Development of an antimicrobial stewardship program in an integrated healthcare system.

PURPOSE: The development of an inpatient antimicrobial stewardship program (ASP) in an integrated healthcare system is described. SUMMARY: With increasing national focus on reducing inappropriate antimicrobial use, state and national regulatory mandates require hospitals to develop ASPs. In 2015, BJC HealthCare, a multihospital health system, developed a system-level, multidisciplinary ASP team to assist member hospitals with ASP implementation. A comprehensive gap analysis was performed to assess current stewardship resources, activities and compliance with CDC core elements at each facility. BJC system clinical leads facilitated the development of hospital-specific leadership support statements, identification of hospital pharmacy and medical leaders, and led development of staff and patient educational components. An antimicrobial-use data dashboard was created for reporting and tracking the impact of improvement activities. Hospital-level interventions were individualized based on the needs and resources at each facility. Hospital learnings were shared at bimonthly system ASP meetings to disseminate best practices. The initial gap analysis revealed that BJC hospitals were compliant in a median of 6 ASP elements (range, 4-8) required by regulatory mandates. By leveraging system resources, all hospitals were fully compliant with regulatory requirements by January 2017. CONCLUSION: BJC's ASP model facilitated the development of broad-based stewardship activities, including education modules for patients and providers and clinical decision support, while allowing hospitals to implement activities based on local needs and resource availability.

The impact of a simple, low-cost oral care protocol on ventilator-associated pneumonia rates in a surgical intensive care unit.

OBJECTIVE: The purpose of this study was to determine the effects of a simple low-cost oral care protocol on ventilator-associated pneumonia rates in a surgical intensive care unit. DESIGN: Preintervention and postintervention observational study. SETTING: Twenty-four bed surgical/trauma/burn intensive care units in an urban university hospital. PATIENTS: All mechanically ventilated patients that were admitted to the intensive care unit between June 1, 2004 and May 31, 2005. INTERVENTIONS: An oral care protocol to assist in prevention of bacterial growth of plaque by cleaning the patients' teeth with sodium monoflurophosphate 0.7% paste and brush, rinsing with tap water, and subsequent application of a 0.12% chlorhexidine gluconate chemical solution done twice daily at 12-hour intervals. MEASUREMENTS AND MAIN RESULTS: During the preintervention period from June 1, 2003 to May 31, 2004, there were 24 infections in 4606 ventilator days (rate = 5.2 infections per 1000 ventilator days). After the institution of the oral care protocol, there were 10 infections in 4158 ventilator days, resulting in a lower rate of 2.4 infections per 1000 ventilator days. This 46% reduction in ventilator-associated pneumonia was statistically significant (P = .04). Staff compliance with the oral care protocol during the 12-month period was also monitored biweekly and averaged 81%. The total cost of the oral care protocol was US$2187.49. There were 14 fewer cases of ventilator-associated pneumonia, which led to a decrease in cost of US$140 000 to US$560 000 based on the estimated cost per ventilator-associated pneumonia infection of US$10 000 to US$40 000. There was an overall reduction in ventilator-associated pneumonia without a change to the gram-negative or gram-positive microorganism profile. CONCLUSIONS: The implementation of a simple, low-cost oral care protocol in the surgical intensive care unit led to a significantly decreased risk of acquiring ventilator-associated pneumonia.

Effect of chlorhexidine/silver sulfadiazine-impregnated central venous catheters in an intensive care unit with a low blood stream infection rate after implementation of an educational program: a before-after trial.

BACKGROUND: Current guidelines recommend using antiseptic- or antibiotic-impregnated central venous catheters (CVCs) if, following a comprehensive strategy to prevent catheter-related blood stream infection (CR-BSI), infection rates remain above institutional goals based on benchmark values. The purpose of this study was to determine if chlorhexidine/silver sulfadiazine-impregnated CVCs could decrease the CR-BSI rate in an intensive care unit (ICU) with a low baseline infection rate. METHODS: Pre-intervention and post-intervention observational study in a 24-bed surgical/trauma/burn ICU from October, 2002 to August, 2005. All patients requiring CVC placement after March, 2004 had a chlorhexidine/silver sulfadiazine-impregnated catheter inserted (post-intervention period). RESULTS: Twenty-three CR-BSIs occurred in 6,960 catheter days (3.3 per 1,000 catheter days)during the 17-month control period. After introduction of chlorhexidine/silver sulfadiazine-impregnated catheters, 16 CR-BSIs occurred in 7,732 catheter days (2.1 per 1,000 catheter days; p = 0.16). The average length of time required for an infection to become established after catheterization was similar in the two groups (8.4 vs. 8.6 days; p = 0.85). Chlorhexidine/silver sulfadiazine-impregnated catheters did not result in a statistically significant change in the microbiological profile of CR-BSIs, nor did they increase the incidence of resistant organisms. CONCLUSIONS: Although chlorhexidine/silver sulfadiazine-impregnated catheters are useful in specific patient populations, they did not result in a statistically significant decrease in the CR-BSI rate in this study, beyond what was achieved with education alone.

