Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now, your host, Dr. Sergio Zanotti.
Speaker: Central venous catheters are commonly utilized in the care of critically ill patients.
Speaker: Central venous catheters provide safe and reliable vascular access for delivering a wide range of therapeutics.
Speaker: However, central line-associated bloodstream infection is a significant problem contributing to increased morbidity, mortality, and cost in the ICU.
Speaker: In today's episode of the podcast, we will discuss central line-associated bloodstream infections, CLABSI.
Speaker: Our guest is Dr. Naomi O'Grady, a critical care and infectious disease physician at the National Institutes of Health.
Speaker: She is chief of the Internal Medicine Service and an attending physician in the Clinical Center's Critical Care Medicine Department.
Speaker: Her research focuses on strategies to reduce the incidence of antimicrobial-resistant pathogens in the ICU,
Speaker: and catheter-related bloodstream infections.
Speaker: She's a prolific author and researcher, has served as chair for numerous clinical guidelines, and recently published an excellent review on prevention of central and associated bloodstream infections in the New England Journal of Medicine.
Speaker: Naomi, welcome to Critical Matters.
Speaker: Thank you.
Speaker: Thank you so much for having me.
Speaker: I think a good place to start would be the why.
Speaker: Why should critical care clinicians care about this topic?
Speaker: Well, that's a good question, and I think the answer is because it impacts our patients so dramatically in the ICU.
Speaker: For decades, the ICU has been the focus of measuring central venous catheter-related bloodstream infections, although it's
Speaker: In the last few years, the infection rates for patients outside of the ICU have also been measured routinely in certain areas of the hospital.
Speaker: But traditionally, it's been the ICU where we've had a focus on this infection because it does cause so much morbidity and some mortality associated with the infections.
Speaker: And in the last couple of decades,
Speaker: CLABSI rates have become proxies for measurement of patient safety and clinical quality.
Speaker: So hospital administrators care a lot about this topic.
Speaker: And when their hospitals are being measured by rates of CLABSI, if they have high rates of CLABSI, the assumption is poor hospital quality or poor clinical quality.
Speaker: care, administrators get agitated about that, and they come to the ICU director to find out what can be done about the infection rates.
Speaker: Perfect.
Speaker: And you did mention morbidity and mortality.
Speaker: Could you tell us a little bit more in detail what the literature shows on the impact of a CLABSI on a patient's risk of dying or having complications and also on the cost of care for that patient?
Speaker: Well, sure.
Speaker: You know, the studies, they don't really measure individual costs, but certainly studies have shown that CLABSI causes a lot of
Speaker: Morbidity, morbidity in terms of excessive length of hospital stay, excessive use of antibiotics.
Speaker: And we know antibiotics have their own downside.
Speaker: There was one study that reported...
Speaker: a significant increase in the unadjusted ICU length of stay, which was 24 days compared to five days for patients without CLABSI.
Speaker: The hospital length of stay was increased.
Speaker: The median was 45 days versus 11 days in patients without CLABSI.
Speaker: And then there's always a debate about mortality.
Speaker: One study did measure mortality at 51% versus 28%.
Speaker: in patients without CLABSI.
Speaker: And then hospital costs are enormously increased just based on the excessive length of stay.
Speaker: So in this one study that I mentioned, the hospital cost was $83,544 compared to $23,800.
Speaker: So CLABSI is something that causes, I think,
Speaker: much more morbidity and possibly mortality than we generally think of.
Speaker: And I think it's a great example of how something can be important to patients, important to clinicians, and important to hospital administrators, right?
Speaker: I mean, for multiple reasons, but I do believe that at the end of the day, as clinicians, we need to recognize that
Speaker: The danger it poses for a patient individually is one that we obviously would not want to expose them to.
Speaker: And I think that alone should be a great reason for us to focus on decreasing or preventing them as much as possible.
Speaker: Absolutely.
Speaker: I wanted to ask you a little bit more about epidemiology of CLABSIs.
Speaker: It seems that obviously this became a hot topic after Peter Pronovost's checklist, and a lot of it was discussed outside of medical journals as well.
Speaker: But like you mentioned, it became a focus of attention for high-value care proxy.
Speaker: And it seems that at least per reports it had improved significantly.
Speaker: But then COVID came.
Speaker: What has happened with the rates and where do we stand today?
Speaker: Well, COVID obviously had a very disruptive effect on our health care systems because it strained hospital resources and exhausted our hospital staff.
