- Email: [email protected]
National survey of suboptimal and unnecessary practices for central line placement and management in Thailand
American Journal of Infection Control 41 (2013) e11-e3
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
National survey of suboptimal and unnecessary practices for central line placement and management in Thailand Anucha Apisarnthanarak MD a, *, Thana Khawcharoenporn MD, MSc a, Linda M. Mundy MD, PhD b a b
Division of Infectious Diseases, Faculty of Medicine, Thammasat University Hospital, Pathumthani, Thailand LM Mundy, LLC, Bryn Mawr, PA
Key Words: Resource limited setting Multidose vial Catheter insertion team Leadership
We conducted a national survey among hospitals in Thailand regarding practices associated with central line placement and management. Results of the survey identified that both suboptimal and unnecessary practices are being conducted. Connectors and hubs were not disinfected before access (49%), multidose vial use (43%), and routine culture of catheter tips (21%). Physician leadership and designated catheter insertion teams were associated with less unnecessary or suboptimal reported practices. Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Opportunities exist to optimize infection prevention and control (IPC) practices for central line placement and management in developing countries.1 Although no standard definitions exist, suboptimal practices are generally regarded as practices that may be associated with harm, whereas unnecessary practices are those that are neither beneficial nor harmful yet usually associated with higher health care consumption. Suboptimal practices for central line-associated bloodstream infection (CLABSI) placement and management include lack of preaccess disinfection of catheter connectors or hubs, use of multidose vials, use of 3-way stopcocks, and central venous cut-down for central venous catheter (CVC) insertion when central line access is difficult.2-5 Additionally, routine submission of catheter tips for culture and routine CVC change are not recommended practices.5,6 In lower- and middle-income countries, limited data are available for the frequency of such practice standards.7 We conducted a national Thai survey to characterize reported practices used in central line placement and management. METHODS Survey execution From January 1, 2010, through April 30, 2011, we surveyed all hospitals in Thailand with an intensive care unit (ICU) and at least * Address correspondence to Anucha Apisarnthanarak, MD, Division of Infectious Diseases, Faculty of Medicine, Thammasat University Hospital, Pathumthani, Thailand. E-mail address: [email protected] (A. Apisarnthanarak). Supported by the National Research University Project of the Thailand Office of Higher Education Commission (to A.A. and T.K.). Conflicts of interest: None to report.
250 hospital beds (n ¼ 256). The list of hospitals was provided by the Ministry of Public Health of Thailand. Five trained research nurses conducted face-to-face interviews with the lead infection control professionals (ICPs) at each participating hospital. To minimize ascertainment and reporting bias, three 3-hour training sessions were held from October 21 to 23, 2009, by author A.A., during which the 71-item survey tool and data collection processes were reviewed. The survey instrument was pilot tested in 10 hospitals to ensure test validity among the 5 research nurses. Each nurse interviewed the same 10 hospitals, and reliability checks were performed; 100% concordance in data capture was observed. Survey design and study definitions Data collected included participating hospitals’ institutional characteristics, presence of hospital epidemiologists and ICPs, participation in any collaborative network targeting prevention of health care-associated infections, affiliation with a medical school, number of ICU beds, institutional safety score, level of administration support, use of short-term nontunneled catheters, use of peripheral-inserted central catheters (PICC), having PICC designated insertion teams, having designated insertion teams for other CVCs, use of antimicrobial-coated CVCs, and IPC practices as identified by the lead ICP to prevent CLABSI. The survey instrument was modified from an instrument developed by Krein et al and previously used in the United States (TRIP instrument).8,9 The survey metric was translated into Thai (by A.A.), and 6 questions were added to further explore suboptimal and unnecessary practices. These questions included “Does your hospital still perform the following practices?” Respondent choices for each answer were as
0196-6553/$36.00 - Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2012.07.019
e12
A. Apisarnthanarak et al. / American Journal of Infection Control 41 (2013) e11-e3