Effectiveness of an educational program to reduce ventilator-associated pneumonia in a tertiary care center in Thailand: a 4-year study.

BACKGROUND: Ventilator-associated pneumonia (VAP) is considered to be an important cause of infection-related death and morbidity in intensive care units (ICUs). We sought to determine the long-term effect of an educational program to prevent VAP in a medical ICU (MICU). METHODS: A 4-year controlled, prospective, quasi-experimental study was conducted in an MICU, surgical ICU (SICU), and coronary care unit (CCU) for 1 year before the intervention (period 1), 1 year after the intervention (period 2), and 2 follow-up years (period 3). The SICU and CCU served as control ICUs. The educational program involved respiratory therapists and nurses and included a self-study module with preintervention and postintervention assessments, lectures, fact sheets, and posters. RESULTS: Before the intervention, there were 45 episodes of VAP (20.6 cases per 1000 ventilator-days) in the MICU, 11 (5.4 cases per 1000 ventilator-days) in the SICU, and 9 (4.4 cases per 1000 ventilator-days) in the CCU. After the intervention, the rate of VAP in the MICU decreased by 59% (to 8.5 cases per 1000 ventilator-days; P=.001) and remained stable in the SICU (5.6 cases per 1000 ventilator-days; P=.22) and CCU (4.8 cases per 1000 ventilator-days; P=.48). The rate of VAP in the MICU continued to decrease in period 3 (to 4.2 cases per 1000 ventilator-days; P=.07), and rates in the SICU and CCU remained unchanged. Compared with period 1, the mean duration of hospital stay in the MICU was reduced by 8.5 days in period 2 (P<.001) and by 8.9 days in period 3 (P<.001). The monthly hospital antibiotic costs of VAP treatment and the hospitalization cost for each patient in the MICU in periods 2 and 3 were also reduced by 45%-50% (P<.001) and 37%-45% (P<.001), respectively. CONCLUSIONS: A focused education intervention resulted in sustained reductions in the incidence of VAP, duration of hospital stay, cost of antibiotic therapy, and cost of hospitalization.

Impact of a methicillin-resistant Staphylococcus aureus active surveillance program on contact precaution utilization in a surgical intensive care unit.

OBJECTIVE: To determine the impact of an active surveillance for methicillin-resistant Staphylococcus aureus (MRSA) on contact precaution utilization, as measured by additional number of contact precaution days attributable to the active surveillance program. DESIGN: Prospective cohort study. SETTING: Twenty-four-bed surgical intensive care unit (ICU). PATIENTS: All patients admitted to the surgical ICU. INTERVENTIONS: Nasal cultures for MRSA were performed at admission to a surgical ICU for 19 months. Patients admitted>48 hrs also received weekly and discharge nasal cultures. MEASUREMENTS AND MAIN RESULTS: Clinical data, including start date and initial indication for contact precautions, were prospectively collected. Of 1,893 admissions, 253 (13%) were found to be MRSA-positive during their ICU stay. One hundred forty-six (58%) were identified by nasal culture alone. Compared with the first 10 months of study, the prevalence of MRSA on admission to the ICU during the last 9 months of the study period significantly increased (7.2% vs. 11.4%, p<.001). Acquisition of MRSA by noncolonized patients remained constant between the first 10 months and last 9 months of study (7.0 vs. 5.5 cases per 1000 patient days, p=.29). Two hundred fourteen (6%) of 3461 total contact precaution days in the ICU were attributable to MRSA active surveillance. In sensitivity analyses, the implementation of rapid, same-day results for MRSA active surveillance would increase contact precaution days by 15% compared with no surveillance. If the total number of vancomycin-resistant enterococci patients in the ICU were reduced by 50%, the contact precaution days attributable to active surveillance would increase to 9%. CONCLUSIONS: MRSA active surveillance increased total contact precaution days in this ICU by 6% yet detected 58% of MRSA cases that would have been otherwise missed. Despite an increasing prevalence of MRSA on admission to the ICU, the acquisition rate has remained constant.

