Editorials
“Near zero” catheter-related bloodstream infections: Turning dreams
into reality*
C atheter-related bloodstream
infection (CR-BSI) is a fre-
quent complication in the
intensive care unit (ICU)
setting. Paradoxically, the presence of
CR-BSI, which contributes substan-
tially to increase patient’s morbidity,
hospital costs, and ICU length of stay,
is largely preventable (1). In fact, care
bundles on line insertion have been ef-
fective to reduce CR-BSI rates. In the
Keystone ICU Project, Berenholtz and
colleagues (2) showed that implementa-
tion of an evidence-based bloodstream
infection bundles that involves five
well-known Centers of Disease Control
and Prevention recommended measures
(hand washing, full-barrier precautions
during line insertion, cleaning the skin
with chlorhexidine, avoiding the femoral
site if possible, and removing unneces-
sary catheters) together with improving
teamwork, communication, and patient
safety culture was able to produce a
large and sustained reduction of CR-BSI
rates over an 18-month study period (3).
Furthermore, most of the participating
ICUs sustained reduced CR-BSI rates
during a further postimplementation
period of 18 months (4). Similar results
were reported by others (5–7).
This quality improvement program
originally developed in Michigan has
spread to many states in United States
and abroad with consistent successful
results (8). In Spain, an agreement of
the Spanish Ministry of Health and the
Patient Safety Programme of the World
Health Organization in collaboration
with the Spanish Society of Intensive
and Critical Care Medicine and Coronary
*See also p. 2933.
Key Words: catheter-related infections; intensive
care units; prevention and control; quality improve-
ment; randomized controlled trials
The authors have not disclosed any potential con-
flicts of interest.
Copyright © 2012 by the Society of Critical Care
Medicine and Lippincott Williams and Wilkins
DOI: 10.1097/CCM.0b013e3182632748
Crit Care Med 2012 Vol. 40, No. 113083
Units and the Johns Hopkins Quality and
Safety Research Group was established
to assess the applicability and effective-
ness of the Keystone ICU Project (9).
As a result, a nationwide multifactorial
intervention program, named “Bacte-
remia Zero,” was designed and progres-
sively implemented in 192 Spanish ICUs
over an 18-month period between 2008
and 2010. Significant reductions of CR-
BSI rates as compared with baseline were
observed (unpublished data), showing
that this multifaceted quality improve-
ment program can be effectively applied
to a different health care system, despite
varying levels of organizational structure
and safety cultures.
The study of the Johns Hopkins Qual-
ity and Safety Research Group had a
cohort design, so that the next logical
scientific step was to perform a random-
ized controlled trial to assess causality
between the multifaceted intervention
used in the Keystone ICU Project and the
reduced CR-BSI rates as well as to evalu-
ate the magnitude of the effectiveness of
the intervention.
In this issue of Critical Care Medicine,
Marsteller and coworkers (10) report the
results of a multicenter, phased, cluster-
randomized controlled trial in 45 ICUs
from 35 hospitals, in two faith-based
affiliated health systems, which was
designed to determine the causal effects
of an intervention to reduce CR-BSIs
in the ICU. The multifaceted interven-
tion consisted of the above mentioned
evidence-based practices to prevent CR-
BSI (2) and the Comprehensive Unit–
based Safety Program to improve safety,
teamwork, and communication (11).
Interestingly, the study included a first
phase (phase 1) in which the interven-
tion was assessed according to the ran-
domized controlled trial design and a
second follow-up period of 1 yr (phase
2) in which the intervention was imple-
mented to all participating ICUs (includ-
ing those in the control arm), aimed to
assess sustainability of the intervention.
The intervention group started in March
2007 and the control group in October
2007, and the study period ended in
September 2008. Baseline data for both
groups were from 2006. The number of
primary CR-BSI per 1000 central-line
days was collected monthly and reported
to the authors through the health sys-
tems corporate headquarters. The main
primary outcome was the quarterly rate
of CR-BSI during the postimplementa-
tion period (third quarter, from October
to December 2007). By that time, the
mean infection rate (CR-BSI per 1,000
central-line days) declined from 4.48 to
1.33 in the intervention group compared
to a decline from 2.71 to 2.16 in the con-
trol group (adjusted incidence rate ratio
0.19; 95% confidence interval 0.06–0.57;
p = .0003). The intervention and the
control groups showed sustained CR-BSI
rates <1/1,000 central-line days at 19
(81% reduction) and at 12 months (69%
reduction), respectively. However, at the
end of the study, reductions in CR-BSI
rates near to 0.8 per 1,000 line days were
observed in both study groups, which
was even lower than the rates achieved in
the Keystone ICU Project (3). The study
shows a casual relationship between the
multifaceted intervention and reduced
rates of CR-BSI, decreased infection
rates in both groups after implementa-
tion, and sustained results over time,
providing further evidence that CR-BSI
is a preventable condition.
In addition to the design, other
strengths of this study were that the
authors decided to incorporate several
modifications to optimize the intervention
that contributed decisively to the Adventist
collaborative success, such as the develop-
ment of a dressing-change check-list, use
of a preplanned educational curriculum,
recognition as a nurse-led program, and
measurement of the influential elements
of the context at each site. However, from a
methodological point of view, the authors
use the zero-inflated Poisson models
to analyze the effect of the intervention
on CR-BSI and to identify other associ-
ated factors. The model is appropriate for
representing the study data due to the
large number of ICUs with zero CR-BSIs.
The zero-inflated Poisson models are suit-
able to identify those factors associated
with CR-BSI presence or absence, and at
the same time, to identify those factors
that determine its intensity, when a cath-
eter infection exists. However, the CR-BSI
rates evolution analysis based on averages
is certainly controversial and could have
been improved using the zero-inflated
Poisson models for longitudinal data (12).