follows: “Yes,” “Yes in some units (eg, ICU),” or “No.” We were interested in identifying failure to disinfect connectors or hubs prior to accessing the catheter, the use of multidose vials, use of 3way stopcocks, performing central venous cut-down for CVC insertions, and use of femoral lines. Routine submission of catheter tips for culture and routine CVC change were considered unnecessary IPC practices. Each institution was assessed for self-reported safety by calculation of a validated 2-item metric.8,9 The score was calculated as the mean of responses in agreement with 2 statements about safety “Leadership is driving us to be a safety-centered institution” and “I would feel safe being treated here as a patient.” Each item was scored from 1 (“Strongly agree”) to 5 (“Strongly disagree”).8,9 Infection control support was defined by a nonvalidated composite response to staffing, financial, and executive management factors of hospital administration and categorically ranked by the lead ICP as poor, fair, good, very good, and excellent, as previously reported.8,9 Good to excellent support was combined as a single response in the multivariate analysis. This study was approved by the Institutional Review Board of Faculty of Medicine, Thammasat University. Statistical analysis Analyses were performed using SPSS version 15 (SPSS, Chicago, IL). The c2 or Fisher exact test was used to compare categorical data, as appropriate. Continuous variables were compared using Student t test. All P values were 2-tailed; P < .05 was considered statistical significant. To determine factors associated with survey responses, variables that were present at a significance level of P < .20 in univariate analysis were entered into multivariate logistic regression models. Adjusted odd ratios and 95% confidence intervals were calculated. RESULTS A total of 204 of 256 eligible hospitals (80%) responded to the survey. Among the responding hospitals, 86% had hospitalists, 80% reported good to excellent support of the infection control programs from hospital administration, 71% had a hospital epidemiologist, 53% had a physician serving as the lead ICP, and 48% were affiliated with a medical school (Table 1). The rank listing of central line placement and management practices were not disinfecting connectors or hubs before catheter access (49%), use of multidose vials (43%), use of central venous cut-downs when central line access was difficult (28%), and use of 3-way stopcocks (25%). Routine submission of catheter tips for culture (21%) was more frequently reported than routine CVC change (15%). No hospital reported femoral CVC insertion in adults. By multivariate analyses, having a designated CVC insertion team, use of PICC, and having an infectious diseases (ID)-trained infection control committee chairperson were protective factors against most of the suboptimal and unnecessary practices (Table 2). Hospitals that received good to excellent infection control support were significantly less likely to insert CVCs by performing central venous cut-down and to routinely submit catheter tips for cultures (Table 2). No association was noted for other hospital characteristics such as hospital size or academic affiliation. DISCUSSION This 2010-2011 national survey of Thai hospitals suggests ongoing opportunities exist for optimizing IPC practices, especially those associated with CLABSIs, eg, preaccess disinfection of catheter connectors and/or hubs, use of 3-way stopcocks, and use of multidose vials.2,3,5 Additionally, central venous cut-down
Table 1 Descriptive characteristics of responses to a 2011 national Thai survey of suboptimal and unnecessary practices for central line placement and management practices at 204 hospitals
Characteristic General Hospitalist(s) present Good to excellent infection control program support Hospital epidemiologist(s) present* Medical school affiliation Infection control committee chair Internal medicine trained Infectious diseases trained Lead ICP Physician Registered nurse Lead ICP located on-site Collaborative prevention effort (s) Full-time ICP(s): mean number (SD) Intensive care unit beds: mean number (SD) Safety scorey Central line placement and management Use of short-term nontunneled catheter Use of PICC Designated PICC insertion team Designated insertion team for other CVCs Use of antimicrobial-coated central catheter Reported practices (defined as unnecessary or suboptimal) Not disinfecting connectors or hubs before line access Use of multidose vial Use of central venous cut-down for any CVC insertion Use of 3-way stopcock Routine submission of catheter tip for culture Routine CVC change Femoral CVC insertion in adults
Number (%) (N ¼ 204) 176 164 145 97
(86) (80) (71) (48)
104 (51) 51 (25) 107 69 192 52 2.3 20.0 1.1
(53) (34) (94) (25) (1.5) (14.4) (0.3)
186 103 48 41 22
(91) (50) (24) (20) (11)
99 87 56 50 43 31 0
(49) (43) (28) (25) (21) (15) (0)
CVC, Central venous catheter; ICP, infection control professional; PICC, peripherally inserted central catheter; SD, standard deviation. *Either a medical doctor, doctor of philosophy, registered nurse, or medical technologist or having a master of science degree. y Score range from 2 to 10 as the average of responses regarding agreement to 2 statements: “Leadership is driving us to be a safety-centered institution,” and “I would feel safe being treated here as a patient.”