Speaker: The interesting thing about the pandemic is that it resulted in an abrupt decrease in hospital admissions for patients who had very common conditions and led to a disproportionate increase in the admission of patients with severe illness.
Speaker: So in addition, the healthcare provider component of the healthcare system was stressed.
Speaker: So what we saw during the pandemic was that essentially 20 years of improvement in CLABSI rates disappeared in about 10 minutes with all of the stress that the health care system was exposed to.
Speaker: So we had things like, when I say providers were stressed, well, they were not only stressed by the numbers of patients they were caring for, but they were stressed by the potential for exposure to infection.
Speaker: So what happened was there were fewer healthcare provider to patient contacts or interactions leading to reduced patients
Speaker: care and maintenance of these catheters.
Speaker: Lines were disrupted by long IV poles and tubing hanging out in the hallway and maybe 20 feet away from the patient's bedside.
Speaker: We had patients that did not receive chlorhexidine baths the way that they have been recommended.
Speaker: And some of that is not related to healthcare
Speaker: providers, but is related to the fact that chlorhexidine wipes were in short supply.
Speaker: And sometimes we were unable to even get any.
Speaker: There were fewer bedside checks on catheters.
Speaker: You know, protocols for, for example, scrubbing the hub for 15 seconds.
Speaker: Well, when health care providers are stressed and their time is at a premium, they don't spend 15 seconds scrubbing the hub of a catheter before accessing it.
Speaker: So lots of little details like that crept in during the pandemic and our rates skyrocketed.
Speaker: Where do we stand today?
Speaker: Today, I think we are getting back to our baseline numbers, but the healthcare system is still stressed.
Speaker: And we learned a lot of things during the pandemic that exposed the fragility and the vulnerabilities in our infection prevention systems.
Speaker: And I think today we can still do better.
Speaker: And I think that in terms of timing, also very important for us to talk about this topic today, because like you said, after the stress, some systems probably have a little bit more resilience than others.
Speaker: But as a whole, I think that that fragility was exposed and there's still a lot of opportunity for us to improve care.
Speaker: A ton, a ton of a lot of a lot of opportunity.
Speaker: And I think it's an important point for our listeners, because this is one of those topics that we've all talked about.
Speaker: We all know about, right?
Speaker: Yet, there's still a lot to do.
Speaker: And the fact that we still have a lot of room for improvement, I think should be enough motivator for all of us to try to move the needle in the right direction.
Speaker: Yeah, I would agree with that.
Speaker: And, you know, I think one thing that the pandemic did teach us was that when we rely on
Speaker: The human element, in other words, health care providers and people as resources, let's say, there's a lot of opportunity for mistakes to happen compared to relying on an engineered system, for example.
Speaker: And I'll talk a little bit more about these prevention systems, but we know we have antibiotic impregnated catheters or antiseptic impregnated catheters.
Speaker: We have...
Speaker: chlorhexidine impregnated dressings, we have alcohol, alcoholic caps that we can put on the hubs of catheters, and little technological improvements like that.
Speaker: When we rely on those things a little more repeatedly, we are able to build some redundancy into the system and some resilience into a system that is currently highly fragile.
Speaker: Excellent.
Speaker: So can we move on to some definitions in pathophysiology?
Speaker: And I think that these are terms that are commonly utilized interchangeably, but they, I don't think, mean the same thing.
Speaker: And I just wanted you to clarify for us.
Speaker: So CLABSI is central line associated bloodstream infection, and CRBSI is central line related bloodstream infection.
Speaker: I hear people talk about both of them as they're the same.
Speaker: Is it the same or is there a difference?
Speaker: Well, there is a difference and the difference is nuanced, but these terms are somewhat, they are used interchangeably, I would say.
Speaker: And when you look at studies that examine the problem, sometimes studies use the definition of CLABSI and sometimes they use the definition of catheter-related bloodstream infection.
Speaker: And that may, it may compromise some of the validity of the evidence because they are used interchangeably.
Speaker: But to get to what CLABSI is, it is a surveillance definition.
Speaker: So the CDC defines CLABSI as a laboratory-confirmed bloodstream infection in a patient who has had a central line in place for more than 48 hours before the date on which the blood culture was drawn.
Speaker: if no other source of bacteremia is identified.
Speaker: So this, again, is a surveillance definition and not a clinical definition because there is no requirement for a patient to have signs or symptoms of infection.
