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AN Australian study showing that bloodstream infections from central venous lines can be slashed by more than half by adhering to simple sterile measures will change clinical practice in Australia, according to a leading intensivist. (1)
At the same time, a large medical defence organisation warned that doctors could be prosecuted if they deliberately breached aseptic techniques.
Professor Jamie Cooper, director of the Australian and New Zealand Intensive Care Research Centre at Monash University, said the study, which showed compliance with maximal sterile barrier precautions in intensive care units cut central line-associated bacteraemia (CLAB) rates by 60%, would almost certainly influence practice.
The research was well done, Australian, with a very large group and produced clear results, he said.
The study, published in this week’s MJA, involved a collaborative quality improvement project in which a checklist was used to record compliance with aseptic central venous line (CVL) insertion in 34 intensive care units (ICUs) in NSW over 18 months.
Maximal sterile precautions were divided into a “clinician bundle”, which included hand scrubbing and wearing sterile gloves and gown plus a theatre hat, mask and eyewear, and a “patient bundle”, which included fully draping the patient with a sterile sheet and checking the position of the CVL by imaging and/or pressure transducer.
A review of 10 890 checklists found the relative risk of CLAB in patients with CVLs inserted by clinicians who were not compliant with the clinician bundle was 1.62 times greater than when the clinicians were compliant with both bundles.
“Non-compliance with the clinician bundle was attributable in 94% of cases to non-compliance with the hat‒mask‒eyewear element”, the authors said.
Specifically, hat wearing was identified as the contentious component.
The authors estimated more than 15 000 CVLs were inserted in patients in ICUs each year in NSW alone.
Professor Cooper said he would support any calls for federal and state governments to fund an ongoing monitoring program to ensure all ICUs complied with the clinician and patient bundles.
“It [the study] is really good because it shows in an Australian setting that it is possible to significantly reduce CLAB or bloodstream infection rates by these incredibly simple things, which are basically having a checklist and trying to get people to comply”, he said. “And that hasn’t been shown before in Australia, so it is a new finding.”
Professor Cooper, who is also deputy director of intensive care at the Alfred Hospital in Melbourne, said washing hands and wearing a gown and gloves were accepted practice in Australian ICUs but donning a theatre hat and mask was more uncertain.
“The reason people don’t [wear a hat and mask] meticulously, I think, is that it hasn’t previously been so clear that it is important and probably partly because of some laziness at various levels,” he said.
Andrew Took, national manager of medicolegal advisory services at Avant, the largest medical indemnity insurer in Australia, said claims arising from alleged breaches of aseptic technique had been a problem for a long time.
“A claim could be brought by the patient for compensation and there is also a potential disciplinary prosecution of the practitioner if they have breached aseptic techniques deliberately”, he said.
Avant had assisted many members dealing with such claims and complaints, he said.
Professor Peter Collignon, professor of infectious diseases and microbiology at the Australian National University in Canberra, said the study “really showed, by not using rocket science, that basically having good sterile techniques [and] full draping, you can actually halve the number of people with bloodstream infections”.
“Ten per cent of people who get a bloodstream infection are likely to die as a result so this is an intervention we need to do”, Professor Collignon said.
“We need to make sure we find mechanisms of ensuring it actually happens and that means a team approach, some auditing, some supervision and checking that the appropriate approaches are being followed.”
– Cathy Saunders
Posted 6 June 2011
Nothing in there about CVLs in the ED. I’m not sure research done in the ICU necessarily translates to the ED, yet it is possible this study will be used to beat Emergency Physicians over the head. I agree with Richard Middleton, that appropriate choice of invasive technologies is as important as how they are deployed, which raises the issue of teaching our juniors the difference between “we can” and “we should”.
One other point…
How does wearing eye protection protect against line infections?
I don’t weep as I put in neck lines (the patients might though.)
Are we shedding eye lashes all the time and if so, should not all of us be completely hairless and coated with an all over epidermal sealant before approaching patients, or even getting on a bus, come to that?
Another ‘study’ to beat the doctor with.
I always observe “F.A.T” when putting in central lines but I do not believe that masks or hats are necessary. Unless of course hair is falling all over, but that is not my problem.
What of the person with the big eyebrow(s), are they going to have to wear a special “monobrow mask?”
Masks have not been shown to protect patients, only the operator.
And why drape the entire patient for a neck line?
I was unaware that bacteria could cover such large distances in so short a time as to render SENSIBLE short draping useless. If that is really making a difference, some other factor(s) is/are clearly operating.
Perhaps practitioners would be better to really observe careful decision-making and proper aseptic technique when they put in lines only when really clearly indicated, and not because of various financial considerations… As obviously occurs too often.
There is a very worrying trend these days for arterial lines to go in even the fittest patient on the flimsiest of excuses.
The more lines needlessly inserted, the more needlessly infected lines.
The authors acknowledge that the evidence does not indicate a causal relationship between wearing caps and masks, only an association. When gestalt suggests that a result is illogical, then it is usually proven to be so. Logic suggests that wearing caps does not affect the rate of CV line infection.
It is a bit sad that the study used a “bundle” of measures, rather than testing specifics. Like all other “bundles”, eg, phone “plans”, this is likely to increase costs for things that are neither needed nor wanted.
While the rationale for scrubbing, sterile gloves and face mask is well proven, there is no real evidence that theatre hats provide benefits for such minimally invasive procedures (as opposed to when leaning over an open body cavity), and likewise surgical eye wear, etc.
We will see whether the outfall of this study will really lead to lowered infection rates, but one thing is sure: it will drive costs up, at times possibly delay urgent procedures, and possibly without need. Will we see a follow-up study looking at the individual value of specific protection measures?