The different etiologies of CRBSI during the 18-month period after implementation of the Bacteremia Zero project are shown in Supplemental Table 1 (Supplemental Digital Content 1, http://links.lww.com/CCM/A683).
The Bacteremia Zero study attempted to reduce CRBSIs throughout Spanish ICUs and demonstrates the impact of a multifaceted intervention known to prevent CRBSI in large scale up in Spain. Despite necessary modifications of the intervention, due to cultural and organizational factors, nearly 70% of ICUs across all regions of Spain significantly reduced CRBSI, impacting over 100,000 ICU admissions during the study period, suggesting the cross-cultural effectiveness of the multifaceted intervention developed by Pronovost et al (14). The results suggest that the intervention was effective in reducing the incidence of CRBSI in all types of hospitals. Although nonteaching hospitals showed higher rate reductions than university-affiliated centers, all participating hospitals saw reductions in infections, suggesting the robustness of the intervention despite the variations adopted in Spain. The strength of the intervention seems thus to lie in its ability to standardize measures and evidence-based practices, while the program encourages local variation in how these practices are implemented.
The results are also consistent with others reporting about 60% reduction in the rate of CRBSI, with final rates close to 1 per 1,000 CVC-days (14–19), although some other studies in developing countries still showed rates at more than 7 per 1,000 CVC-days (10).
The overall infection rate in the Bacteremia Zero study did drop more slowly than in the original project (14). Furthermore, the median rate of zero achieved in the third month of implementation in Michigan was never reached in Spain. One important reason may be due to the lesser uptake of the full intervention. Few ICUs implemented the entire safety intervention, notably the comprehensive Unit-based safety component as was proposed in Michigan (14, 20, 21) (most ICUs performed safety rounds and partnered with executives, only occasionally or not at all). Difficulties in the follow-up and acceptability of some of these elements were observed among participants since the start of the program. Although the reasons behind this observation need to be further studied, this experience suggests the need for strengthening the patient safety culture and the cross-cultural adaptation of interventions to ensure their uptake and effectiveness.
Possible differences in the healthcare system across the United States and Spain and in the organization across and within Spain ICU may also contribute to differences in the overall result. Whereas the Keystone project involved one state only, whereas the Spanish program involved the whole National Health System, with 17 Health Regions and high variability in implementation, leadership, and patient safety culture.
For example, there is great variability across the different health regions regarding incentives for health professionals. Furthermore, the Spanish Health system is for the most part public, providing free access to care; thus, there were no restrictions in access according to ability to pay. At the same time, in Spain, there are only 8.2 ICU beds per 100,000 inhabitants as compared with 20 beds per 100,000 inhabitants in the United States (22), but patients in Spanish ICUs seem to have more CVC (78% of Spanish patients (2) compared with 50% in the U.S. patients (23). Multiple catheterizations may magnify the rates of CRBSI (24), and in the Bacteremia Zero project, patients showed a mean of 1.3 CVC and 0.5 arterial catheters inserted, while many of the CRBSI occurred in patients having concurrent CVC, arterial catheters, and/or hemodialysis catheters.
Overall, rates for CRBSI in Europe seem, in general, consistently higher than those in the United States (25), although differences in the systems and definitions of surveillance of ICU-acquired infections make comparisons difficult (26).
Interestingly, we observed an unexpected peak in the rate of CRBSI during the months of May and June corresponding with the arrival of temporary staff to cover summer leaves. As a result, specific training for temporary staff was reinforced in the second year of the intervention, although the peak remained still observable. This finding was an important lesson learnt from the study, which will presumably lead to further action in the healthcare system.
There are limitations to our study. Baseline data were only available for 106 ICUs, and the number of ICUs participating postintervention varied over time. This is typical for large-scale quality improvement studies having voluntary data collection (15). However, improvement was comparable among ICUs with data available for the basal period and those joining the program later, although the fact to remain in the program for more than 12 months appeared to optimize the results. Although a validation study was not performed, the annual Spanish national incidence study (Estudio Nacional de Prevalencia de la Infección Nosocomial en los hospitales españoles) showed a reduction in both the incidence of infected patients and infections, particularly the incidence of bacteremia decreased progressively from 0.25% in 2008 to 0.20% in 2009 and 0.19 in 2010 (27). Nonetheless, most participating ICUs had an extensive experience in nosocomial infection surveillance, which would minimize BSI identification and notification errors as demonstrated in other registries (28).
This study has important public health implications. On extrapolating the study results to the baseline rates according to the reduction in the rates of CRBSI obtained in the study and considering the number of catheter-days in the postimplementation period, approximately 742 CRBSIs were prevented with the Bacteremia Zero intervention. With an attributable mortality of 9% and a prolonged ICU stay of 12 days per bacteremia (29), this decrease may have save 66 lives, 8,904 ICU days, and approximately 27,629,112€ (for an average cost of 3,103€/ICU day) (30). The cost of the project for the Ministry of Health including contracts with Sociedad Española de Medicina Críticay Unidades Coronarias and Health Regions, meetings, and statistical analysis was 2.340.000€. In the present era of budget and economic constraints, the repercussion of this strategy to reduce CRBSI in ICU patients is very relevant.
