Implementing the central venous catheter infection prevention bundle in the emergency department: experiences among early adopters.

STUDY OBJECTIVE: Central line-associated bloodstream infections (CLABSI) cause preventable morbidity and mortality. Hospitals have reduced CLABSI by using a bundle of evidence-based infection prevention practices. Systems factors in the emergency department (ED) present unique barriers to bundle adoption, and no guidelines exist for bundle implementation. We aim to identify barriers and facilitators to central line bundle adoption in EDs. METHODS: We used a qualitative, grounded theory approach, enrolling 6 EDs that were early adopters of the central line bundle. We interviewed 49 administrators and staff (nurses and physicians) through 26 semistructured interviews and 3 focus groups of 6 to 8 individuals. Investigators read each transcript and then iteratively built and refined a set of themes that emerged from the data. RESULTS: Barriers to central line bundle adoption included high acuity, time constraints, staffing, space, ED culture, high ED volume and acuity, role ambiguity, and a lack of methods to track compliance and infection surveillance. Facilitators included champions, staff engagement, workflow redesign that includes a checklist and central line kit or cart, clear staff responsibilities, observer empowerment, and compliance and infection surveillance data. CONCLUSION: The strategies for implementing and sustaining a central line infection prevention bundle in the ED are distinct from those of other clinical settings. Our findings describe the central line bundle workflow in the ED, staff motivations, and the critical systems factors that impede and foster its use. Knowledge of these systems factors should improve bundle adoption in the ED and thereby reduce hospital incidence of CLABSIs.

Infection and natural history of emergency department-placed central venous catheters.

STUDY OBJECTIVES: Central line-associated bloodstream infection (CLABSI, hereafter referred to in this paper as "bloodstream infection") is a leading cause of hospital-acquired infection. To our knowledge, there are no previously published studies designed to determine the rate of bloodstream infection among central venous catheters placed in the emergency department (ED). We design a retrospective chart review methodology to determine bloodstream infection and duration of catheterization for central venous catheters placed in the ED. METHODS: Using hospital infection control, administrative, and ED billing databases, we identified patients with central venous catheters placed in the ED between January 1, 2007, and December 31, 2008, at one academic, urban ED with an annual census of 57,000. We performed a structured, explicit chart review to determine duration of catheterization and confirm bloodstream infection. RESULTS: We screened 4,251 charts and identified 656 patients with central venous catheters inserted in the ED, 3,622 catheter-days, and 7 bloodstream infections. The rate of bloodstream infection associated with central venous catheters placed in the ED was 1.93 per 1,000 catheter-days (95% confidence interval 0.50 to 3.36). The mean duration of catheterization was 5.5 days (median 4; range 1 to 29 days). Among infected central venous catheters, the mean duration of catheterization was 8.6 days (median 7; range 2 to 19 days). A total of 667 central venous catheters were placed in the internal jugular (392; 59%), subclavian (145; 22%), and femoral (130; 19%) veins. The sensitivity of using ED procedural billing code for identifying ED-placed central venous catheters among patients subsequently admitted to any ICU was 74.9% (95% confidence interval 71.4% to 78.3%). CONCLUSION: The rate of ED bloodstream infection at our institution is similar to current rates in ICUs. Central venous catheters placed in the ED remain in admitted patients for a substantial period.

Systematic review of emergency department central venous and arterial catheter infection.

BACKGROUND: There is an extensive critical care literature for central venous catheter and arterial line infection, duration of catheterization, and compliance with infection control procedures. The emergency medicine literature, however, contains very little data on central venous catheters and arterial lines. As emergency medicine practice continues to incorporate greater numbers of critical care procedures such as central venous catheter placement, infection control is becoming a greater issue. AIMS: We performed a systematic review of studies reporting baseline data of ED-placed central venous catheters and arterial lines using multiple search methods. METHODS: Two reviewers independently assessed included studies using explicit criteria, including the use of ED-placed invasive lines, the presence of central line-associated bloodstream infection, and excluded case reports and review articles. Finding significant heterogeneity among studies, we performed a qualitative assessment. RESULTS: Our search produced 504 abstracts, of which 15 studies were evaluated, and 4 studies were excluded because of quality issues leaving 11 cohort studies. Four studies calculated infection rates, ranging 0-24.1/1,000 catheter-days for central line-associated and 0-32.8/1,000 catheter-days for central line-related bloodstream infection. Average duration of catheterization was 4.9 days (range 1.6-14.1 days), and compliance with infection control procedures was 33-96.5%. The data were too poor to compare emergency department to in-hospital catheter infection rates. CONCLUSIONS: The existing data for emergency department-placed invasive lines are poor, but suggest they are a source of infection, remain in place for a significant period of time, and that adherence to maximum barrier precautions is poor. Obtaining accurate rates of infection and comparison between emergency department and inpatient lines requires prospective study.