DECREASING CATHETER-RELATED INFECTION AND HOSPITAL COSTS BY CONTINUOUS QUALITY IMPROVEMENT

Objectives: a) To reduce the rate of catheter related infection, using improved skin preparation and catheters impregnated with silver sulfa diazine and chlorhexidine; b) to decrease the number of unnecessary gu idewire exchanges of existing catheters by substituting suspected cath eter-related sepsis for fever alone as an indication to change an indw elling 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 universit y teaching hospital. Patients: Patients (n = 147) admitted from July 1 to December 31, 1992 (phase 1); 34 patients admitted in June and Sept ember 1993 (phase 2); and 156 patients admitted between January 1 and June 30, 1994 (phase 3). Interventions: Phase 1: Proportions of cathet er related infections and catheter-related bacteremia were compared wi th our prior reported results. Indications for guidewire exchange were analyzed, and the rate of catheter-related infection for each indicat ion was derived. Phase 2: The rate of catheter-related infection was d etermined 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 unpro tected catheters. Chlorhexidine skin cleanser was substituted for povi done-iodine solution during initial aseptic preparation during cathete r insertion and subsequent guidewire exchange. Suspected catheter-rela ted sepsis was substituted for fever as an indication for guidewire ex change. The ''safe'' period (the time before considering changing a ca theter because catheter-related sepsis was suspected) was extended fro m 2 to 4 days. Measurements and Main Results: The overall rate of cath eter-related infection in phase 1 was 15% (15% for triple-lumen cathet ers and 16% for introducers). Catheters changed for site inflammation had a 46% rate of catheter related infection, significantly higher tha n for all other indications, including fever (p < .03). The rate of ca theter-related infection was significantly (p = .0002) higher for cath eters in place for >10 days compared with lesser durations. Fever was the indication for 42% of all guidewire exchanges. In phase 2, the cat heter related infection rate was 2% (one positive of 48 catheters), si gnificantly (p = .0231) lower than the phase 1 rate. In phase 3, the o verall rate of catheter-related infection was 8.6%, significantly (p = .0067) lower than the 15% rate in phase 1. The proportion of protecte d triple lumen catheter catheter-related infections decreased signific antly (p = .0024) from 15% to 6%. The rate of catheter-related infecti on 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 pro portion 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 ph ase 3 (p = .43). The total number of catheters used per patient in pha se 3 was 1.9 +/- 1.4, significantly lower than the 2.6 +/- 2.7 cathete rs used in phase 1 (p = .0018). The number of triple lumen catheters d ecreased from 1.8 +/- 1.2 to 1.0 +/- 1.2 in phase 3 (p = .0001). Concl usions: Catheters impregnated with silver sulfadiazine and chlorhexidi ne had a smaller proportion of catheter-related infection compared wit h unprotected catheters. Fever alone as an indication for guidewire ex change resulted in an increased number of unnecessary procedures. Usin g protected catheters and suspected catheter related sepsis, together with an increase in the safe period before guidewire exchange, decreas ed the rate of catheter related infection and increased the duration o f catheterization. Together, these factors significantly decreased the number of catheters used for guidewire exchange and new catheter inse rtions per patient. The cost savings to the hospital were similar to$4 ,750 per month.