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Veterans Health Administration


Nationwide Program to Reduce Hospital-Associated Infections

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By following a simple checklist when inserting a central line into a patient, VA medical teams have reduced central line infections by more than half.

Central Line Infections Reduced by More Than Half in VA Intensive Care Units

The fact is, when you get admitted to the hospital — any hospital — your chances of developing some kind of infection go way up. Sad but true.

In a lot of cases, these infections are avoidable.

“Of the 1.7 million hospital patients who annually experience a health care-acquired infection, one third likely could have been prevented,” said Dr. Marta Render of the Department of Veterans Affairs.

“Of the 1.7 million hospital patients who annually experience a healthcare-acquired infection, one third likely could have been prevented.”

— Dr. Marta Render, Department of Veterans Affairs

Render, who is chief of VA’s Inpatient Evaluation Center in Cincinnati, said the three health care-associated infections that are most common — and most serious — are those caused by a catheter in the bladder, a mechanical ventilator (also known as a breathing machine), and what medical professionals call a ‘central line’ — a long catheter inserted into a large vein in the neck, chest, or groin. Central lines are used to administer medication or fluids, obtain blood tests, or directly obtain cardiovascular measurements.

“At VA we figured out a fairly simple way to reduce central line infections,” Render explained. “In fact, we’ve reduced them by more than half in all 174 intensive care units, or ICUs, throughout VA.”

So how’d they do it?

“We went into all our ICUs and gave them a protocol to follow,” Render explained. “It’s a checklist of things doctors and nurses need to do before they insert a central line into a patient. Most importantly, we trained our ICU medical teams how to do these things, and we measured how well each ICU stuck to the program.”

“You can’t just tell people to do things a certain way,” observed Dr. Peter Almenoff, VA’s Assistant Under Secretary for Health for Quality and Safety. “You have to show them how to do it. At first, our medical teams regarded the checklist as just one more bureaucratic chore. But then, once they started seeing positive results from following the checklist, they wanted to keep doing it. Success is a powerful incentive for continuing to do something.”

“When ICU nurses saw their infection rates drop by more than 50 percent, they enforced use of the protocol,” Render added. “ICU nurses are incredibly protective of their patients.”

So what’s on the checklist, anyway? Here are the highlights:

Wash your hands. “ICUs are busy places,” Almenoff said. “A lot of things are going on at once. Even seasoned professionals in a hurry can sometimes forget to do something as basic as washing their hands before they touch a patient. But when there’s a checklist, your team helps you remember to do it.”

Dress appropriately: put on your cap, your mask, your sterile gown, your sterile gloves.

Use the correct antiseptic to sterilize the incision site: the one that works best, and quickly. “We want all our ICUs using the exact same product,” Render noted. “We want uniformity.”

Finally, avoid inserting the central line in the femoral area, if possible. “The femoral vein is located in the groin area,” said Almenoff. “The femoral vein is nice and big, and therefore tempting as a point of entry. But the groin area is not exactly the cleanest place on the human body. Better to go for a large vein in the chest, or neck. It’s a cleaner area.”

Render said that in addition to its ICUs, VA is now implementing its central line insertion ‘checklist’ at all of its nursing homes, community living centers, acute care facilities, and dialysis centers

“None of this would have happened without support from our leadership,” she noted. “We had total commitment from leadership on this — at the ICU level, the hospital level, the VISN [Veteran Integrated Service Network] level, all the way up to the Under Secretary. Buy-in from leadership is essential. Thankfully, our VA leadership is 100 percent committed to patient safety.”

A scientific paper explaining how VA reduced central line infections appeared in the British Medical Journal (online version) on April 2. It was written by Render and Almenoff, along with Rachael Hasselbeck and Ron Freyberg of the VA Inpatient Evaluation Center in Cincinnati, Ohio; and Timothy Hofer and Anne Sales of the VA Health Services Research Center of Excellence in Ann Arbor, Mich.