Epidemiology of methicillin-resistant Staphylococcus aureus colonization in a surgical intensive care unit.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is a cause of healthcare-associated infections among surgical intensive care unit (ICU) patients, though transmission dynamics are unclear. OBJECTIVE: To determine the prevalence of MRSA nasal colonization at ICU admission, to identify associated independent risk factors, to determine the value of these factors in active surveillance, and to determine the incidence of and risk factors associated with MRSA acquisition. DESIGN: Prospective cohort study. SETTING: Surgical ICU at a teaching hospital. PATIENTS: All patients admitted to the surgical ICU. RESULTS: Active surveillance for MRSA by nasal culture was performed at ICU admission during a 15-month period. Patients who stayed in the ICU for more than 48 hours had nasal cultures performed weekly and at discharge from the ICU, and clinical data were collected prospectively. Of 1,469 patients, 122 (8%) were colonized with MRSA at admission; 75 (61%) were identified by surveillance alone. Among 775 patients who stayed in the ICU for more than 48 hours, risk factors for MRSA colonization at admission included the following: hospital admission in the past year (1-2 admissions: adjusted odds ratio [aOR], 2.60 [95% confidence interval {CI}, 1.47-4.60]; more than 2 admissions: aOR, 3.56 [95% CI, 1.72-7.40]), a hospital stay of 5 days or more prior to ICU admission (aOR, 2.54 [95% CI, 1.49-4.32]), chronic obstructive pulmonary disease (aOR, 2.16 [95% CI, 1.17-3.96]), diabetes mellitus (aOR, 1.87 [95% CI, 1.10-3.19]), and isolation of MRSA in the past 6 months (aOR, 8.18 [95% CI, 3.38-19.79]). Sixty-nine (10%) of 670 initially MRSA-negative patients acquired MRSA in the ICU (corresponding to 10.7 cases per 1,000 ICU-days at risk). Risk factors for MRSA acquisition included tracheostomy in the ICU (aOR, 2.18 [95% CI, 1.13-4.20]); decubitus ulcer (aOR, 1.72 [95% CI, 0.97-3.06]), and receipt of enteral nutrition via nasoenteric tube (aOR, 3.73 [95% CI, 1.86-7.51]), percutaneous tube (aOR, 2.35 [95% CI, 0.74-7.49]), or both (aOR, 3.33 [95% CI, 1.13-9.77]). CONCLUSIONS: Active surveillance detected a sizable proportion of MRSA-colonized patients not identified by clinical culture. MRSA colonization on admission was associated with recent healthcare contact and underlying disease. Acquisition was associated with potentially modifiable processes of care.

Efficacy and safety of an insulin infusion protocol in a surgical ICU.

BACKGROUND: Hyperglycemia is associated with complications in the surgical intensive care unit. The purpose of this study was to determine the efficacy and safety of nurse-driven insulin infusion protocols in lowering blood glucose (BG) in critical illness. STUDY DESIGN: All patients in a 24-bed surgical intensive care unit who required i.v. insulin infusions during 3 noncontiguous 6-month periods from 2002 to 2004 were evaluated. In the preintervention phase, 71 patients received a physician-initiated insulin infusion without a developed protocol. They were compared with 95 patients who received a nurse-driven insulin infusion protocol with a target BG of 120 to 150 mg/dL and to 119 patients who received a more stringent protocol with a target BG of 80 to 110 mg/dL. RESULTS: There was a stepwise decrease in average daily BG levels, from 190 to 163 to 132 mg/dL (p < 0.001). The less stringent protocol decreased the time to achieve a BG level < 150 mg/dL from 14.1 to 7.4 hours compared with physician-driven management (p < 0.05) resulting in similar time on an insulin infusion (53 versus 48 hours). The more intensive protocol brought BG levels < 150 mg/dL in 7.2 hours and < 111 mg/dL in 13.6 hours, but increased the length of time a patient was on an insulin infusion to 77 hours. The incidence of severe hypoglycemia (BG < 40 mg/dL) was statistically similar between the groups, ranging between 1.1% and 3.4%. CONCLUSIONS: Implementation of a nurse-driven protocol led to more rapid and more effective BG control in critically ill surgical patients compared with physician management. Tighter BG control can be obtained without a significant increase in hypoglycemia, although this is associated with increased time on an insulin infusion.

