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

Attitudes and practices of nurses on a pediatric cancer and stem cell transplant ward: adaptation of an oral care protocol

This study evaluated nurses' current practices and understanding of oral health for hematology and oncology patients. A written questionnaire administered to 33 nurses on the pediatric cancer and blood disorders unit of Children's Medical Center of Dallas included questions on oral evaluation, oral hygiene, and case-based questions. Information gathered was used to develop an oral care protocol. The study found that nurses were proficient in diagnosing obvious conditions including mucositis and pseudomembranous candidiasis, but they were less than proficient when diagnosing less easily recognizable conditions such as xerostomia. The nurses were found to have inadequate knowledge of the treatment and oral hygiene protocols for conditions that they could and could not diagnose. The protocol based on the questionnaire results included information gathering, oral hygiene protocol, evaluation of viral infection, evaluation of fungal infection, oral assessment guide, and treatment protocol. Through information gathering, an oral health care policy may be developed and implemented to aid in the treatment of children undergoing care for malignancies.

Ventilator-associated pneumonia in neonatal and pediatric intensive care unit patients

Ventilator-associated pneumonia (VAP) is the second most common hospital-acquired infection among pediatric intensive care unit (ICU) patients. Empiric therapy for VAP accounts for approximately 50% of antibiotic use in pediatric ICUs. VAP is associated with an excess of 3 days of mechanical ventilation among pediatric cardiothoracic surgery patients. The attributable mortality and excess length of ICU stay for patients with VAP have not been defined in matched case control studies. VAP is associated with an estimated $30,000 in attributable cost. Surveillance for VAP is complex and usually performed using clinical definitions established by the CDC. Invasive testing via bronchoalveolar lavage increases the sensitivity and specificity of the diagnosis. The pathogenesis in children is poorly understood, but several prospective cohort studies suggest that aspiration and immunodeficiency are risk factors. Educational interventions and efforts to improve adherence to hand hygiene for children have been associated with decreased VAP rates. Studies of antibiotic cycling in pediatric patients have not consistently shown this measure to prevent colonization with multidrug-resistant gram-negative rods. More consistent and precise approaches to the diagnosis of pediatric VAP are needed to better define the attributable morbidity and mortality, pathophysiology, and appropriate interventions to prevent this disease.

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.

Prevention of ventilator-associated pneumonia: analysis of studies published since 2004

As the most recent guidelines for the prevention of ventilator-associated pneumonia (VAP) were published four years ago, we have conducted a systematic review to discover whether the recently published articles should further influence existing guidelines. Articles published since 2004 dealing with infection control measures for prevention of VAP were gathered and evaluated in order to identify evidence for the possible modification of routine practice. Special emphasis was placed on randomized controlled trials (RCTs), meta-analyses or systematic reviews and studies applying multi-module interventions. A total of 15 RCTs and seven meta-analyses or systematic reviews were found. In addition to these, five cohort studies were identified where multi-module programmes were introduced for reducing VAP rates. The data lead to the conclusion that topical use of chlorhexidine for oral care is beneficial and subglottic secretion drainage may lead to delayed onset of VAP. The remaining studies had only a minor influence on existing guidelines for the prevention of VAP and confirmed the earlier recommendations in several points. However, the studies investigating multi-module programmes led to a substantial reduction of VAP of between 31 and 57%. The data show that many VAP cases are preventable and that there is room for improvement in many institutions. Often simple interventions are useful for the reduction of VAP rates, for which the best chances appeared to be the application of multi-module programmes. On average a reduction of more than 40% seems to be possible.

Impact of a protocol for prevention of ventilator-associated pneumonia

BACKGROUND

Several interventions have been shown to be effective in reducing the incidence of ventilator-associated pneumonia (VAP), but their implementation in clinical practice has not gained widespread acceptance.

OBJECTIVE

To determine the impact of a protocol that incorporates evidence-based interventions shown to reduce the frequency of VAP on the overall rate of VAP, early-onset VAP, and late-onset VAP in the intensive care unit (ICU) of a tertiary care adult teaching hospital.