Speaker: Now, because it's often difficult to determine whether the bloodstream infection is related to the central line or whether it's a secondary source such as an abdominal abscess or pneumonia, the NHSN definition may actually overestimate the true incidence of central line-associated infections.
Speaker: But this is a definition used by the NHSN network because it's easy to apply to areas of the hospital where tracking the rates of CLABSI is important.
Speaker: So if it's applied consistently, it will provide very useful information on an institution's trends towards reduced or increased CLABSI.
Speaker: Now, the catheter-related bloodstream infection definition is
Speaker: It's a clinical definition used for the diagnosis and treatment of a patient at the bedside, basically.
Speaker: It requires the specific laboratory testing that...
Speaker: identifies a bloodstream infection.
Speaker: It meets the criteria of the surveillance definition.
Speaker: In other words, it's all of those components of the surveillance definition plus a patient with signs and symptoms of infection.
Speaker: That could be either fever, elevated white count, or erythema at the catheter exit site.
Speaker: It can be influenced by a variety of other factors such as catheter removal, laboratory resources such as quantitative blood cultures or time to positivity,
Speaker: But catheter-related bloodstream rates are not used for surveillance because the definition is complex, and the process of establishing the catheter as the source of the infection would make the broad application for epidemiologic purposes very challenging.
Speaker: So in other words...
Speaker: It sometimes takes a day or two to sort this out.
Speaker: Whereas if you are using the CLABSI definition, you can look at all your bloodstream infections in a particular unit, say the ICU, and you would just have somebody count the number of bloodstream infections and count the number of patients with catheters, and you would come up with a CLABSI rate.
Speaker: Again, that might overestimate the actual true rate of infection.
Speaker: I think it's important, even though it's nuanced, because as physicians and APPs in the ICU care for these patients, understanding what we're talking about is important, and what we're measuring, I think, is also important.
Speaker: How do these catheters get infected?
Speaker: How do we develop a catheter-related bloodstream infection?
Speaker: What's the pathophysiology in terms of roots of contamination?
Speaker: Sure.
Speaker: Well, there are essentially four routes for contamination.
Speaker: The most common are the first two.
Speaker: First, skin pathogens at the insertion site enter the cutaneous catheter tract and then migrate down the external surface of the catheter toward the catheter tip.
Speaker: This most commonly happens within the first seven days after catheter placement, and it's thought to occur at the time of insertion.
Speaker: So insertion site contamination can also happen when the skin microorganism density increases underneath the catheter dressing over time.
Speaker: And if this area is not decontaminated frequently, microorganisms can migrate down that external surface of the catheter.
Speaker: Second, the intraluminal contamination happens when the catheter hub is manipulated.
Speaker: This happens when blood is drawn through the catheter or medications are infused through the catheter.
Speaker: Pathogens gain access to the intraluminal surface of the device where they adhere and become incorporated into the biofilm.
Speaker: This allows for sustained infection and hematogenous dissemination.
Speaker: This type of contamination typically happens more than seven days after the catheter has been inserted, and it's related to care and maintenance of the catheter, as well as the number of times the catheter is accessed or manipulated.
Speaker: Less commonly, catheters become contaminated hematogenously from a secondary bloodstream infection that develop from another focus of infection, for example, a pneumonia or urinary tract infection.
Speaker: Bacteria stick to the biofilm that is formed and adhere to the internal lumen of the catheter.
Speaker: And then lastly, in rare cases, contaminated infusate taints the catheter.
Speaker: In other words, there have been reports of outbreaks with contaminated injectable flushes and such things.
Speaker: So those are the four basic ways that catheters become contaminated.
Speaker: Is there one in particular that is overwhelmingly more commonly seen?
Speaker: Yes.
Speaker: Well, I think it depends on your institution, but in general, the most common way is the intraluminal contamination that happens when the catheter is manipulated is probably the most common way.
Speaker: We've gotten very good at inserting catheters using aseptic technique, using chlorhexidine as skin antisepsis and large sterile drapes as barrier precautions.
Speaker: So catheters rarely are infected at the time of insertion, unless, of course, they've been put in under duress or in an emergency situation or in an obvious situation where there's contamination.
Speaker: But in general, we've gotten quite good at inserting these aseptically.
Speaker: So catheters,
Speaker: The most common way of catheters becoming contaminated is really with the manipulation of the catheter after seven days from insertion.
Speaker: Perfect.
Speaker: And I think it's important just to highlight that to our listeners.
Speaker: Our audience, obviously, is mostly composed of physicians and APPs.