procedures for CVC access have associated complications such as vascular injury, wound infection, wound dehiscence, and CLABSI.4 These survey findings are consistent with the results from a prior study that reported routine culture of catheter tips in 78% (n ¼ 67/ 82) of participating hospitals.1 Together, these studies underscore that IPC opportunities exist to reduce potential excess health careassociated practices and costs. Our survey findings identified that 20% of surveyed hospitals had a dedicated CVC insertion team, yet the presence of this team was associated with other optimized central line placement and management policies. Medical school affiliation or private hospital status with established line care education and performance auditing was reported by survey respondents from all hospitals with CVC insertion teams (n ¼ 41) or PICC (n ¼ 48); this variable was associated with a reduction in suboptimal and unnecessary practices. These findings are consistent with a prior report of an association between a dedicated, trained vascular access team and reduction in CLABSI, and, together, these studies provide evidence of benefit for a dedicated CVC insertion team in CLABSI prevention.10 The association of an ID-trained infection control committee chairperson and less suboptimal and unnecessary IPC practices may be attributed to the role of ID-trained infection control physicians in specific preventive practices and other interventions that contribute to additional IPC opportunities and policies. There are recognized limitations in this study. First, with an 80% response rate, our results have some susceptibility to nonresponse bias. If the 52 nonresponding hospitals were systematically
A. Apisarnthanarak et al. / American Journal of Infection Control 41 (2013) e11-e3
e13
Table 2 Association of institutional factors and reported practices for central line placement and management in multivariate analyses from a 2011 national Thai survey
Reported practice Not disinfecting connectors or hubs before line access Use of multidose vial
Use of central venous cut-down
Use of 3-way stopcock
Routine submission of catheter tip for culture
Routine CVC change
Institutional (protective) factor
Adjusted odds ratio (95% confidence interval)
Designated CVC insertion team
0.17 (0.06-0.49)
Designated CVC insertion team Use of PICC Participation in a collaborative prevention effort Infectious diseases-trained ICC chair Designated CVC insertion team Use of PICC Good to excellent infection control support Infectious diseases-trained ICC chair Designated CVC insertion team Use of PICC Hospital epidemiologist Infectious diseases-trained ICC chair Designated CVC insertion team Use of PICC Good to excellent infection control support None
0.40 0.37 0.26 0.18 0.26 0.36 0.13 0.18 0.30 0.47 0.28 0.12 0.18 0.16 0.14
(0.17-0.95) (0.18-0.75) (0.11-0.60) (0.08-0.40) (0.11-0.61) (0.17-0.78) (0.03-0.53) (0.08-0.40) (0.13-0.70) (0.21-1.04) (0.10-0.81) (0.04-0.32) (0.06-0.52) (0.06-0.48) (0.02-0.96) e
P value .001 .04 .006 .002 <.001 .002 .009 .004 <.001 .005 .06 .02 <.001 .002 .001 .04 e
CVC, Central venous catheter; ICC, infection control committee; PICC, peripherally inserted central catheter.
different from the 204 that did respond, generalization of our results to nonparticipating Thai hospitals may not be possible. Second, we relied on self-reported data from the lead ICP at each hospital to determine how frequently central line placement and management practices occurred. Although it is possible that an individual respondent may have overestimated or underestimated how frequently the various practices were used, we have no reason to believe this would be a systematic issue. Future investigations would be required to confirm survey responses for observed central line placement and management practices, as well as potential associations with institution-specific CLABSI rates and costs. Third, although single-dose vials are preferred, there was no current recommendation against use of multidose vials. Finally, we did not have access to, and thus could not adjust for, patient-level or hospital case-mix data, and our regression estimates could be biased because of unmeasured confounding. Despite these limitations, our study provides an important first step in collecting information that is crucial to the development, implementation, and management of IPC interventions to improve patient safety in developing countries. Additional studies that rigorously evaluate such strategies would help bolster efforts to optimize central line placement and management practices in developing countries and elsewhere.