METHODS

This pre- and postintervention observational study included mechanically ventilated patients admitted to the Montreal General Hospital ICU between November 2003 and May 2004 (preintervention) and between November 2004 and May 2005 (postintervention). A multidisciplinary prevention protocol was developed, implemented, and reinforced. Rates of VAP per 1000 ventilator-days were calculated pre- and postprotocol implementation for all patients, for patients with early-onset VAP, and for those with late-onset VAP.

RESULTS

In the pre- and postintervention groups, 349 and 360 patients, respectively, were mechanically ventilated. Twenty-three VAP episodes occurred in 925 ventilator-days (crude incidence rate 25 per 1000) in the preintervention period. Following implementation, the VAP rate decreased to 22 episodes in 988 ventilator-days (crude incidence rate 22.3 per 1000), corresponding to a relative reduction in rate of 10.8% (p < 0.001). The incidence of early-onset VAP decreased from 31.0 to 18.5 VAP per 1000 ventilator-days (p < 0.001), while the incidence of late-onset VAP increased from 21.9 to 24.1 VAP per 1000 ventilator-days (p < 0.001). However, when all covariates were adjusted, the impact of the prevention protocol was not statistically significant.

CONCLUSIONS

Implementation of a VAP prevention protocol incorporating evidence-based interventions reduced the crude incidence of VAP, early-onset VAP, and late-onset VAP. However, when covariates were adjusted, the beneficial effect was no longer observed. Further research is needed to assess the impact of such measures on VAP, early-onset VAP, and late-onset VAP.

Underresourced hospital infection control and prevention programs: penny wise, pound foolish?

OBJECTIVES

To estimate the cost of healthcare-associated infections (HAIs) in a network of 28 community hospitals and to compare this sum to the amount budgeted for infection control programs at each institution and for the entire network.

DESIGN

We reviewed literature published since 1985 to estimate costs for specific HAIs. Using these estimates, we determined the costs attributable to specific HAIs in a network of 28 hospitals during a 1-year period (January 1 through December 31, 2004). Cost-saving models based on reductions in HAIs were calculated.

SETTING

Twenty-eight community hospitals in the southeastern region of the United States.

RESULTS

The weight-adjusted mean cost estimates for HAIs were $25,072 per episode of ventilator-associated pneumonia, $23,242 per nosocomial blood stream infection, $10,443 per surgical site infection, and $758 per catheter-associated urinary tract infection. The median annual cost of HAIs per hospital was $594,683 (interquartile range [IQR], $299,057-$1,287,499). The total annual cost of HAIs for the 28 hospitals was greater than $26 million. Hospitals budgeted a median of $129,000 (IQR, $92,500-$200,000) for infection control; the median annual cost of HAIs was 4.6 (IQR, 3.4-8.0) times the amount budgeted for infection control. An annual reduction in HAIs of 25% could save each hospital a median of $148,667 (IQR, $74,763-$296,861) and could save the group of hospitals more than $6.5 million.

CONCLUSIONS

The economic cost of HAIs in our group of 28 study hospitals was enormous. In the modern age of infection control and patient safety, the cost-control ratio will become the key component of successful infection control programs.

Preventing ventilator associated pneumonia

Oral antiseptic agents should be part of a multifaceted preventive care package

Bringing quality improvement into the intensive care unit

BACKGROUND

During the last several years, many governmental and nongovernmental organizations have championed the application of the principles of quality improvement to the practice of medicine, particularly in the area of critical care.

OBJECTIVE

To review the breadth of approaches to quality improvement in the intensive care unit, including measures such as mortality and length of stay, and the use of protocols, bundles, and the role of large, multiple-hospital collaboratives.

RESULTS

Several agencies have participated in the application of the quality movement to medicine, culminating in the development of standards such as the intensive care unit core measures of the Joint Commission on Accreditation of Healthcare Organizations. Although "zero defects" may not be possible in all measurable variables of quality in the intensive care unit, several measures, such as catheter-related bloodstream infections, can be significantly reduced through the implementation of improved processes of care, such as care bundles. Large, multiple-center, quality improvement collaboratives, such as the Michigan Keystone Intensive Care Unit Project, may be particularly effective in improving the quality of care by creating a "bandwagon effect" within a geographic region.

