Decreasing catheter-related infection and hospital costs by continuous quality improvement

Abstract

Objectives: a) To reduce the rate of catheter-related infection, using improved skin preparation and catheters impregnated with silver sulfadiazine and chlorhexidine; b) to decrease the number of unnecessary guidewire exchanges of existing catheters by substituting suspected catheter-related sepsis for fever alone as an indication to change an indwelling catheter; and c) to decrease the hospital costs associated with guidewire exchanges and new catheter insertions.

Design: Sequential, prospective, descriptive studies using a continuous quality management approach.

Setting: A 20-bed trauma intensive care unit at a university teaching hospital.

Patients: Patients (n = 147) admitted from July 1 to December 31, 1992 (phase 1); 34 patients admitted in June and September 1993 (phase 2); and 156 patients admitted between January 1 and June 30, 1994 (phase 3).

Interventions: Phase 1: Proportions of catheter-related infections and catheter-related bacteremia were compared with our prior reported results. Indications for guidewire exchange were analyzed, and the rate of catheter-related infection for each indication was derived. Phase 2: The rate of catheter-related infection was determined for a trial group of triple-lumen catheters impregnated with silver sulfadiazine and chlorhexidine. Phase 3: Four components were altered. Impregnated triple-lumen catheters were used instead of unprotected catheters. Chlorhexidine skin cleanser was substituted for povidone-iodine solution during initial aseptic preparation during catheter insertion and subsequent guidewire exchange. Suspected catheter-related sepsis was substituted for fever as an indication for guidewire exchange. The "safe" period (the time before considering changing a catheter because catheter-related sepsis was suspected) was extended from 2 to 4 days.

Measurements and main results: The overall rate of catheter-related infection in phase 1 was 15% (15% for triple-lumen catheters and 16% for introducers). Catheters changed for site inflammation had a 46% rate of catheter-related infection, significantly higher than for all other indications, including fever (p < .03). The rate of catheter-related infection was significantly (p = .0002) higher for catheters in place for > 10 days compared with lesser durations. Fever was the indication for 42% of all guidewire exchanges. In phase 2, the catheter-related infection rate was 2% (one positive of 48 catheters), significantly (p = .0231) lower than the phase 1 rate. In phase 3, the overall rate of catheter-related infection was 8.6%, significantly (p = .0067) lower than the 15% rate in phase 1. The proportion of protected triple-lumen catheter catheter-related infections decreased significantly (p = .0024) from 15% to 6%. The rate of catheter-related infection for introducers was the same in both phases (p = .33). The days of catheterization for all catheters increased from 4.5 +/- 2.6 to 5.4 +/- 3.6 (p < .0001). The days for triple-lumen catheters increased from 4.7 +/- 2.7 to 7.0 +/- 3.9 (p < .0001). For introducers, there was no difference in the days of catheterization. The proportion of catheters changed for suspected catheter-related sepsis decreased significantly (p < .0001) to 23% from the 42% changed for fever in phase 1. The proportion of catheter-related infections for catheters changed for fever was 18% in phase 1. The proportion of catheter-related infections for catheters changed for suspected catheter-related sepsis was 13% in phase 3 (p = .43). The total number of catheters used per patient in phase 3 was 1.9 +/- 1.4, significantly lower than the 2.6 +/- 2.7 catheters used in phase 1 (p = .0018). The number of triple-lumen catheters decreased from 1.8 +/- 1.2 to 1.0 +/- 1.2 in phase 3 (p = .0001).

Conclusions: Catheters impregnated with silver sulfadiazine and chlorhexidine had a smaller proportion of catheter-related infection compared with unprotected catheters. Fever alone as an indication for guidewire exchange resu