VA tops private hospitals in infection-control study

Jun 3 2007

Department of Veterans Affairs (VA) medical centers are more likely than non-VA hospitals to follow recommendations for preventing bloodstream infections associated with central venous catheters, says a survey of more than 500 U.S. health care centers.

The results appear in the June issue of Mayo Clinic Proceedings.

The recommendations were published by the Agency for Healthcare Research and Quality in 2001, and by the Centers for Disease Control in 2002. Since then, "There really had not been any national studies that had looked at whether hospitals were following the recommendations," said Sarah Krein, PhD, a research health scientist with the Center for Practice Management and Outcomes Research at the VA Ann Arbor Healthcare System, and a research assistant professor at the University of Michigan.

The recommendations include:

• Maximal sterile barrier precautions for inserting a central venous catheter. This includes sterile gloves and gown, mask, cap, and a large sterile drape
• Chlorhexidine gluconate (2 percent) on the skin as an antiseptic before insertion, rather than povidone iodine or alcohol
• Replacing catheters as needed, rather than every 4 to 7 days
• Using antimicrobial catheters, but only if other precautions do not reduce infection rates

Krein and colleagues completed a survey of 95 VA and 421 non-VA hospitals between March 16 and August 1, 2005. "Regular use" refers to always, or almost always, using a procedure.

Most hospitals reported regular use of maximal sterile barrier precautions (MSB) to prevent infection: 84 percent of VA hospitals and 71 percent of non-VA hospitals. Ninety-one percent of VA hospitals regularly used chlorhexidine gluconate as an antiseptic, compared with 69 percent of non-VA hospitals.

There were no differences between VA and non-VA hospitals with regard to routine central line changes or antimicrobial catheters.

However, 62 percent of VA hospitals reported regularly using a combined approach of MSB, chlorhexidine gluconate and the avoidance of routine central line changes. Only 44 percent of non-VA hospitals used this combination of techniques.

"While we're seeing the use of some of these recommendations in many hospitals, there are fewer hospitals outside the VA that are using them," said Krein.

A central venous catheter (CVC), or central line, is inserted in a vein in the chest to facilitate giving drugs, fluids or nutrition. In the United States, about 200,000 CVC-associated bloodstream infections occur each year. These infections increase mortality risk, morbidity, and hospital stays. They also cost the U.S. health care system as much as $6 billion per year.

The VA hospitals that responded to the survey differed in several ways from the non-VA hospitals. The VA hospitals:

• Had higher RN staffing ratios
• Were more likely to have an approved residency training program (75 percent vs. 24 percent of non-VA hospitals)
• Were more likely to be located in metropolitan areas
• Were more likely (50 percent vs. 39 percent) to have a hospital epidemiologist
• Were more likely (75 percent vs. 57 percent) to have a supervisory infection control professional who was certified in infection control and epidemiology

The centralization of the VA may be one reason for the increased adherence to the recommendations, Krein said. "Centralized purchasing in the VA is definitely a factor. Chlorhexidine gluconate is part of the VA's blanket purchase agreement, so that might facilitate its use."

Communication within the VA could also help make good practices more widespread, she added. "Infection control practitioners within the VA have their own website and email list, so there's a lot of communication there. That could lead to changes in practice."

The authors note that the study does have limitations. Just because an infection control procedure is done regularly does not mean it's done properly. Also, the survey was completed by the hospitals themselves, rather than by a neutral party.

Krein and colleagues are now completing more in-depth interviews of hospital personnel. "We're trying to find out more about why hospitals are, or are not, using some of these practices," she said. "We hope those results will provide guidance for hospitals and let them know about ways to overcome barriers or problems they might encounter."