Acknowledgment The authors thank Sanjay Saint, MD, MPH, and Sarah Krein, PhD, RN, for discussion of the survey instrument for this study
and Leonard Mermel, DO, for his manuscript review and suggestions.
References 1. Kunaratanapruk S, Silpapojakul K. Unnecessary hospital infection control practices in Thailand: a survey. J Hosp Infect 1998;40:55-9. 2. Tanaka T, Takahashi H, Kobayashi JM, Ohyama T, Okabe N. A nosocomial outbreak of febrile bloodstream infection caused by heparinized-saline contaminated with Serratia marcescens, Tokyo, 2002. Jpn J Infect Dis 2004;57: 189-92. 3. Oto J, Imanaka H, Konno M, Nakataki E, Nishimura M. A prospective clinical trial on prevention of catheter contamination using the hub protection cap for needleless injection device. Am J Infect Control 2011;39:309-13. 4. Chappell S, Vilke GM, Chan TC, Harrigan RA, Ufberg JW. Peripheral venous cutdown. J Emerg Med 2006;31:411-6. 5. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011;52:e162-93. 6. Mrozek N, Lautrette A, Aumeran C, Laurichesse H, Forestier C, Traoré O, et al. Bloodstream infection after positive catheter cultures: what are the risks in the intensive care unit when catheters are routinely cultured on removal? Crit Care Med 2011;39:1301-5. 7. Rosenthal VD. Central line-associated bloodstream infections in limitedresource countries. Clin Infect Dis 2009;49:1899-907. 8. Saint S, Kowalski CP, Kaufman SR, et al. Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis 2008;46: 243-50. 9. Krein SL, Hofer TP, Kowalski CP, et al. Use of central venous catheter-related bloodstream infection prevention practices by US hospitals. Mayo Clin Proc 2007;82:672-8. 10. Royer T. Implementing a better bundle to achieve and sustain a zero central line-associated bloodstream infection rate. J Infus Nurs 2010;33: 398-406.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
National survey of suboptimal and unnecessary practices for central line placement and management in Thailand Anucha Apisarnthanarak MD a, *, Thana Khawcharoenporn MD, MSc a, Linda M. Mundy MD, PhD b a b
Division of Infectious Diseases, Faculty of Medicine, Thammasat University Hospital, Pathumthani, Thailand LM Mundy, LLC, Bryn Mawr, PA
Key Words: Resource limited setting Multidose vial Catheter insertion team Leadership
We conducted a national survey among hospitals in Thailand regarding practices associated with central line placement and management. Results of the survey identified that both suboptimal and unnecessary practices are being conducted. Connectors and hubs were not disinfected before access (49%), multidose vial use (43%), and routine culture of catheter tips (21%). Physician leadership and designated catheter insertion teams were associated with less unnecessary or suboptimal reported practices. Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Opportunities exist to optimize infection prevention and control (IPC) practices for central line placement and management in developing countries.1 Although no standard definitions exist, suboptimal practices are generally regarded as practices that may be associated with harm, whereas unnecessary practices are those that are neither beneficial nor harmful yet usually associated with higher health care consumption. Suboptimal practices for central line-associated bloodstream infection (CLABSI) placement and management include lack of preaccess disinfection of catheter connectors or hubs, use of multidose vials, use of 3-way stopcocks, and central venous cut-down for central venous catheter (CVC) insertion when central line access is difficult.2-5 Additionally, routine submission of catheter tips for culture and routine CVC change are not recommended practices.5,6 In lower- and middle-income countries, limited data are available for the frequency of such practice standards.7 We conducted a national Thai survey to characterize reported practices used in central line placement and management. METHODS Survey execution From January 1, 2010, through April 30, 2011, we surveyed all hospitals in Thailand with an intensive care unit (ICU) and at least * Address correspondence to Anucha Apisarnthanarak, MD, Division of Infectious Diseases, Faculty of Medicine, Thammasat University Hospital, Pathumthani, Thailand. E-mail address: [email protected] (A. Apisarnthanarak). Supported by the National Research University Project of the Thailand Office of Higher Education Commission (to A.A. and T.K.). Conflicts of interest: None to report.