Speaker: And our role in these catheters is usually heavily focused on the insertion because that's what we do.
Speaker: Right.
Speaker: And and I think a lot of times a lot of focus in trying to analyze collapse cases on the insertion.
Speaker: But the most common cause, like you said, in most ICUs would be, I mean, the manipulation.
Speaker: And we need to be very well aware of that.
Speaker: Yes.
Speaker: But, you know, we are pretty good at maintaining catheters for long, long periods of time without any consequence of infection.
Speaker: So it can be done if we pay attention to the details.
Speaker: Perfect.
Speaker: What about risk factors for CLABSI?
Speaker: Obviously, we think of it as a preventable disease or a problem, and that in many cases is true, but there are also risk factors at different levels that are important to understand.
Speaker: Yes, for sure.
Speaker: I like to think of risk factors divided into sort of three different categories.
Speaker: First are patient factors, which are certain risk factors.
Speaker: So
Speaker: Patients who are immunocompromised, such as patients who are receiving cancer treatments, patients who are neutropenic, patients who have burns.
Speaker: Malnutrition is a big risk factor.
Speaker: Patients who have a BMI greater than 40 are at risk.
Speaker: So patient factors are one category of risk factors.
Speaker: Provider factors are another category of risk factors.
Speaker: So when I think of provider factors, I think about catheters being inserted under emergency conditions.
Speaker: I think about incomplete adherence to aseptic technique.
Speaker: Low patient, I'm sorry, low nurse to patient ratio is another risk factor.
Speaker: And
Speaker: That just reflects the demand on nursing time to, you know, if there's a low nurse-to-patient ratio, nurses have lots of patients, and they just don't have the time to spend carrying and maintaining that catheter in the best possible condition.
Speaker: And then lastly, failure to remove unnecessary catheters.
Speaker: I would consider a provider risk factor.
Speaker: And then lastly, there are device factors.
Speaker: So the catheter material, the catheter insertion site, for example, the
Speaker: The femoral site has a higher risk for infection than the subclavian site.
Speaker: The subclavian site is the site for the lowest risk for infection.
Speaker: Of course, there are other risks associated with putting a catheter into the subclavian site, but that is a device factor.
Speaker: And then the
Speaker: The last device factor that I would consider is the indications for its use.
Speaker: So if you need a catheter for hemodialysis or you need a catheter for pulmonary artery measurements, those types of catheters have a slightly higher risk than a standard catheter for access.
Speaker: Perfect.
Speaker: So I guess we can talk about really the prime topic here, which is prevention of clapsies, right?
Speaker: I mean, ultimately, what we want to do is prevent these as much as possible.
Speaker: And I think there is...
Speaker: Evidence-based prevention, and then there seems to be game-ship-based prevention in many institutions, and we can talk about those later, but I would like to start with sticking to the evidence.
Speaker: What have been evidence-based approaches that can help us reduce that number of CLABSIs?
Speaker: Well, I'll start with checklists.
Speaker: Checklists are basically one prevention strategy that has been shown to reduce rates of infection by using step-by-step instructions on how to insert the catheter with the use of standard infection prevention practices and aseptic technique.
Speaker: Usually the list begins with hand hygiene and works through all the steps related to infection control, including gowning, gloving, masking, draping the patient, and applying the antiseptic agents to the patient's skin.
Speaker: They've been shown to improve adherence to infection control practices at the time of insertion and to reduce the incidence of infection.
Speaker: It's usually completed by someone who is directly observing the procedure, and the thought is that this approach helps the members of the procedure team focus their attention on the details in the list and makes them less prone to skipping any of the small but very important steps.
Speaker: The second approach
Speaker: area of prevention would be catheter insertion kits.
Speaker: This is the use of an all-inclusive catheter insertion kit or a bundle, which has been shown to reduce the risk of CLABSI by ensuring that everything that's needed for the successful insertion of that central line is in one place, thus making it easy to do the right thing and more difficult to make a mistake.
Speaker: So for example, choosing the correct antiseptic agent, CLABSI.
Speaker: for the skin is no longer a decision that the proceduralist needs to make if the agent comes bundled in the kit or in the catheter insertion cart.
Speaker: So these kits usually contain all the necessary components for completion of the sterile procedure, including the gowns, the gloves, the masks, the drapes, the antiseptic agent, the local anesthetic, and of course the catheter itself.
Speaker: Maximal sterile barrier precautions.
