THE ROLE OF UNDERSTAFFING IN CENTRAL VENOUS CATHETER-ASSOCIATED BLOOD-STREAM INFECTIONS

OBJECTIVE: To determine risk factors for central venous catheter-assoc iated bloodstream infections (CVC-BSI) during a protracted outbreak. D ESIGN: Case-control and cohort studies of surgical intensive care unit (SICU) patients. SETTING: A university-affiliated Veterans Affairs me dical center. PATIENTS: Case-control study: all patients who developed a CVC-BSI during the outbreak period (January 1992 through September 1993) and randomly selected controls. Cohort study: all SICU patients during the study period (January 1991 through September 1993). MEASURE MENTS: CVC-BSI or site infection rates, SICU patient clinical data, an d average monthly SICU patient-to-nurse ratio. RESULTS: When analyzed by hospital location and site, only CVC-BSI in the SICU had increased significantly in the outbreak period compared to the previous year (Ja nuary 1991 through December 1991: pre-outbreak period). In SICU patien ts, CVC-BSI were associated with receipt of total parenteral nutrition [TPN]; odds ratio, 16; 95% confidence interval, 4 to 73). When we con trolled for TPN use, CVC-BSI were associated with increasing severity of illness and days on assisted ventilation. SICU patients in the outb reak period had shorter SICU and hospital stays, were younger, and had similar mortality rates, but received more TPN compared with patients in the pre-outbreak period. Furthermore, the patient-to-nurse ratio s ignificantly increased in the outbreak compared with the pre-outbreak period. When we controlled for TPN use, assisted ventilation, and the period of hospitalization, the patient-to-nurse ratio was an independe nt risk factor for CVC-BSI in SICU patients. CONCLUSIONS: Nursing staf f reductions below a critical level, during a period of increased TPN use, may have contributed to the increase in CVC-BSI in the SICU by ma king adequate catheter care difficult. During healthcare reforms and h ospital downsizing, the effect of staffing reductions on patient outco me (ie, nosocomial infection) needs to be critically assessed.