250 hospital beds (n ¼ 256). The list of hospitals was provided by the Ministry of Public Health of Thailand. Five trained research nurses conducted face-to-face interviews with the lead infection control professionals (ICPs) at each participating hospital. To minimize ascertainment and reporting bias, three 3-hour training sessions were held from October 21 to 23, 2009, by author A.A., during which the 71-item survey tool and data collection processes were reviewed. The survey instrument was pilot tested in 10 hospitals to ensure test validity among the 5 research nurses. Each nurse interviewed the same 10 hospitals, and reliability checks were performed; 100% concordance in data capture was observed. Survey design and study definitions Data collected included participating hospitals’ institutional characteristics, presence of hospital epidemiologists and ICPs, participation in any collaborative network targeting prevention of health care-associated infections, affiliation with a medical school, number of ICU beds, institutional safety score, level of administration support, use of short-term nontunneled catheters, use of peripheral-inserted central catheters (PICC), having PICC designated insertion teams, having designated insertion teams for other CVCs, use of antimicrobial-coated CVCs, and IPC practices as identified by the lead ICP to prevent CLABSI. The survey instrument was modified from an instrument developed by Krein et al and previously used in the United States (TRIP instrument).8,9 The survey metric was translated into Thai (by A.A.), and 6 questions were added to further explore suboptimal and unnecessary practices. These questions included “Does your hospital still perform the following practices?” Respondent choices for each answer were as
0196-6553/$36.00 - Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2012.07.019
e12
A. Apisarnthanarak et al. / American Journal of Infection Control 41 (2013) e11-e3
follows: “Yes,” “Yes in some units (eg, ICU),” or “No.” We were interested in identifying failure to disinfect connectors or hubs prior to accessing the catheter, the use of multidose vials, use of 3way stopcocks, performing central venous cut-down for CVC insertions, and use of femoral lines. Routine submission of catheter tips for culture and routine CVC change were considered unnecessary IPC practices. Each institution was assessed for self-reported safety by calculation of a validated 2-item metric.8,9 The score was calculated as the mean of responses in agreement with 2 statements about safety “Leadership is driving us to be a safety-centered institution” and “I would feel safe being treated here as a patient.” Each item was scored from 1 (“Strongly agree”) to 5 (“Strongly disagree”).8,9 Infection control support was defined by a nonvalidated composite response to staffing, financial, and executive management factors of hospital administration and categorically ranked by the lead ICP as poor, fair, good, very good, and excellent, as previously reported.8,9 Good to excellent support was combined as a single response in the multivariate analysis. This study was approved by the Institutional Review Board of Faculty of Medicine, Thammasat University. Statistical analysis Analyses were performed using SPSS version 15 (SPSS, Chicago, IL). The c2 or Fisher exact test was used to compare categorical data, as appropriate. Continuous variables were compared using Student t test. All P values were 2-tailed; P < .05 was considered statistical significant. To determine factors associated with survey responses, variables that were present at a significance level of P < .20 in univariate analysis were entered into multivariate logistic regression models. Adjusted odd ratios and 95% confidence intervals were calculated. RESULTS A total of 204 of 256 eligible hospitals (80%) responded to the survey. Among the responding hospitals, 86% had hospitalists, 80% reported good to excellent support of the infection control programs from hospital administration, 71% had a hospital epidemiologist, 53% had a physician serving as the lead ICP, and 48% were affiliated with a medical school (Table 1). The rank listing of central line placement and management practices were not disinfecting connectors or hubs before catheter access (49%), use of multidose vials (43%), use of central venous cut-downs when central line access was difficult (28%), and use of 3-way stopcocks (25%). Routine submission of catheter tips for culture (21%) was more frequently reported than routine CVC change (15%). No hospital reported femoral CVC insertion in adults. By multivariate analyses, having a designated CVC insertion team, use of PICC, and having an infectious diseases (ID)-trained infection control committee chairperson were protective factors against most of the suboptimal and unnecessary practices (Table 2). Hospitals that received good to excellent infection control support were significantly less likely to insert CVCs by performing central venous cut-down and to routinely submit catheter tips for cultures (Table 2). No association was noted for other hospital characteristics such as hospital size or academic affiliation. DISCUSSION This 2010-2011 national survey of Thai hospitals suggests ongoing opportunities exist for optimizing IPC practices, especially those associated with CLABSIs, eg, preaccess disinfection of catheter connectors and/or hubs, use of 3-way stopcocks, and use of multidose vials.2,3,5 Additionally, central venous cut-down
