.

• Patients were undergoing multiple phases of care.
• The study has clinical applicability for pediatrics. 

The results were not summarized.

The guidelines provided extensive recommendations regarding the education and training of staff; selection of catheters and sites, including avoidance of the femoral vein for central venous access and use of the central venous catheter with the minimum number of ports needed; hand hygiene; use of maximal sterile barrier precautions for insertion; skin preparation with alcohol, iodine, or chlorhexidine; use of standard catheter site dressing regimens; specific aspects of care for umbilical and dialysis catheters; and use of piggybacks, stopcocks, and catheter flushing. Guideline recommendations include a bundling of multiple recommendations: antimicrobial-impregnated catheters and cuffs are recommended in patients with long-term use if the organizational central line-associated blood stream infection (CLABSI) rate is not decreasing despite the implementation of comprehensive strategies for improvement. Lower-level (category II) recommendations include the use of prophylactic antimicrobial lock solutions in patients with long-term catheters who have a history of CLABSIs despite optimal aseptic technique as well as daily cleansing of patients in the intensive care unit with 2% chlorhexidine-impregnated washcloths. Recommends changing IV administration sets no more often than every 96 hours unless used for blood products. For needleless components, recommends changing according to administration set timing as above, and states no benefit to changing more than every 72 hours.

Provides extensive recommendations for management of all types of intravenous catheters and system components. Nurses should refer to the full set of guidelines for all specific aspects of care.