CONCLUSION

The quality revolution is having a significant effect in the critical care unit and is likely to be facilitated by the transition to the electronic medical record.

Nosocomial infections in the pediatric intensive care unit: affecting the impact on safety and outcome

OBJECTIVE

To define the most common types of nosocomial infections in critically ill children and to summarize the effect of methods to reduce their prevalence.

DESIGN

Review of published literature.

RESULTS

While in the pediatric intensive care unit, 16% of children develop a nosocomial infection. Processes affecting modifiable factors of care can reduce the prevalence of hospital-acquired infections.

CONCLUSIONS

The occurrence of a nosocomial infection represents failure and is not an acceptable outcome of treating critically ill children. Evidence-based process improvement can lead to significant reductions in hospital-acquired infections in children. Most of the processes and practices discussed are not novel or intriguing but, when performed routinely and appropriately, can lead to reductions in hospital-acquired infections.

Évaluation de la prescription antibiotique dans un service de réanimation pédiatrique

The antibiotic prescription in intensive care units is frequent using often broad-spectrum antibiotics; its quality has never been evaluated in paediatric intensive care units.

OBJECTIVES

To describe the modalities of antibiotic prescriptions in a paediatric intensive care unit and confront them to the literature guidelines and bacteriological data.

METHODS

From January 1st to March 31st 2005, 52 consecutive prescriptions regarding 45 children, with a total of 47 hospitalisations were prospectively analysed.

RESULTS

Confirmed diagnosis of bacterial infection was retained for 50 of the 52 patients: community acquired infection in 35 cases (70%) and a nosocomial infection in 15 cases. Ten children died during the antibiotic treatment (22%), with 5 deaths related to the infection (11%). Monotherapy represented 56% of the prescriptions of antibiotics. The initial antibiotic treatment was empirical in 42 of 52 cases (81%). The empirical prescriptions were documented afterward in 48% of cases. One or more microorganisms were isolated for 60% of the initial prescriptions. Misuses in antibiotic doses (in excess [10%] or by insufficiency [13%]), number of daily administration (4%), and way of administration and/or length of treatment were observed. Seventy-seven percent of the initial prescriptions seemed to be adapted to the identified or suspected bacteria, but only 63% adequate to recommendations.

CONCLUSION

Almost 2/3rd of the antibiotic prescriptions were adequate to the recommendations. The implementation of standardized and specific protocols should contribute to improve the quality of these prescriptions.

Evidence-Based Practice: Use of the Ventilator Bundle to Prevent Ventilator-Associated Pneumonia

• Purpose To examine critical care nurses’ knowledge about the use of the ventilator bundle to prevent ventilator-associated pneumonia.

• Method Published reports were reviewed for current evidence on the use of the ventilator bundle to prevent ventilator-associated pneumonia, and education sessions were held to present the findings to 61 nurses in coronary care and surgical intensive care units. Changes in the nurses’ knowledge were evaluated by using a 10-item test, given both before and after the sessions. Changes in the nurses’ practices related to ventilator-associated pneumonia, including elevation of the head of the bed to 30° to 45°, were observed in 99 intubated patients.

• ResultsAfter the education sessions, the nurses performed better on 8 of the 10 items tested (P from .03 to &lt;.001). The areas of most significant improvement were elevation of the head of the bed (P &lt; .001), charting of the elevation of the head of the bed (P= .009), oral care (P= .009), checking of the nasogastric tube for residual volume (P = .008), washing of hands before contact with patients (P &lt; .001), and limiting the wearing of rings (P &lt; .001) and nail polish (P = .04). Even after the education sessions, the nurses’ compliance with hand-washing recommendations before contact with patients was low, though statistically some improvement was apparent. Contraindications to elevation of the head of the bed did not appear to affect the nurses’ practices (P= .38).

• Conclusion Education sessions designed to inform nurses about the ventilator bundle and its use to prevent ventilator-associated pneumonia have a significant effect on participants’ knowledge and subsequent clinical practice.

Nurses’ Implementation of Guidelines for Ventilator-Associated Pneumonia From the Centers for Disease Control and Prevention

• Background Ventilator-associated pneumonia accounts for 47% of infections in patients in intensive care units. Adherence to the best nursing practices recommended in the 2003 guidelines for the prevention of ventilator-associated pneumonia from the Centers for Disease Control and Prevention should reduce the risk of ventilator-associated pneumonia.