Table 1 Descriptive characteristics of responses to a 2011 national Thai survey of suboptimal and unnecessary practices for central line placement and management practices at 204 hospitals
Characteristic General Hospitalist(s) present Good to excellent infection control program support Hospital epidemiologist(s) present* Medical school affiliation Infection control committee chair Internal medicine trained Infectious diseases trained Lead ICP Physician Registered nurse Lead ICP located on-site Collaborative prevention effort (s) Full-time ICP(s): mean number (SD) Intensive care unit beds: mean number (SD) Safety scorey Central line placement and management Use of short-term nontunneled catheter Use of PICC Designated PICC insertion team Designated insertion team for other CVCs Use of antimicrobial-coated central catheter Reported practices (defined as unnecessary or suboptimal) Not disinfecting connectors or hubs before line access Use of multidose vial Use of central venous cut-down for any CVC insertion Use of 3-way stopcock Routine submission of catheter tip for culture Routine CVC change Femoral CVC insertion in adults
Number (%) (N ¼ 204) 176 164 145 97
(86) (80) (71) (48)
104 (51) 51 (25) 107 69 192 52 2.3 20.0 1.1
(53) (34) (94) (25) (1.5) (14.4) (0.3)
186 103 48 41 22
(91) (50) (24) (20) (11)
99 87 56 50 43 31 0
(49) (43) (28) (25) (21) (15) (0)
CVC, Central venous catheter; ICP, infection control professional; PICC, peripherally inserted central catheter; SD, standard deviation. *Either a medical doctor, doctor of philosophy, registered nurse, or medical technologist or having a master of science degree. y Score range from 2 to 10 as the average of responses regarding agreement to 2 statements: “Leadership is driving us to be a safety-centered institution,” and “I would feel safe being treated here as a patient.”
procedures for CVC access have associated complications such as vascular injury, wound infection, wound dehiscence, and CLABSI.4 These survey findings are consistent with the results from a prior study that reported routine culture of catheter tips in 78% (n ¼ 67/ 82) of participating hospitals.1 Together, these studies underscore that IPC opportunities exist to reduce potential excess health careassociated practices and costs. Our survey findings identified that 20% of surveyed hospitals had a dedicated CVC insertion team, yet the presence of this team was associated with other optimized central line placement and management policies. Medical school affiliation or private hospital status with established line care education and performance auditing was reported by survey respondents from all hospitals with CVC insertion teams (n ¼ 41) or PICC (n ¼ 48); this variable was associated with a reduction in suboptimal and unnecessary practices. These findings are consistent with a prior report of an association between a dedicated, trained vascular access team and reduction in CLABSI, and, together, these studies provide evidence of benefit for a dedicated CVC insertion team in CLABSI prevention.10 The association of an ID-trained infection control committee chairperson and less suboptimal and unnecessary IPC practices may be attributed to the role of ID-trained infection control physicians in specific preventive practices and other interventions that contribute to additional IPC opportunities and policies. There are recognized limitations in this study. First, with an 80% response rate, our results have some susceptibility to nonresponse bias. If the 52 nonresponding hospitals were systematically
A. Apisarnthanarak et al. / American Journal of Infection Control 41 (2013) e11-e3
e13
Table 2 Association of institutional factors and reported practices for central line placement and management in multivariate analyses from a 2011 national Thai survey
Reported practice Not disinfecting connectors or hubs before line access Use of multidose vial
Use of central venous cut-down
Use of 3-way stopcock
Routine submission of catheter tip for culture
Routine CVC change
Institutional (protective) factor
Adjusted odds ratio (95% confidence interval)
Designated CVC insertion team
0.17 (0.06-0.49)
Designated CVC insertion team Use of PICC Participation in a collaborative prevention effort Infectious diseases-trained ICC chair Designated CVC insertion team Use of PICC Good to excellent infection control support Infectious diseases-trained ICC chair Designated CVC insertion team Use of PICC Hospital epidemiologist Infectious diseases-trained ICC chair Designated CVC insertion team Use of PICC Good to excellent infection control support None
0.40 0.37 0.26 0.18 0.26 0.36 0.13 0.18 0.30 0.47 0.28 0.12 0.18 0.16 0.14
(0.17-0.95) (0.18-0.75) (0.11-0.60) (0.08-0.40) (0.11-0.61) (0.17-0.78) (0.03-0.53) (0.08-0.40) (0.13-0.70) (0.21-1.04) (0.10-0.81) (0.04-0.32) (0.06-0.52) (0.06-0.48) (0.02-0.96) e
P value .001 .04 .006 .002 <.001 .002 .009 .004 <.001 .005 .06 .02 <.001 .002 .001 .04 e
CVC, Central venous catheter; ICC, infection control committee; PICC, peripherally inserted central catheter.
