Hospital Targets, Reduces Central-Line Infection Rate

The physicians, nurses, and other clinical staffers at Tacoma (Wash.) General Hospital aren't sweating the new Joint Commission on Accreditation of Healthcare Organizations' requirements on central line-associated bloodstream infections that are scheduled to be phased in throughout 2009.

They have already implemented a central-line protocol that has brought their hospital's infection rate down to virtually zero over the last few years.

“Rather than accepting a certain rate of infections, we adopted the position that they should never happen,” said Dr. James R. Taylor, medical director of the adult intensive care unit at Tacoma General Hospital and the hospital's physician champion on reducing central-line infections.

In 2005, he began educating physicians and nurses in his ICU about a bundle of measures for reducing central-line infections that he learned about as part of the TICU (Transformation of the ICU) project, a program from the national health care alliance VHA Inc.

Before implementing the central-line protocol, Tacoma General Hospital had an infection rate of about 1.5–2.0 infections per 1,000 central-line days, which was better than the national benchmark set by the Centers for Disease Control and Prevention. Since 2005, the hospital's central line-associated infection rate has been even lower. There were no infections in the adult ICU at Tacoma General Hospital for all of 2006 and 2007, said Marcia Patrick, R.N., director of infection prevention and control for MultiCare Health System, which operates Tacoma General Hospital and three other hospitals in the area.

“It's a whole change in mind-set to zero tolerance,” Ms. Patrick said.

Based on the success in the ICU, the hospital generalized the process to the emergency department, operating rooms, and anywhere else central-line placement was being performed.

The protocol is surprisingly simple, Dr. Taylor said. The main elements are proper hand hygiene, the use of chlorhexidine-based antiseptic for skin preparation, the use of a sterile drape to cover the whole patient, the placement of the line in those locations shown to have lower infection rates, and the removal of the catheter as soon as possible.

The key is to make it easy to follow the measures and difficult to do things the wrong way, Dr. Taylor said. For example, the hospital decided to remove from its line carts anything that might contribute to improper line placement, and to include only those materials that would aid in proper line placement.

Another element of the hospital's success has been empowering the nurses to speak up, Dr. Taylor said. Under the protocol, if a physician breaks sterile technique during the line placement, the nurses are required to step in and ask the physician to stop and start over. The hospital also created a checklist for the nurses to record that all the proper steps in the line placement were performed.

“It's pretty simple stuff, but when you do it in every line placement, the infections go away,” Dr. Taylor said.