• Objective To evaluate the extent to which nurses working in intensive care units implement best practices when managing adult patients receiving mechanical ventilation.

• Methods Nurses attending education seminars in the United States completed a 29-item questionnaire about the type and frequency of care provided.

• Results Twelve hundred nurses completed the questionnaire. Most (82%) reported compliance with hand-washing guidelines, 75% reported wearing gloves, half reported elevating the head of the bed, a third reported performing subglottic suctioning, and half reported having an oral care protocol in their hospital. Nurses in hospitals with an oral care protocol reported better compliance with hand washing and maintaining head-of-bed elevation, were more likely to regularly provide oral care, and were more familiar with rates of ventilator-associated pneumonia and the organisms involved than were nurses working in hospitals without such protocols.

• Conclusions The guidelines for the prevention of ventilator-associated pneumonia from the Centers for Disease Control and Prevention are not consistently or uniformly implemented. Practices of nurses employed in hospitals with oral care protocols are more often congruent with the guidelines than are practices of nurses employed in hospitals without such protocols. Significant reductions in rates of ventilator-associated pneumonia may be achieved by broader implementation of oral care protocols.

The intensive care unit as a research laboratory: developing strategies to prevent antimicrobial resistance

OBJECTIVE

To assemble the available clinical data on the prevention of antimicrobial resistance in the intensive care unit (ICU) setting.

DATA SOURCE

A MEDLINE database search and references from identified articles were employed to obtain the literature relating to the prevention of antimicrobial resistance in the ICU.

CONCLUSIONS

The ICU presents a unique environment for the conduct of clinical research. The closed physical space with centralized patient management and efficient data recovery allows important clinical questions to be evaluated in a timely manner. Antimicrobial resistance has emerged as an important determinant of mortality for patients in the ICU. Additionally, there is currently a limited pipeline of new agents for the treatment of emerging bacteria with new resistance genes that pose an increasing threat to the ICU patient. Effective strategies for the prevention of antimicrobial resistance within ICUs are available and should be implemented aggressively. These strategies can be divided into non-pharmacologic infection- control strategies (e.g., routine hand hygiene, infection-specific prevention protocols) and antibiotic management strategies (e.g., shorter courses of appropriate antibiotics, narrowing of the antimicrobial spectrum on the basis of culture results). Additional studies conducted in ICUs are needed urgently to identify the optimal approaches for the management of antibiotics in order to balance the need for efficacy with the ability to minimize resistance.

Preventing ventilator-associated pneumonia in adults: sowing seeds of change

Ventilator-associated pneumonia (VAP), a major cause of ICU infection, results in high morbidity, mortality, and health-care costs. Multiple risk factors for VAP involve complex host factors and ubiquitous pathogens that require several different types of prevention strategies. Prevention efforts should focus on reducing bacterial colonization, and limiting aspiration, antibiotic exposure, and use of invasive devices. Although evidence-based prevention guidelines are available, they are lengthy, often ignored, and not implemented. New insights into the barriers to implementation of effective prevention programs are emerging. This article provides highlights from recent guidelines and publications discussing VAP prevention strategies and examines barriers to their implementation. Prevention and implementation of cost-effective strategies to reduce risk and improve patient outcomes should be prioritized. Clearly, prevention programs should be population specific and may vary among hospitals, but a multidisciplinary prevention team led by a "champion" is recommended to help set priorities, benchmarking goals, analyze data, and sow the seeds of change for risk reduction.

Impact of an infection control program on rates of ventilator-associated pneumonia in intensive care units in 2 Argentinean hospitals

BACKGROUND

Hospitalized, critically ill patients have a significant risk of developing nosocomial infection. Most episodes of nosocomial pneumonia occur in patients undergoing mechanical ventilation (MV).

OBJECTIVE

To ascertain the effect of an infection control program on rates of ventilator-associated pneumonia (VAP) in intensive care units (ICUs) in Argentina.