Speaker: That's another one that's defined as wearing a mask, a cap, a sterile gown, and sterile gloves and placing a large sterile drape that fully covers the patient's entire body.
Speaker: The use of the maximal sterile barrier precaution during catheter placement has been associated with reduced incidence of CLABSI as compared with the use of just sterile gloves and a small drape alone.
Speaker: Of course, I don't have to mention hand hygiene because hand hygiene has become so ingrained to all of us, I hope.
Speaker: Well, I would push back there.
Speaker: I think we do have to mention it.
Speaker: I do find it interesting that for probably the single most impactful intervention in medicine and saving lives, we're still not perfect at it.
Speaker: Well, it's a good point.
Speaker: Hand hygiene before the insertion is, let me put it this way.
Speaker: Sterile gloves are not a substitute for hand hygiene.
Speaker: We always want to do hand hygiene prior to the donning of the sterile gloves.
Speaker: Hopefully the checklist is,
Speaker: uh, ensures that everybody's doing hand hygiene before embarking on the procedure.
Speaker: But, uh, hand hygiene, you know, it, it requires, it's an essential, uh, part of the, uh, part of the procedure.
Speaker: It, uh, involves washing with either conventional soap and water or with an alcohol-based waterless hand scrub.
Speaker: Uh, the alcohol-based sanitizer is preferred for hands that are not visibly soiled.
Speaker: Um,
Speaker: Alcohol-based products should be applied according to the manufacturer's guidelines on the dispensing product.
Speaker: Typically, it's 3 to 5 cc's applied to the palm of the hands, and the fingers are rubbed vigorously for usually about 20 seconds and allowed to dry before donning your sterile gloves.
Speaker: Perfect.
Speaker: And you did mention chlorhexidine.
Speaker: So there's definitely a lot of literature that has emerged on chlorhexidine, antisepsis, dressings, and bath bathing of patients.
Speaker: Can you tell us a little bit more about that, Naima?
Speaker: Sure.
Speaker: Well, I'll start with chlorhexidine as skin antisepsis.
Speaker: There has been a lot of literature that has come out in the last decade or two that a preparation containing at least 2% chlorhexidine gluconate at the time of insertion has become the standard of care based on multiple randomized trials showing a reduced incidence of CLABSI using the chlorhexidine compared to the povidone iodine.
Speaker: Now, although both antiseptic preparations have broad-spectrum antimicrobial activity, the superior clinical protection provided by the chlorhexidine is probably related to a more rapid onset of action and a shorter drying time,
Speaker: owing to the combination of alcohol and the residual effect at the site of the catheter insertion by the chlorhexidine thought to last maybe a few days.
Speaker: Chlorhexidine has been added to dressings, and they've been available for more than a handful of years, I think even more than a decade.
Speaker: So,
Speaker: There is a chlorhexidine impregnated sponge dressing that is used to cover the catheter insertion site.
Speaker: There is also an available chlorhexidine impregnated translucent dressing.
Speaker: It's basically a chlorhexidine coated tape, if you will, that goes over the catheter exit site.
Speaker: There are advantages and disadvantages to both of these.
Speaker: The sponge dressing is an opaque dressing, so you can't actually visualize the catheter insertion site properly.
Speaker: while that dressing is in place and that dressing is designed to stay in place for up to seven days.
Speaker: So you put that dressing on and it should not be disrupted for seven days, but you have to acknowledge that you're not going to be looking at the insertion site for those seven days.
Speaker: The chlorhexidine coated tape is a translucent tape coated with that chlorhexidine preparation.
Speaker: You are able to visualize the catheter exit site, but that dressing is extremely sticky, and patients complain about it from time to time because it is quite sticky.
Speaker: And then lastly, chlorhexidine bathing.
Speaker: So chlorhexidine baths basically consist of wiping the patient down like a sponge bath using a chlorhexidine sponge or a chlorhexidine wash or wipe daily.
Speaker: And that has been shown to reduce catheter-related bloodstream infection as well.
Speaker: So chlorhexidine has really revolutionized our ability to keep these catheters in place safely.
Speaker: Now, you mentioned the chlorhexidine dressings, right, with evidence to support its use, yet I don't think it's commonly utilized or maybe not utilized as much as it could be due to cost concerns, I presume.
Speaker: Any thoughts on that?
Speaker: Well, I...
Speaker: I think that some of it, I think, depends on how well these products are marketed in terms of whether or not you're using them.
Speaker: But the data is clearly in favor of reduced CLABSI rates when these dressings are utilized.
