Implementation of central line-associated bloodstream infection prevention bundles in a surgical intensive care unit using peer tutoring

Park et al. Antimicrobial Resistance and Infection Control Implementation of central line-associated bloodstream infection prevention bundles in a surgical intensive care unit using peer tutoring Sang-Won Park 0 1 Suhui Ko 1 Hye-sun An 1 Ji Hwan Bang 0 1 Woo-Young Chung 0 2 0 Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine , 20 Boramae-ro 5-Gil, Dongjak-gu, Seoul 07061 , Republic of Korea 1 Infection Control Office, Boramae Medical Center , Seoul , Republic of Korea 2 Intensive Care Units, Boramae Medical Center , Seoul , Republic of Korea Background: Central line-associated bloodstream infections (CLABSIs) can be prevented through well-coordinated, multifaceted programs. However, implementation of CLABSI prevention programs requires individualized strategies for different institutional situations, and the best strategy in resource-limited settings is uncertain. Peer tutoring may be an efficient and effective method that is applicable in such settings. Methods: A prospective intervention was performed to reduce CLABSIs in a surgical intensive care unit (SICU) at a tertiary hospital. The core interventions consisted of implementation of insertion and maintenance bundles for CLABSI prevention. The overall interventions were guided and coordinated by active educational programs using peer tutoring. The CLABSI rates were compared for 9 months pre-intervention, 6 months during the intervention and 9 months post-intervention. The CLABSI rate was further observed for three years after the intervention. Results: The rate of CLABSIs per 1000 catheter-days decreased from 6.9 infections in the pre-intervention period to 2.4 and 1.8 in the intervention (6 m; P = 0.102) and post-intervention (9 m; P = 0.036) periods, respectively. A regression model showed a significantly decreasing trend in the infection rate from the pre-intervention period (P < 0.001), with incidence-rate ratios of 0.348 (95% confidence interval [CI], 0.98-1.23) in the intervention period and 0.257 (95% CI, 0.07-0.91) in the post-intervention period. However, after the 9-month post-intervention period, the yearly CLABSI rates reverted to 3.0-5.4 infections per 1000 catheter-days over 3 years. Conclusions: Implementation of CLABSI prevention bundles using peer tutoring in a resource-limited setting was useful and effectively reduced CLABSIs. However, maintaining the reduced CLABSI rate will require further strategies. Central line-associated bloodstream infection; Intensive care unit; Education; Intervention; Learning by teaching; Peer tutoring Background Central line-associated bloodstream infection (CLABSI) is one of serious healthcare-associated infections that cause increased medical costs, morbidity and mortality; however, CLABSIs have been prevented in many developed and developing countries using multifaceted approaches [ 1–5 ]. Several guidelines for the prevention of CLABSIs are available, but the core contents of the evidence-based recommendations are shared in common [ 6, 7 ]. Although the objectives of the CLABSI prevention guidelines are evident and simple, the implementation of these guidelines in clinical practices requires many factors to be well-coordinated. Heterogeneity in compliance or performance with the guidelines exists worldwide, and interventions have not always been successful [8]. The importance of infection control in healthcare settings for patient safety and quality of care cannot be emphasized enough, but the available resources including expert personnel, reimbursement systems and managerial support are not always sufficient to deal with many active issues in most healthcare facilities. Different strategies for different regional or institutional situations are needed for the successful implementation of CLABSI prevention guidelines. The education of and feedback from healthcare workers are core components of implementing an intervention program. The education component should be organized in a manner that allows the healthcare workers to collaborate, learn from, and support each other. We used ‘learning by teaching method’-based education to implement CLABSI prevention bundles in a surgical intensive care unit (SICU) with a high CLABSI rate. This peer tutoring approach was intended to motivate the healthcare workers to actively participate in their own workplace problems and to develop a safety culture in the unit through the sharing of a common understanding. Methods Setting and subjects This study was conducted in a surgical intensive care unit at a 767-bed tertiary hospital. The SICU had 15 beds, and most of the beds were occupied by patients from the neurosurgery and thoracic surgery departments. The patient to nurse ratio was 3:1. The SICU did not have a full-time intensivist responsible for overall clinical care but instead had a medical director whose main responsibility was administrative. All patients admitted to the SICU during the study per (...truncated)