The effect of an education program on the incidence of central venous catheter-associated bloodstream infection in a medical ICU.

OBJECTIVE: To determine whether an education initiative could decrease the rate of catheter-associated bloodstream infection. DESIGN: Preintervention and postintervention observational study. SETTING: The 19-bed medical ICU in a 1,400-bed university-affiliated urban teaching hospital. PATIENTS: Between January 2000 and December 2003, all patients admitted to the medical ICU were surveyed prospectively for the development of catheter-associated bloodstream infection. INTERVENTION: A mandatory education program directed toward ICU nurses and physicians was developed by a multidisciplinary task force to highlight correct practices for the prevention of catheter-associated bloodstream infection. The program consisted of a 10-page self-study module on risk factors and practice modifications involved in catheter-related bloodstream infections and in-services at scheduled staff meetings. Each participant was required to complete a pretest before reviewing the study module and an identical test after completion of the study module. Fact sheets and posters reinforcing the information in the study module were also posted throughout the ICU. MEASUREMENTS AND MAIN RESULTS: Seventy-four episodes of catheter-associated bloodstream infection occurred in 7,879 catheter-days (9.4 per 1,000 catheter-days) in the 24 months before the introduction of the education program. Following implementation of the intervention, the rate of catheter-associated bloodstream infection decreased to 41 episodes in 7,455 catheter days (5.5 per 1,000 catheter-days) [p = 0.019]. The estimated cost savings secondary to the decreased rate of catheter-associated bloodstream infection for the 24 months following introduction of the education program was between $103,600 and $1,573,000. CONCLUSIONS: An intervention focused on the education of health-care providers on the prevention of catheter-associated bloodstream infections may lead to a dramatic decrease in the incidence of primary bloodstream infections. Education programs may lead to a substantial decrease in medical-care costs and patient morbidity attributed to central venous catheterization when implemented as part of mandatory training.

An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects.

STUDY OBJECTIVES: To determine whether an educational initiative could decrease rates of ventilator-associated pneumonia in a regional health-care system. SETTING: Two teaching hospitals (one adult, one pediatric) and two community hospitals in an integrated health system. DESIGN: Preintervention and postintervention observational study. PATIENTS: Patients admitted to the four participating hospitals between January 1, 1999, and June 30, 2002, who acquired ventilator-associated pneumonia. INTERVENTION: An educational program for respiratory care practitioners and ICU nurses emphasizing correct practices for the prevention of ventilator-associated pneumonia. The program included a self-study module on risk factors for, and strategies to prevent, ventilator-associated pneumonia and education-based in-services. Fact sheets and posters reinforcing the information were posted throughout the ICU and respiratory care departments. MEASUREMENTS AND RESULTS: Completion rates for the module were calculated by job title at each hospital. Rates of ventilator-associated pneumonia per 1,000 ventilator days were calculated for all hospitals combined and for each hospital separately. Overall 635 of 792 ICU nurses (80.1%) and 215 of 239 respiratory therapists (89.9%) completed the study module. There were 874 episodes of ventilator-associated pneumonia at the four hospitals during the 3.5-year study period out of 129,527 ventilator days. Ventilator-associated pneumonia rates for all four hospitals combined dropped by 46%, from 8.75/1,000 ventilator days in the year prior to the intervention to 4.74/1,000 ventilator days in the 18 months following the intervention (p < 0.001). Statistically significant decreased rates were observed at the pediatric hospital and at two of the three adult hospitals. No change in rates was seen at the community hospital with the lowest rate of study module completion among respiratory therapists (56%). CONCLUSIONS: Educational interventions can be associated with decreased rates of ventilator-associated pneumonia in the ICU setting. The involvement of respiratory therapy staff in addition to ICU nurses is important for the success of educational programs aimed at the prevention of ventilator-associated pneumonia.

The impact of bedside behavior on catheter-related bacteremia in the intensive care unit.