different from the 204 that did respond, generalization of our results to nonparticipating Thai hospitals may not be possible. Second, we relied on self-reported data from the lead ICP at each hospital to determine how frequently central line placement and management practices occurred. Although it is possible that an individual respondent may have overestimated or underestimated how frequently the various practices were used, we have no reason to believe this would be a systematic issue. Future investigations would be required to confirm survey responses for observed central line placement and management practices, as well as potential associations with institution-specific CLABSI rates and costs. Third, although single-dose vials are preferred, there was no current recommendation against use of multidose vials. Finally, we did not have access to, and thus could not adjust for, patient-level or hospital case-mix data, and our regression estimates could be biased because of unmeasured confounding. Despite these limitations, our study provides an important first step in collecting information that is crucial to the development, implementation, and management of IPC interventions to improve patient safety in developing countries. Additional studies that rigorously evaluate such strategies would help bolster efforts to optimize central line placement and management practices in developing countries and elsewhere.
Acknowledgment The authors thank Sanjay Saint, MD, MPH, and Sarah Krein, PhD, RN, for discussion of the survey instrument for this study
and Leonard Mermel, DO, for his manuscript review and suggestions.
References 1. Kunaratanapruk S, Silpapojakul K. Unnecessary hospital infection control practices in Thailand: a survey. J Hosp Infect 1998;40:55-9. 2. Tanaka T, Takahashi H, Kobayashi JM, Ohyama T, Okabe N. A nosocomial outbreak of febrile bloodstream infection caused by heparinized-saline contaminated with Serratia marcescens, Tokyo, 2002. Jpn J Infect Dis 2004;57: 189-92. 3. Oto J, Imanaka H, Konno M, Nakataki E, Nishimura M. A prospective clinical trial on prevention of catheter contamination using the hub protection cap for needleless injection device. Am J Infect Control 2011;39:309-13. 4. Chappell S, Vilke GM, Chan TC, Harrigan RA, Ufberg JW. Peripheral venous cutdown. J Emerg Med 2006;31:411-6. 5. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011;52:e162-93. 6. Mrozek N, Lautrette A, Aumeran C, Laurichesse H, Forestier C, Traoré O, et al. Bloodstream infection after positive catheter cultures: what are the risks in the intensive care unit when catheters are routinely cultured on removal? Crit Care Med 2011;39:1301-5. 7. Rosenthal VD. Central line-associated bloodstream infections in limitedresource countries. Clin Infect Dis 2009;49:1899-907. 8. Saint S, Kowalski CP, Kaufman SR, et al. Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis 2008;46: 243-50. 9. Krein SL, Hofer TP, Kowalski CP, et al. Use of central venous catheter-related bloodstream infection prevention practices by US hospitals. Mayo Clin Proc 2007;82:672-8. 10. Royer T. Implementing a better bundle to achieve and sustain a zero central line-associated bloodstream infection rate. J Infus Nurs 2010;33: 398-406.