This excellent study is the first clini-
cal trial that have assessed a bundle of
evidence-based infection prevention
practices and a structured program to
improve safety, teamwork, and commu-
nication to reduce CR-BSI in critically
ill patients admitted to the ICU. A causal
link between the multifaceted interven-
tion and a substantial reduction <1/1000
central-line days by the end of the study
with sustained decrease in CR-BSI rates
was also demonstrated. Complexities of
catheter management in ICU patients
make think to all of us that it is unlikely
to achieve and sustain CR-BSI zero rates.
However, the “near zero” sustained reduc-
tion of CR-BSI among ICU patients shown
by Marsteller et al (10) deserves congratu-
lations and recognition.
Sergio Ruiz-Santana, MD, PhD
Critical Care Unit
Pediatric cardiopulmonary resuscitation outcomes: Is bigger
always better?*
I s there a reason to believe that
another cardiopulmonary resus-
citation (CPR) outcomes study of
in-hospital pediatric patients can
deliver to us more information than we
have had previously? It turns out that us-
ing a large multi-institutional database,
the Kids’ Inpatient Database, a group of
*See also p. 2940.
Key Word: cardiopulmonary resuscitation
Dr. Schleien is a board member for Out2Play, and
a consultant for PingMD. He provides expert testimony
for legal firms, and earns royalties through Wolters
Kluwer.
Copyright © 2012 by the Society of Critical Care
Medicine and Lippincott Williams and Wilkins
DOI: 10.1097/CCM.0b013e318267a9e9
3084
Hospital Universitario
Dr Negrín
University of Las Palmas de
Gran Canaria
Las Palmas de Gran Canaria,
Spain
Pedro Saavedra, PhD
Department of Mathematics
University of Las Palmas de
Gran Canaria
Las Palmas de Gran Canaria,
Spain
Cristóbal León, MD
Critical Care Unit
Hospital Universitario de Valme
Seville, Spain
REFERENCES
1. Aswani MS, Reagan J, Jin L, et al: Variation
in public reporting of central line-associated
bloodstream infections by state. Am J Med
Qual 2011; 26:387–395
2. Berenholtz SM, Pronovost PJ, Lipsett PA, et
al: Eliminating catheter-related bloodstream
infections in the intensive care unit. Crit Care
Med 2004; 32:2014–2020
3. Pronovost P, Needham D, Berenholtz S, et al:
An intervention to decrease catheter-related
bloodstream infections in the ICU. N Engl J
Med 2006; 355:2725–2732
4. Pronovost PJ, Goeschel CA, Colantuoni E, et
al: Sustaining reductions in catheter related
bloodstream infections in Michigan intensive
care units: Observational study. BMJ 2010;
340:c309
investigators from Houston, TX, have
delivered to us a study that does add to
the literature in some surprising fash-
ions (1). Using Kids’ Inpatient Database,
a database of the Healthcare Cost and
Utilization Project (2) of the Agency for
Healthcare Research and Quality allows
for multiple demographic, etiologic, and
financial factors to be compared. Both
uni- and multivariable comparisons
were made on a number of factors on a
patient cohort of over 3 million pediatric
hospital admissions. Thus, the number
of patients studied was unprecedented
compared to the dozens of CPR outcome
studies published to date. Utilizing this
representative sample of over 3 million
5. DePalo VA, McNicoll L, Cornell M, et al: The
Rhode Island ICU collaborative: A model for
reducing central line-associated bloodstream
infection and ventilator-associated pneumo-
nia statewide. Qual Saf Health Care 2010;
19:555–561
6. Peredo R, Sabatier C, Villagrá A, et al: Reduc-
tion in catheter-related bloodstream infec-
tions in critically ill patients through a
multiple system intervention. Eur J Clin
Microbiol Infect Dis 2010; 29:1173–1177
7. Marra AR, Cal RG, Durão MS, et al: Impact of
a program to prevent central line-associated
bloodstream infection in the zero tolerance
era. Am J Infect Control 2010; 38:434–439
8. Pronovost PJ, Marsteller JA, Goeschel CA:
Preventing bloodstream infections: A mea-
surable national success story in quality
improvement. Health Aff (Millwood) 2011;
30:628–634
9. Palomar Martínez M, Alvarez Lerma F, Riera
Badía MA, et al: Prevention of bacteriema
related with ICU catheters by multifactorial
intervention: A report of the pilot study. Med
Intensiva 2010; 34:581–589
10. Marsteller JA, Sexton JB, Hsu Y-J, et al: A
multicenter, phased, cluster-randomized con-
trolled trial to reduce central line-­associated
bloodstream infections in intensive care
units. Crit Care Med 2012; 40:2933–2939
11. Pronovost PJ, Berenholtz SM, Goeschel C,
et al: Improving patient safety in intensive
care units in Michigan. J Crit Care 2008;
23:207–221
12. Hasan MT, Sneddon G: Zero-inflated Poisson
regression for longitudinal data. Commun
Stat Simul Comput 2009; 38:638–653
pediatric patients, data were extrapolat-
ed to over 7 million patients across the
country, to determine a prevalence rate
of CPR events, associated with common
etiologies as well as mortality and factors
associated with those patient deaths.
The use of very large databases to study
unusual or rare occurrences is growing and
becoming a more important part of our sta-
tistical armamentarium. The advantages
are obvious and inherent to their large size.
These advantages include not only size but
also a well built database, decreases in data
redundancy, reduced updating errors with
increased consistency, greater data integ-
rity and independence from application
programs in general, improved data access
Crit Care Med 2012 Vol. 40, No. 11