How frequently do patients in intensive care units develop infections related to the use of invasive devices?

Hospitals participating in a voluntary national surveillance system reduced rates of ventilator-associated pneumonias and catheter-related urinary tract and bloodstream infections by 11 percent to 13 percent over five years.

Why is this important?

Each year, health care–associated infections affect an estimated two million Americans, including 500,000 intensive care unit (ICU) patients, resulting in an estimated 90,000 deaths and $4.5 billion in excess health care costs (NCID 2006). ICU patients are at increased risk of acquiring infections, most of which are associated with the use of invasive devices (Richards et al. 2000), such as:

• Urinary tract infection associated with the use of indwelling urinary catheters to drain the bladder (Saint et al. 2002).
• Bloodstream infections associated with the use of central line catheters, which are inserted in about one-half of ICU patients to provide medication, nutrition, and fluids (O'Grady et al. 2002).
• Pneumonia associated with the use of mechanical ventilators in patients requiring assisted breathing (Tablan et al. 2004).

Findings

The rates of three types of device-associated infections acquired by ICU patients declined by 11 percent to 13 percent on average among more than 300 hospitals participating in a voluntary national surveillance system during 1998–2003.

• The rate of catheter-associated urinary tract infections decreased by 11 percent (from 5.5 to 4.9 per 1,000 device-days) among adult ICU patients.
• Rates of central line–associated bloodstream infections decreased by 11 percent (from 5.5 to 4.9 per 1,000 device-days) among all ICU patients and by 13 percent (from 12.2 to 10.6 per 1000 device-days) among very low birthweight infants in neonatal intensive care units (NICUs).
• The rate of ventilator-associated pneumonias decreased by 10 percent (from 10.1 to 9.1 infections per 1,000 device-days) among adult ICU patients from 1998 to 2001, but there was little change in the rate among very low birthweight infants in NICUs during this time. (New criteria for nosocomial pneumonia were adopted in 2002, so rates for 2002 and beyond are not comparable to those reported before 2002.) (AHRQ 2005)

Implications

A rigorous multi-hospital surveillance system can help ICUs accurately monitor and decrease rates of health care–acquired infections. This system is currently being redesigned as a "web-based knowledge management and adverse events reporting system" (to be called the National Healthcare Safety Network) that will be available to all U.S. health care facilities and organizations.

Improvement Ideas and Resources

Quality improvement collaborations among ICUs have reported substantial increases in rates of adherence to infection control practices along with collective decreases of 29 percent to 45 percent in rates of ventilator-associated pneumonias and of 23 percent to 68 percent in rates of central line–associated bloodstream infections (Kaye et al. 2006; MHA 2006; Muto et al. 2005; Pronovost and Berenholtz 2004; Render et al. 2006; Resar et al. 2005). Some commonly applied elements included:

• forming multidisciplinary teams for patient rounds and improvement;
• educating staff on evidence and testing their knowledge;
• empowering staff to cross-check one another's performance;
• using tools such as checklists, standing orders, visual reminders, computerized data collection, prompts, and performance feedback; and
• ensuring easy availability of sterile supplies needed for catheter insertion.

Other effective improvement strategies include:

• making systematic efforts to increase adherence to recommended hand hygiene practices (Boyce and Pittet 2002; Eldridge et al. 2006);
• prompting physicians to remove catheters as soon as appropriate (Berenholtz et al. 2004; Saint et al. 2002; Topal et al. 2005); and
• promoting vigilance through real-time measurement and investigation of infections as they occur (Shannon et al. 2006; Wall et al. 2005).

Differences between children and adults in factors such as immune system maturity, site and types of infections, processes of care, and patient interactions mean that a child-specific approach often is necessary (Harris 1997). A collaboration among neonatal intensive care units that used performance benchmarking to identify "potentially better practices" was associated with a 25 percent reduction in targeted ICU-acquired infections (Horbar et al. 2001).

Staffing all nonrurual ICUs with critical care specialist physicians (intensivists) might prevent up to 54,000 patient deaths and save an estimated $3.4 billion in health care costs nationally (Conrad and Gardner 2005; Young and Birkmeyer 2000). Some hospitals have successfully implemented technology to permit electronic monitoring of ICU patients by remote intensivists (Breslow et al. 2004), which represents one approach to help overcome the shortage of intensivists (HRSA 2006).

Measure:

The National Nosocomial Infections Surveillance System (NNIS) includes more than 300 participating hospitals that report data on certain hospital-acquired infections to the Centers for Disease Control and Prevention (CDC) using standard protocols for at least one month each year. Accuracy of reporting is generally high (Emori et al. 1998).

• A health care–associated infection is a localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that 1) occurs in a patient in a health care setting (e.g., a hospital), 2) was not found to be present or incubating at the time of admission unless the infection was related to a previous admission to the same setting, and 3) if the setting is a hospital, meets the criteria for a specific infection site (McKibben et al. 2005).
• A device-associated infection is an infection in a patient with a device (e.g., ventilator or central line) that was used within the 48-hour period before the infection's onset. If the time interval was longer than 48 hours, compelling evidence must be present to indicate that the infection was associated with use of the device. For catheter-associated urinary tract infection (UTI), the indwelling urinary catheter must have been in place within the seven-day period before positive laboratory results or signs and symptoms meeting the criteria for UTI were evident (McKibben et al. 2005).
• A ventilator is a device to assist or control respiration continuously through a tracheostomy or by endotracheal intubation (Horan and Emori 1997).
• A central line is a vascular access device that terminates at or close to the heart or one of the great vessels (Horan and Emori 1997).
• An indwelling urinary catheter is a drainage tube that is inserted into the urinary bladder through the urethra, left in place, and connected to a closed collection system; also called a Foley catheter (Horan and Emori 1997).

Limitations:

Data are not representative of all U.S. hospitals. Data are voluntarily reported and may underestimate the incidence of nosocomial infections.

Source:

National Center for Infectious Diseases, National Nosocomial Infections Surveillance System (NNIS), as reported by the Agency for Healthcare Research and Quality (AHRQ 2005). Participating NNIS hospitals must have at least 100 beds and meet minimum requirements for infection control staffing; they are larger on average but have similar geographic distribution compared with U.S. hospitals generally (Richards et al. 2001).

References:

* Indicates source of data used in the chart(s).

* AHRQ (Agency for Healthcare Research and Quality). 2005. National Healthcare Quality Report, 2005. AHRQ Publication No. 06-0018. Rockville, Md.: U.S. Department of Health and Human Services.

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