Speaker: I'm not sure if it's a cost issue because I don't think they're terribly expensive.
Speaker: It's possibly a...
Speaker: a familiarity issue, and there may be some... There may be some...
Speaker: issues about wondering which patients would really benefit.
Speaker: In other words, if you're going to have a central line in place for only two or three days, there sometimes is that thought in the back of people's head that, well, it's not going to be in place for that long.
Speaker: We don't need to use all of these technologically advanced ways of preventing infection because we're going to pull the catheter out in two or three days.
Speaker: I would say that that's sort of a false line of reasoning.
Speaker: Okay, perfect.
Speaker: And another area that you did mention a little bit, but I just wanted to reemphasize because it's also a source of discussion among clinicians is site selection.
Speaker: Well, there have been lots of studies looking at site selection in terms of the best
Speaker: place for a catheter for reduced infection.
Speaker: And the subclavian site is the preferred site for reducing risk of CLABSI.
Speaker: In the non-ICU setting, the difference in infection risk among insertion sites is less clear, but the influence of the site on the risk of CLABSI is related in part to the density of the skin flora at the site.
Speaker: So the femoral catheter has the highest colonization rate, and in some studies, it
Speaker: are associated with higher incidence of CLABSI than catheters inserted at the subclavian or the internal jugular site.
Speaker: All three sites have some pluses and minuses associated with them, but in terms of the lower risk for CLABSI, the subclavian site is the preferred site.
Speaker: Perfect.
Speaker: And the last thing I wanted to ask you about in terms of prevention is the use of antibiotic and antiseptic impregnated catheters or antibiotic antiseptic impregnated hubs and caps.
Speaker: Well, sure.
Speaker: Catheters impregnated with chlorhexidine, silver sulfadiazine, or minocyclin and fampain have been studied for more than 20 years and have been shown to be very effective in reducing the risk of CLABSI.
Speaker: When these catheters were first introduced, they were expensive.
Speaker: They were certainly more expensive than standard catheters, and that higher cost prevented widespread adoption since the cost-benefit ratio was not perceived to be very favorable.
Speaker: But over the years, the costs have decreased, and these catheters have been recommended for use in hospital units or special patient populations that have
Speaker: high incidence of CLABSI despite compliance with the essential prevention practices of gowns and gloves, hand washing, large barrier precautions, etc.
Speaker: So I think that antibiotic and antiseptic impregnated catheters certainly have a role.
Speaker: Many studies investigating the effectiveness of these catheters were performed before chlorhexidine-based skin antisepsis became the standard of care.
Speaker: Now, some data suggests that for patient care units with a very low incidence of CLABSI, the use of these antimicrobial impregnated catheters may not provide additional benefit.
Speaker: But what I would posit is that the
Speaker: COVID-19 pandemic showed how fragile our healthcare system is.
Speaker: And if we can rely on things like antimicrobial impregnated catheters more firmly, I think we would have a better chance of not having such dramatic spikes in catheter-related bloodstream infection during times of crisis.
Speaker: I would liken it to the use of seatbelts in automobiles, actually.
Speaker: Years ago, we didn't have any seatbelts.
Speaker: Your parents threw you in the back of the car on a bench seat, and nobody had a seatbelt.
Speaker: Then we had a lap belt, which we complained about, and then they added a shoulder strap, which we also complained about.
Speaker: Now we have...
Speaker: shoulder straps and airbags and side airbags.
Speaker: And no one has shown, you know, the incremental contribution to each.
Speaker: And we also acknowledge that you don't benefit from these things unless you get into a wreck.
Speaker: So I would liken the whole CLABSI situation and the idea that we shouldn't be using, you know, antimicrobial impregnated catheters or antimicrobial impregnated dressings, that we shouldn't be using them on everyone,
Speaker: to sort of the automobile analogy.
Speaker: I mean, we should be using them.
Speaker: And I think it's a great analogy.
Speaker: And also, I think, speaks to the fact that this is not a zero sum game.
Speaker: It's additive and synergistic, right?
Speaker: We have these evidence based interventions, the idea is to add layers of resiliency, that we can decrease the number at a large scale.
Speaker: And
Speaker: And I do believe that the fact that you haven't had a clapsy at your ICU for X amount of months or years is great, but it doesn't mean that something like COVID can happen and that goes just out the window very, very quickly.
Speaker: Exactly.
Speaker: Perfect.
Speaker: So...
