Page 55 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

24 PART 1: An Overview of the Approach to and Organization of Critical Care

Several methods exist for performing surveillance in the ICU, includ- will be ignored or will result in even wider variation in how care is deliv-
ing the traditional methods of medical chart review and review of ered owing to individual interpretation. Most private and state hospital
microbiology, radiology, and autopsy reports. More recently, the use of accreditation programs base their review of ICUs not only on whether
computerized expert systems and medical informatics in health care– ICUs have required policies but also on whether they actually follow
associated infection surveillance has reduced the need for manual chart them. Therefore, it is important that ICU physician and nursing staff
review, improved case ascertainment, and allowed for more resources to review these policies on a routine basis in consultation with infection
be used for intervention and prevention. 11,12 prevention practitioners or the hospital infection control committee and
revise these policies when needed.
STRUCTURAL/ORGANIZATIONAL FACTORS
THAT AFFECT ICU INFECTION PREVENTION INVASIVE DEVICES AND ICU-ACQUIRED INFECTIONS
■ ICU DESIGN AND LAYOUT ■ CENTRAL VENOUS CATHETERS/PULMONARY ARTERIAL CATHETERS

While published architectural guidelines require that isolation rooms Catheter-associated bloodstream infection is one of the most common
be included in the layout of critical care units, few data are available to health care–associated infections seen in ICU patients. Approximately
address the impact of ICU design on prevention of nosocomial infec- 80,000 of these infections have been estimated to occur annually in
tion. Mulin and colleagues demonstrated a lower rate of bronchopul- ICUs in the United States (excluding insertion-site infection and septic
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monary colonization with Acinetobacter baumannii among mechanically thrombophlebitis). These infections are associated with increased ICU
ventilated patients in a surgical ICU after the unit was converted from length of stay, health care costs, and use of broad-spectrum antibiotics.
one with a mixture of enclosed isolation rooms and open rooms to all Risk factors for catheter-associated bloodstream infections include
enclosed rooms with hand washing facilities. Another study demon- the anatomic catheter insertion site, type of catheter used, and the
strated a reduction in the incidence of ventilator-associated pneumonia patient population. The pathogenesis includes microbial colonization of
and urinary tract infections in a pediatric ICU after it was converted the subcutaneous catheter tract by skin flora with subsequent coloniza-
from an open ward to separate isolation rooms, without a significant tion of the catheter and biofilm formation, as well as colonization of
change in patient to staff ratios. Single, private rooms are the current the catheter hub from microbes introduced during catheter use. While
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trend in hospital planning and design, and single rooms may be associ- intravascular catheters can result in bloodstream infections by other
ated with preventing health care–associated bloodstream infection. 15,16 means, such as the infusion of contaminated fluids, the mechanisms
Despite the lack of data, it is prudent to ensure that adequate access to just mentioned are the primary means by which nontunneled central
hand hygiene exists for ICU personnel. 15 venous catheters in place for less than 2 to 4 weeks cause bloodstream
■ NURSING STAFFING RATIOS Numerous infection control practices have been effective in prevent-
infections.
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Much attention has been given to the issue of nurse staffing levels and ing intravascular catheter–related infections (Table 4-1). Meticulous
hand hygiene before and after handling intravascular catheters, along
the impact that this has on patient outcomes and complications, includ- with maintaining an intact, nonsoiled dressing at the catheter insertion
ing infection. With increased workloads for registered nurses and the site, is essential to prevent device-related infections. Maximal sterile
reliance on less trained health care personnel for the delivery of care, barrier precautions (ie, sterile gowns, gloves, surgical mask and hat, and
there is concern that lapses in infection prevention will occur, resulting a large surgical drape) during insertion reduce the incidence of infec-
in increased infections. In a pediatric cardiac ICU over a 1-year period, tion. In one randomized trial, subclavian vein insertion was associated
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a decrease in nurse-to-patient staffing ratios correlated significantly with with a lower incidence of infectious complications and complete vessel
an increase in nosocomial infections. In a multicenter, retrospective thrombosis when compared with femoral insertion. However, another
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cohort study among 2606 patients admitted to an ICU after abdominal randomized controlled trial demonstrated no significant difference
aortic surgery, patients cared for in ICUs that reported nurse-to-patient in the incidence of catheter-related bloodstream infection for either
ratio of 1:3 or greater on either day or night shifts were at greater risk femoral or jugular hemodialysis catheter insertion sites for nontunneled
of respiratory complications, including postoperative pneumonia. hemodialysis catheters. 23
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This relationship was independent of patient age, comorbidity, level of Use of a chlorhexidine-based antiseptic for skin preparation has
surgical urgency, ICU size, and hospital procedure volume. Another been associated with reducing the incidence of catheter-related blood-
study demonstrated that lower nurse to patient ratio was associated with stream infection. 24,25 Using an all-inclusive catheter insertion kit or
increase in the risk for late onset ventilator-associated pneumonia. 19 cart is ideal. Structured educational programs incorporating the use
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These studies, along with several others, have limitations, including of maximal sterile precautions have reduced the incidence of catheter-
retrospective design, no determination of nursing experience or level associated bloodstream infections by 27% to 66%. 27,28 In a multicentered
of training, and no comment on the role that other types of health care interventional study, optimizing combination of preventive measures
worker staffing levels, such as respiratory therapists, have on health (ie, maximal barrier precaution, avoidance of femoral vein as a inser-
care–associated infection rates. Despite these limitations, a direct tion site, hand hygiene before catheter insertion and manipulation, and
association between increased nursing workload and the occurrence use of a chlorhexidine antiseptic for skin preparation and removing
of infections among ICU patients appears to exist. The optimal level unnecessary catheter) and using a checklist led to dramatic decline
of both nursing staffing and experience needed to minimize the risk of in the incidence of catheter-related bloodstream infection. It is also
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infection in ICUs remains to be determined but is unlikely to be uniform important to empower all health care workers to stop the procedure if
for every type of unit. sterile technique was not performed.
■ INFECTION PREVENTION POLICIES AND PROCEDURES stream infection have been investigated. Chlorhexidine-containing
Several adjunctive approaches to prevent catheter-related blood-

Given the complexity of delivering care to critically ill patients, poli- sponge dressing is shown to be effective to reduce the incidence of
cies and procedure are a necessary part of the organization of any ICU. catheter-related bloodstream infection in a randomized controlled
These policies ensure that personnel perform certain procedures, such trial. Antibiotic-coated catheters are also effective. However, the
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as central venous catheter insertion and care, in a consistent manner. unexplored issue of emerging resistance associated with the use of
Written ICU policies should incorporate evidence-based infection con- these catheters makes their role in an overall infection control strategy
trol practices. For policies to be effective, they should be clear, concise, unclear. Antibiotic lock therapy may be considered in selective situa-
and shared with the staff. Policies that are complex or unrealistic either tions. Antibiotic lock therapy involves instilling a highly concentrated
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