METHODS

All adult patients who received MV for at least 24 hours in 4, level III adult ICUs in 2 Argentinean hospitals were included in the study. A before-after study in which rates of VAP were determined during a period of active surveillance without an infection control program (phase 1) were compared with rates of VAP after implementation of an infection control program that included educational and surveillance feedback components (phase 2).

RESULTS

One thousand six hundred thirty-eight MV-days were accumulated in phase 1, and 1520 MV-days were accumulated during phase 2. Rates of VAP were significantly lower in phase 2 than in phase 1 (51.28 vs 35.50 episodes of VAP per 1000 MV-days, respectively, RR = 0.69, 95% CI: 0.49-0.98, P <or= .003).

CONCLUSION

Implementation of a multicomponent infection control program in Argentinean ICUs was associated with significant reductions in rates of VAP.

Ventilatory and hemodynamic management of potential organ donors: An observational survey*

OBJECTIVE

To determine the current standard ventilatory and cardiovascular management in potential organ donors.

DESIGN

Prospective, multiple-center, observational survey.

SETTING

A total of 15 intensive care units in 13 hospitals in Piedmont, Italy.

PATIENTS

A total of 34 brain-dead patients enrolled in 6 months.

MEASUREMENTS AND MAIN RESULTS

Demographics and reasons for lung transplant exclusion were recorded. Ventilatory and hemodynamic variables were compared before and after confirmation of brain death. A total of 23 potential donors were ineligible for lung donation based on pulmonary status and age. Of the 11 eligible lung donors, only two donated the lungs because five had Pao2/Fio2 ratios of <300 and four were ineligible for logistic problems. Tidal volume was 10 +/- 2 mL/kg, positive end-expiratory pressure was 3.3 +/- 2.7 cm H2O, Fio2 was 50% +/- 18% before brain death diagnosis, and no changes were made after brain death confirmation. In potential lung donors, apnea tests were performed with apneic oxygenation after disconnection from the ventilator in all cases; tracheal suction was performed with an open circuit in eight cases, and no recruitment maneuvers were performed. Crystalloid infusion was increased after diagnosis of brain death from 187 +/- 151 to 275 +/- 158 mL/hr (p < .05), and central venous pressure increased from 6 +/- 3 to 7 +/- 3 mm Hg (p < .05). Inotropic support was used in 24 donors (70%).

CONCLUSIONS

Five of 11 potential lung donors (45%) had a Pao2/Fio2 ratio of <300, making them ineligible for lung donation. After the diagnosis of brain death, ventilatory management remained the same, no maneuvers for prevention of derecruitment of the lung were performed, and cardiovascular management was modified to optimize peripheral organ perfusion. These data represent the current standard of care for ventilatory management of potential organ donors and may be suboptimal in preserving lung function.

Strategies to prevent antimicrobial resistance in the intensive care unit

OBJECTIVE

To assemble the available clinical data for the prevention of antimicrobial resistance into practical recommendations for clinicians.

DATA SOURCE

A Medline database and references from identified articles were employed to perform a literature search relating to the prevention of antimicrobial resistance.

CONCLUSIONS

Antimicrobial resistance has emerged as an important determinant of mortality for patients in the intensive care unit. This is largely due to the increasing presence of pathogenic microorganisms with resistance to existing antimicrobial agents, resulting in the administration of inappropriate treatment. Effective strategies for the prevention of antimicrobial resistance within intensive care units are available and should be aggressively implemented. These strategies can be divided into nonpharmacologic infection control strategies (e.g., routine hand hygiene, implementation of infection-specific prevention protocols) and antibiotic management strategies (e.g., shorter courses of appropriate antibiotic treatment, narrowing of antimicrobial spectrum based on culture results). Increasing current efforts aimed at the prevention of antimicrobial resistance is especially important given the limited availability of new antimicrobial drug classes for the foreseeable future.

Improving Oral Care in Patients Receiving Mechanical Ventilation

• Background Comprehensive oral care is an evidence-based prevention strategy to reduce the risk of ventilator-associated pneumonia in patients receiving mechanical ventilation. Until recently, no comprehensive guidelines or standards existed to define necessary tasks, methods, and frequency of oral care to provide patients with optimal results.

• Objectives To observe current practice of, define best practice for, and measure compliance with standardized comprehensive oral care.