Speaker: Just a comment maybe on the gamemanship part of it, right?
Speaker: I do believe that a lot of times people are just fudging with definitions as opposed to really working on improving processes with a lot of healthcare-related quality measures.
Speaker: And ultimately, as clinicians, I think our goal is always or should be always to improve care.
Speaker: Any comments on that real quickly, Naomi?
Speaker: Well, you know, certainly...
Speaker: In 2008, I'll talk a little bit about the public policy aspect of it.
Speaker: In 2008, as part of an effort to encourage hospitals to strengthen their CLABSI prevention measures, Medicare and Medicaid stopped reimbursement for the treatment of hospital-acquired infections that were not present on admission.
Speaker: So this change in policy shifted the cost of CLABSI acquired in the health care system to the hospital or the nursing home or the rehab facility where the CLABSI was acquired.
Speaker: Now, several studies have reviewed the effects of these financial penalties on CLABSI.
Speaker: hospital CLABSI rates.
Speaker: And while one study showed no effect and another showed a decline in infection rates, and a third one showed no change in infection rates, one of those studies did report a change in the provider's coding patterns with an increase in codes that categorized the infections as present on admission.
Speaker: So the findings suggest that the financial penalties may change practice patterns and
Speaker: But one concern is that these policies provide an incentive to stop ordering blood cultures for patients with catheters.
Speaker: If you do less testing, you would lower your detection rates and improve hospital performance without actually changing clinical care at the bedside.
Speaker: So, you know, in addition to that, financial penalties put forward back in 2008.
Speaker: At about the same time, several states were passing laws requiring public reporting of hospital-acquired infections.
Speaker: So in my mind, it's difficult to determine how those policies affect clinical care, but they put pressure by design on hospital administrators to reduce CLABSI rates within their institution,
Speaker: So these pressures lead to unintended consequences, such as how changes in CLABSI definitions are applied or how CLABSI is detected.
Speaker: And I think that also, like you mentioned, it leads to people coming up with strategies like, let's put more PICC lines, or now they're using midline catheters.
Speaker: Any comments on that?
Speaker: Yeah, they are.
Speaker: People are finding all kinds of ways to avoid using central lines because because they want to reduce their central line.
Speaker: bloodstream infection rate.
Speaker: Substituting one catheter for another just so that you don't have to count it as part of your rate doesn't really change care at the bedside or the care we provide to the patient.
Speaker: One thing that I've always been in favor of is simplifying the definition so that we collect all hospital-acquired bloodstream infections.
Speaker: not just central lines.
Speaker: We know that PICC lines are central lines, so let's be clear about that.
Speaker: We know that midline catheters, we know that peripheral IVs, we know that arterial catheters also have bacteremia associated with them.
Speaker: And so simplifying the definition of
Speaker: of how we collect, simplifying the definition and collecting all hospital-acquired bacterimia would do everybody a favor because it would,
Speaker: It would allow us to grapple with the extent of the problem.
Speaker: Right now, we don't know how extensive the problem is because we are not counting the peripheral, the arterial, or the midline catheters.
Speaker: So I think...
Speaker: I think in the next few years, we will see a push towards simplifying this definition such that we could use the electronic medical record to help us acquire all the data rather than relying on people with clipboards to run around in the ICU and count the number of catheters and count the number of bloodstream infections manually.
Speaker: Absolutely.
Speaker: Absolutely.
Speaker: We talked a lot about prevention, but sometimes catheter-related bloodstream infections do occur.
Speaker: And you did mention also that we have changed our behavior towards cultures, and people have all sorts of rules for blood cultures in these catheters.
Speaker: Could we just talk as we close a little bit about how do you diagnose and treat a true catheter-related bloodstream infection?
Speaker: Well, sure.
Speaker: The first thing you need is a positive blood culture.
Speaker: So we tend to use a lot of time to positivity.
Speaker: So these are blood cultures taken, ideally, one from the catheter and one peripherally.
Speaker: That doesn't always happen, but in patients who have, say, two different catheters, you could draw blood cultures from both catheters.
Speaker: And in a situation where one culture turns positive...
Speaker: two hours more than the other blood culture, that time to positivity is sort of a poor man's quantitative culture and gives you an indication that that catheter is the source of the bacteremia.
Speaker: The antibiotic selection for a
Speaker: A bloodstream infection is obviously based on the organism and the sensitivity pattern, but we have to be clear about pulling the catheter, and the duration of antibiotic treatment is usually about seven days for a typical organism.