HYPOTHESIS: The success of an educational program in July 1999 that lowered the catheter-related bloodstream infection (CRBSI) rate in our intensive care unit (ICU) 3-fold is correlated with compliance with "best-practice" behaviors. DESIGN: Before-after trial. SETTING: Surgical ICU in a referral hospital. PATIENTS: A random sample underwent bedside audits of central venous catheter care (n = 187). All ICU admissions during a 39-month period (N = 4489) were prospectively followed for bacteremia. INTERVENTIONS: On the basis of audit results in December 2000, a behavioral intervention was designed to improve compliance with evidenced-based guidelines of central venous catheter management. MAIN OUTCOME MEASURES: Compliance with practices known to decrease CRBSI. Secondary outcome was CRBSI rate on all ICU patients. RESULTS: Multiple deficiencies were identified on bedside audits 18 months after the previous educational program. After the implementation of a separate behavioral intervention in July 2001, a second set of bedside audits in December 2001 demonstrated improvements in documenting the dressing date (11% to 21%; P<.001) and stopcock use (70% to 24%; P<.001), whereas nonsignificant trends were observed in hand hygiene (17% to 30%; P>.99) and maximal sterile barrier precautions (50% to 80%; P =.29). Appropriate practice was observed before and after the behavioral intervention in catheter site placement, dressing type, absence of antibiotic ointment, and proper securing of central venous catheters. Thirty-two CRBSIs occurred in 9353 catheter-days 24 months before the behavioral intervention compared with 17 CRBSIs in 6152 catheter-days during the 15 months after the intervention (3.4/1000 to 2.8/1000 catheter-days; P =.40). CONCLUSIONS: Although a previous educational program decreased the CRBSI rate, this was associated with only modest compliance with best practice principles when bedside audits were performed 18 months later. A behavioral intervention improved all identified deficiencies, leading to a nonsignificant decrease in CRBSIs.

Ventilator-associated pneumonia in a multi-hospital system: differences in microbiology by location.

OBJECTIVE: To determine whether there were differences in the microbiologic etiologies of ventilator-associated pneumonia in different clinical settings. DESIGN: Observational retrospective cohort study of microbiologic etiologies of ventilator-associated pneumonia from 1998 to 2001 in a multi-hospital system. Microbiologic results were compared between hospitals and between different intensive care units (ICUs) within hospitals. SETTING: Three hospitals--one pediatric teaching hospital, one adult teaching hospital, and one community hospital--in one healthcare system in the midwestern United States. PATIENTS: Patients at the target hospitals who developed ventilator-associated pneumonia and for whom microbiologic data were available. RESULTS: Seven hundred fifty-three episodes of ventilator-associated pneumonia had culture data available for review. The most common organisms at all hospitals were Staphylococcus aureus (28.4%) and Pseudomonas aeruginosa (25.2%). The pediatric hospital had higher proportions of Escherichia coli (9.5% vs 2.3%; P < .001) and Klebsiella pneumoniae (13% vs 3.1%; P < .001) than did the adult hospitals. In the pediatric hospital, the pediatric ICU had higher P aeruginosa rates than did the neonatal ICU (33.3% vs 17%; P = .01). In the adult hospitals, the surgical ICU had higher Acinetobacter baumannii rates (10.2% vs. 1.7%; P < .001) than did the other ICUs. CONCLUSIONS: Microbiologic etiologies of ventilator-associated pneumonia vary between and within hospitals. Knowledge of these differences can improve selection of initial antimicrobial regimens, which may decrease mortality.

An educational intervention to prevent catheter-associated bloodstream infections in a nonteaching, community medical center.