• Methods This observational study was part of a larger research study performed at 5 acute care hospitals. Time blocks of 4 hours were randomized over 8 intensive care units and the 7 days of the week. Baseline data were collected before implementation of multifaceted education on an oral-cleansing protocol; interventional data were collected afterward.

• Results Oral care practices were observed for 253 patients. During the baseline period, oral cleansing was primarily via suction swabs. Toothbrushing and moisturizing of the oral tissues were not observed. Only 32% of the patients had suctioning to manage oral secretions. During the interventional period, 33% of patients had their teeth brushed, 65% had swab cleansing, and 63% had a moisturizer applied to the oral mucosal tissues. A total of 61% had management of oral secretions; 38% had oropharyngeal suctioning via a special catheter.

• Conclusions Implementation of an evidence-based oral cleansing protocol improved the care of patients receiving mechanical ventilation. Multifaceted education and implementation strategies motivated staff to increase oral care practices.

Ventilator-associated pneumonia

PURPOSE OF REVIEW

This review summarises some of the notable papers on ventilator-associated pneumonia (VAP) from January 2003 to October 2004.

RECENT FINDINGS

Ventilator-associated pneumonia remains an important drain on hospital resources. All population groups are affected, but patients with VAP are more likely to be older, sicker, and male, with invasive medical devices in situ. Early VAP diagnosis is desirable to reduce VAP mortality and to retard emergence of multidrug-resistant microbes. This may be possible using preliminary culture results or intracellular organism in polymorphonuclear cells. In most intensive care units, Staphylococcus aureus, Pseudomonas aeruginosa, and Acinetobacter baumannii are the commonest organisms isolated in VAP. However, causative organisms vary between and within hospitals. Consequently, individual intensive care units should develop empirical antibiotic policies to target the pathogenic bacteria prevalent in their patient populations. Preventative strategies aimed at reducing aerodigestive tract colonisation by pathogenic organisms, and also their subsequent aspiration, are becoming increasingly important. Educating medical staff about these simple measures is therefore pertinent. To reduce the occurrence of multidrug-resistant organisms, limiting the duration of antibiotic treatment to 8 days and antimicrobial rotation should be contemplated. Empirical therapy with antipseudomonal penicillins plus beta-lactamase inhibitors should be considered. If methicillin-resistant Staphylococcus aureus VAP is a possibility, linezolid may be better than vancomycin.

SUMMARY

Prevention remains the key to reducing VAP prevalence.

The therapeutic challenge of Gram-negative sepsis: Prolonging the lifespan of a scarce resource

Mortality from severe bacterial sepsis remains high. The pathogenesis involves production of pro and anti-inflammatory cytokines which mediate: neutrophil adhesion to the endothelium, diffuse capillary leak, disseminated intravascular coagulation, vasodilatation and mitochondrial dysfunction, all of which culminate in microcirculatory failure. Therapy is multifaceted. As described in 'the surviving sepsis guidelines', many therapeutic interventions, such as early goal-directed resuscitation, low dose intravenous steroids, strict glucose control, recombinant activated protein C and ventilation according to ARDS- net criteria are critical to survival. However appropriate empiric antibiotic therapy initiated early is pivotal. Empiric therapy should be designed with regard to the bacterial epidemiology within the unit and the aim should be to optimise outcome while yet attempting to reduce the potential for resistance development. Antibiotic therapy for resistant organisms consists of the carbapenems, including ertapenem for ESBL's, cefepime, piperacillin/tazobactam and, on occasion, the Gram-negative quinolones, ciprofloxacin and levofloxacin. Consideration should be given to the possibility of 'collateral damage', where overuse of an antibiotic predisposes to multi-drug resistance. Antibiotics should be limited, where possible, to those organisms that are pathogens and not colonisers and should be discontinued if sepsis is not confirmed or there is rapid resolution of clinical indicators of sepsis. De-escalation strategies should be consistently employed and the duration of therapy should be tailored to clinical response. Continuation beyond 8 days is generally detrimental in terms of the potential for superinfection with resistant organisms. Failure of response necessitates, initially, a re-evaluation of source control and obsessive culturing of likely sites of sepsis prior to random antibiotic changes.

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.