Objective: To improve compliance with best practices for CVC insertion in the ED.
Methods: A prospective observational cohort study was performed between Nov 2006 and Jan 2009 in two EDs of a tertiary care referral center. Observations were conducted by nurses assisting with the procedure using a standardized audit tool. Data were collected for each new site attempted and each new operator. Following 1 year of baseline data collection, physicians were trained using a web-based simulation. Nurses were empowered to identify a breach and advise the physician so that corrective action could be taken. Compliance data were collected post-intervention to measure the effectiveness of the intervention.
Results: 98 central line insertions on 85 patients were observed. CVC insertions were performed by staff physicians (26%) or residents (74%) from Emergency Medicine (37%), Intensive Care (33%), Medicine (10%), or other services (20%). Most insertions were considered emergent (44%) or urgent (54%). Post-intervention, compliance with all recommended infection control practices increased significantly from 29% to 69% (OR=5.6; CI=2.1-14.4). A significant improvement in compliance was seen in residents (75% vs 29%; p<0.001) but not staff physicians (57% vs 30%; p=0.1). There was no relationship between compliance and the urgency of the procedure, service, time of day or day of the week.
Compliance with Infection Control Measures During CVC Insertion in the ED
Measure % Compliance Pre-Intervetion % Compliance Post-Intervention Odds Ratio 95% Confidence Interval P-value Operator hand hygiene 86.4 85.9 1.0 0.2-4.5 NS Operator use of barrier equipment 65.6 90.8 5.1 1.5-18.2 0.002 Assistant hand hygiene 80.0 93.3 3.5 0.6-19.4 NS Assistant use of barrier equipment 42.3 87.3 9.4 2.7-33.5 <0.001 Proper skin disinfection 90.6 98.5 6.6 0.6-172.7 NS Use of sterile drape 75.0 92.2 3.9 1.0-15.7 NS Maintenance of sterile field 84.3 98.4 11.7 1.2-276.9 0.01
Conclusions: A significant improvement in compliance with infection control measures during CVC insertion can be achieved in the ED despite the urgency of the procedure. The greatest impact was seen among resident physicians and in the use of proper barrier equipment. These findings can have an important impact on preventing CVC-associated bloodstream infections and supporting patient safety initiatives.