Speaker: With Staph epi,
Speaker: That's typically, it's typically a contaminant, although it is listed as the CDC's, one of the CDC's most common organisms that infect catheters.
Speaker: There is some literature that indicates you can pull those catheters and not use antibiotics to treat the bacteremia, although I would not particularly recommend that.
Speaker: I think a five to seven day course treating the Staph epi is appropriate.
Speaker: There are some studies that indicate you could treat through an infection, meaning leaving the catheter in place, giving antibiotics to which the organism is sensitive, and treating that for 7 to 10 days.
Speaker: That is typically used in a patient who has a very short-term need for the catheter, knowing that we're going to pull the catheter out in two or three days and there won't be a need for that catheter, or that the patient is going to be getting a more permanent catheter in a few days' time.
Speaker: I don't think that treating catheters in place often
Speaker: usually has a good long-term resolution.
Speaker: These typically relapse after several days of no antibiotics.
Speaker: So pulling the catheter is the ideal practice.
Speaker: Perfect.
Speaker: Any other things you want to add as we close?
Speaker: Well, I think, you know, again, I would emphasize what I've talked about earlier, which is relying more firmly on new and novel technologies such as antimicrobial impregnated catheters, impregnated dressings, alcoholic caps, and things that don't depend on people themselves.
Speaker: spending lots of time at the patient's bedside, you know, scrubbing the hub for 15 seconds and attending to aseptic technique and cleaning the exit site of the catheter daily.
Speaker: It's not that these practices shouldn't be done.
Speaker: They absolutely should be done in addition to the new technologies that we have.
Speaker: Again, I think that...
Speaker: making the argument that we don't know what the impact of each component of these strategies are, what value each technology adds, I think using them all together adds redundancy and resilience to a very fragile system.
Speaker: And the more we can rely on that, I think the less risk we are at risk
Speaker: the less risk we have in facing our next health care crisis with spiking infection rates all over the place.
Speaker: Absolutely.
Speaker: And I think that we don't put enough emphasize on improving the system.
Speaker: And I think over and over again, outside of medicine, it's been demonstrated and also in medicine that a bad system will beat good people every single time.
Speaker: Right.
Speaker: So it's not about having not having good intentions, but I think it's just making the system more robust.
Speaker: Mm hmm.
Speaker: Perfect.
Speaker: Well, Naomi, I really appreciate you sharing your expertise with us.
Speaker: On the podcast, we like to close with a couple of questions that are unrelated to the clinical topic, just to tap into the knowledge of our guest.
Speaker: Would that be okay?
Speaker: Sure.
Speaker: So the first question relates to books.
Speaker: Are there any books that have influenced you significantly or books that you have gifted often to other people?
Speaker: Oh, that's a tough one.
Speaker: There have been so many important books.
Speaker: I think one of the most influential was long ago when I read the Nancy Drew Mystery Series.
Speaker: Those books ignited my general interest in reading and specifically in solving mysteries.
Speaker: I think that's kind of how important teamwork is in seeing the whole picture and considering alternatives.
Speaker: I love the Nancy Drew mysteries, and I've given them to lots of kids.
Speaker: Perfect.
Speaker: And I think it's a great way for people to start reading, right?
Speaker: Give them something that is interesting at an early age and capture that interest, which I think, unfortunately, is an interest that might be going in the wrong direction.
Speaker: The second question is, what do you believe to be true in medicine or in life that most other people do not believe or at least don't behave like they believe?
Speaker: I think luck favors the prepared.
Speaker: I think that is true in life.
Speaker: I think that is true in medicine for health care conditions, for illnesses.
Speaker: I think a lot of people don't believe that, but luck does favor the prepared.
Speaker: Perfect.
Speaker: And the last would be just anything you want our listeners to know.
Speaker: Could be a thought, a quote, a fact, just to close.
Speaker: Sure.
Speaker: Put your own oxygen mask on before helping others.
Speaker: How's that?
Speaker: I think this quote, we hear it on airplanes all the time, right?
Speaker: But this really emphasizes the importance of self-care and maintaining strong interpersonal relationships outside of work in order to be your best self and be the best doctor you can be.
Speaker: Absolutely.
Speaker: And I think it's a perfect place to stop.
Speaker: Again, thank you for sharing your time and expertise with us.
Speaker: I hope that we will have you back as a guest to talk about other important topics in critical care and look forward to talking with you soon.
Speaker: Thank you for having me.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound's transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