OBJECTIVE: To evaluate the effectiveness of an evidence-based intervention to prevent catheter-associated bloodstream infections among intensive care unit patients at a nonteaching, community hospital. DESIGN: Nonrandomized pre/post observational trial. SETTING: Two intensive care units at Missouri Baptist Medical Center, Saint Louis, MO. PARTICIPANTS: Nurses and critical care physicians. INTERVENTION: A ten-page, self-study module on the prevention of catheter-associated bloodstream infections, lectures, and posters given between July and September 1999. MEASUREMENTS: The incidence of nosocomial catheter-associated bloodstream infection and patient demographics were measured for patients admitted between March 1998 and July 2000. MAIN RESULTS: Thirty cases of catheter-associated bloodstream infections during 6110 catheter-days were noted in the preintervention period (4.9 cases/1000 catheter-days) vs. 11 cases during the 5210 catheter-days in the postintervention period (2.1 cases/1000 catheter-days). The relative risk for catheter-associated infection in the postintervention period was 0.43 (95% confidence interval, 0.22-0.84). Among catheterized patients, Acute Physiology and Chronic Health Evaluation II score (25.2 preintervention vs. 25.1 postintervention; p =.86), hemodialysis (91 of 647 [14%] patients vs. 69 of 541 [13%]; p =.70), and the mean number of catheter days per patient (9.1 vs. 9.6 days; p =.46) did not differ between the pre- and postintervention periods. CONCLUSIONS: A focused, educational intervention among nurses and physicians in a nonteaching community hospital resulted in a significant, sustained reduction in the incidence of catheter-associated bloodstream infection.

Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia.

OBJECTIVE: The purpose of the study was to determine whether an education initiative could decrease the hospital rate of ventilator-associated pneumonia. DESIGN: Pre- and postintervention observational study. SETTING: Five intensive care units in Barnes-Jewish Hospital, an urban teaching hospital. PATIENTS: Patients requiring mechanical ventilation who developed ventilator-associated pneumonia between October 1, 1999, and September 30, 2001. INTERVENTIONS: An education program directed toward respiratory care practitioners and intensive care unit nurses was developed by a multidisciplinary task force to highlight correct practices for the prevention of ventilator-associated pneumonia. The program consisted of a ten-page self-study module on risk factors and practice modifications involved in ventilator-associated pneumonia, inservices at staff meetings, and formal didactic lectures. Each participant was required to take a preintervention test before the study module and identical postintervention tests following completion of the study module. Fact sheets and posters reinforcing the information in the study module were also posted throughout the intensive care units and the Department of Respiratory Care Services. MEASUREMENTS AND MAIN RESULTS: One hundred ninety-one episodes of ventilator-associated pneumonia occurred in 15,094 ventilator days (12.6 per 1,000 ventilator days) in the 12 months before the intervention. Following implementation of the education module, the rate of ventilator-associated pneumonia decreased to 81 episodes in 14,171 ventilator days (5.7 per 1,000 ventilator days), a decrease of 57.6% (p <.001). The estimated cost savings secondary to the decreased rate of ventilator-associated pneumonia for the 12 months following the intervention were between $425,606 and $4.05 million. CONCLUSIONS: A focused education intervention can dramatically decrease the incidence of ventilator-associated pneumonia. Education programs should be more widely employed for infection control in the intensive care unit setting and can lead to substantial decreases in cost and patient morbidity attributed to hospital-acquired infections.

Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit.

OBJECTIVE: The purpose of the study was to determine whether an education initiative aimed at improving central venous catheter insertion and care could decrease the rate of primary bloodstream infections. DESIGN: Pre- and postintervention observational study. SETTING: Eighteen-bed surgical/burn/trauma intensive care unit (ICU) in an urban teaching hospital. PATIENTS: A total of 4,283 patients were admitted to the ICU between January 1, 1998, and December 31, 2000. INTERVENTIONS: A program primarily directed toward registered nurses was developed by a multidisciplinary task force to highlight correct practice for central venous catheter insertion and maintenance. The program consisted of a 10-page self-study module on risk factors and practice modifications involved in catheter-related infections as well as a verbal in-service at staff meetings. Each participant was required to take a pretest before taking the study module and an identical test after its completion. Fact sheets and posters reinforcing the information in the study module were also posted throughout the ICU. MEASUREMENTS AND MAIN RESULTS: Seventy-four primary bloodstream infections occurred in 6874 catheter days (10.8 per 1000 catheter days) in the 18 months before the intervention. After the implementation of the education module, the number of primary bloodstream infections fell to 26 in 7044 catheter days (3.7 per 1000 catheter days), a decrease of 66% (p < .0001). The estimated cost savings secondary to the decreased infection rate for the 18 months after the intervention was between $185,000 and $2.808 million. CONCLUSIONS: A focused intervention primarily directed at the ICU nursing staff can lead to a dramatic decrease in the incidence of primary bloodstream infections. Educational programs may lead to a substantial decrease in cost, morbidity, and mortality attributable to central venous catheterization.