Reducing Hospital-Acquired Infections Among the Neurologically Critically Ill: Beyond the Abstract

Nosocomial infections occur frequently in critically ill neurologic patients who often are immobile, intubated, with urinary catheters and multiple vascular access lines. A preliminary review indicated our rates (based on National Hospital Safety Network standard definitions and data) of catheter associated urinary tract infections (CAUTIs) and ventilator associated events (VAEs) were higher than other NeuroICUs’.

We found that both CAUTIs and VAEs were more frequent in patients who had more transports out of the unit, specifically to go for head CT scans in Radiology, located on a different floor in the hospital, at some distance from the unit.  We then instituted 3 successive interventions. First, we re-educated all personnel on optimal technique for urinary catheter insertion and maintenance; this had no impact on the number or rate of CAUTI’s, suggesting existing  practices were appropriate. Second, we began reviewing the appropriateness of continued use of each urinary catheter on daily work rounds, fully implementing the Ann Arbor criteria for catheter use. With this, the number of catheter days dropped in half, with no reduction in the total number of CAUTIs – suggesting the existence of a sub-population of patients at high risk of infections, and the elimination of a group at low risk. Finally, we placed a mobile CT in the NeuroICU. We instituted daily morning CT rounds for patients who we expected would need a scan that day. For this, the patient remains in the same bed, equipment is repositioned and the patient is scanned in their own ICU room. Within 4-6 weeks of starting this we found that 2/3 of all head CTs were being performed in the unit, with no net increase in the number of scans, no need for additional personnel (the process actually saves nursing time) and no clinically significant loss of scan quality. (Some scans are still done in Radiology when there is a need for higher resolution images, CT angiography or perfusion imaging).  The number of VAEs and CAUTIs dropped precipitously and has remained low ever since. In 2015, the first year of implementation, the number of CAUTIs was 1/3 the number in 2014; in 2016 the projected annualized rate is less than half 2015. We conclude that implementing bed side CTs in a NeuroICU had a major, highly statistically significant effect decreasing hospital acquired infections, with a demonstrable effect on ICU length of stay and cost per patient, easily recouping the cost of the equipment in year 1 of implementation.

Written by: John J Halperin

Meddings J, Saint S, Fowler KE, et al. The Ann Arbor criteria for appropriate urinary catheter use in hospitalized medical patients: results obtained by using the RAND/UCLA appropriateness method. Ann Int Med. 2015;162:S1–34.

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