We are grateful for the collaboration of Alberto Infante former General Director of the Quality Agency of the National Health System of Spain (currently at the National School of Health) in ensuring the project could get off the ground; we thank Abiguei Torrents, Hospital Clinic Barcelona, in conducting the data analysis; Cyrus Engineer, Nittita Prasopa-Plaizier, Katthyana Aparicio, and Edward Kelley from the World Health Organization in supporting the preparation of the intervention and its study proposal; María Santaolaya from the Quality Agency of the National Health System and José Rodríguez Paz from the Johns Hopkins Hospital in supporting the cultural adaptation of the materials and the preparation of the intervention; Elizabeth Colantuoni, statistician at Johns Hopkins University, for providing valuable statistical advice; Martin Fletcher, now with the Australian Health Practitioner Regulation Agency, was instrumental in the setting up of the intervention; and Sir Liam Donaldson, now WHO Envoy for Patient Safety, provided the vision. We are indebted to managers and healthcare personnel of the participating hospitals, as well as staff members of the ICUs for their valuable cooperation. We also thank Marta Pulido, MD, PhD, freelance author’s editors for editing the manuscript and editorial assistance. The fees of medical editing were supported by the Spanish Society of Intensive Care Medicine (SEMICYUC). We also thank Christine G. Holzmueller, BLA, for her assistance in editing the manuscript; she was not compensated for her work.
1. Edwards JR, Peterson KD, Yi Mu Y, et al.National Healthcare Safety Network (NHSN) Report. Data summary for 2006 through 2008, issued December 2009 Am J Infect Control. 2009;37:783–805
2. Sociedad Española de Medicina Intensiva, Grupo de Trabajo de Enfermedades Infecciosas (SEMICYUC-GTEI). . Estudio Nacional de Vigilancia de Infección Nosocomial en UCI (ENVIN-UCI). Informes de los años 2001–2009. Available at: http://hws.vhebron.net/envin-helics/
. Accessed July 25, 2013
3. European Centre for Disease Prevention
and Control. Annual Epidemiological Report on Communicable Diseases in Europe 2009. 2009 Stockholm, Sweden European Centre for Disease Prevention
4. Lambert ML, Suetens C, Savey A, et al. Clinical outcomes of health-care-associated infections and antimicrobial resistance in patients admitted to European intensive-care units: A cohort study. Lancet Infect Dis. 2011;11:30–38
5. Olaechea PM, Ulibarrena MA, Alvarez-Lerma F, et al.ENVIN-UCI Study Group. Factors related to hospital stay among patients with nosocomial infection acquired in the intensive care unit
. Infect Control Hosp Epidemiol. 2003;24:207–213
6. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;49:1–45
7. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51:1–45
8. Rubinson L, Wu AW, Haponik AE, et al. Why is it that internists do not follow guidelines for preventing intravascular catheter infections? Infect Control Hosp Epidemiol. 2005;26:525–33
9. Krein SL, Hofer TP, Kowalski CP, et al. Use of central venous catheter-related bloodstream infection prevention
practices by US hospitals. Mayo Clin Proc. 2007;82:672–678
10. Rosenthal VD, Maki DG, Rodrigues C, et al.International Nosocomial Infection Control Consortium Investigators. Impact of International Nosocomial Infection Control Consortium (INICC) strategy on central line-associated bloodstream infection rates in the intensive care units of 15 developing countries. Infect Control Hosp Epidemiol. 2010;31:1264–1272
11. Mehta A, Rosenthal VD, Mehta Y, et al. Device-associated nosocomial infection rates in intensive care units of seven Indian cities. Findings of the International Nosocomial Infection Control Consortium (INICC). J Hosp Infect. 2007;67:168–174
12. Institute for Healthcare Improvement. Available at: http://www.ihi.org
. Accessed December 22, 2010
13. Miller MR, Griswold M, Harris JM 2nd, et al. Decreasing PICU catheter-associated bloodstream infections: NACHRI’s quality transformation efforts. Pediatrics. 2010;125:206–213
14. 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
15. 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
16. Saturno PJ, Da Silva ZA, Oliveira-Sousa SL, et al.Grupo Proyecto ISEP:. Análisis de la cultura sobre seguridad del paciente en los hospitales del Sistema Nacional de Salud Español. Med Clin Monogr (Barc). 2008;131(Suppl 3):18–25
18. Molenberghs G, Verbeke G Models for Discrete Longitudinal Data. 2005 New York Springer Science+Business Media
19. Peredo R, Sabatier C, Villagrá A, et al. Reduction in catheter-related bloodstream infections in critically ill patients through a multiple system intervention. Eur J Clin Microbiol Infect Dis. 2010;29:1173–1177
20. Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med. 2011;39:934–939
21. Romig M, Goeschel C, Pronovost P, et al. Integrating CUSP and TRIP to improve patient safety
. Hosp Pract (Minneap). 2010;38:114–121
22. Wunsch H, Angus DC, Harrison DA, et al. Variation in critical care services across North America and Western Europe. Crit Care Med. 2008;36:2787–2793, e1
23. Centers for Disease Control and Prevention
(CDC). . Vital signs: Central line-associated blood stream infections - United States, 2001, 2008 and 2009. MMWR Morb Mortal Wkly Rep. 2011;60:243–248
24. Aslakson RA, Romig M, Galvagno SM, et al. Effect of accounting for multiple concurrent catheters on central line-associated bloodstream infection rates: Practical data supporting a theoretical concern. Infect Control Hosp Epidemiol. 2011;32:121–124
26. Hansen S, Sohr D, Geffers C, et al. The concordance of European and US definitions for healthcare-associated infections (HAI). BMC Proc. 2011;5(Suppl 6):O2
28. Backman LA, Melchreit R, Rodriguez R. Validation of the surveillance and reporting of central line-associated bloodstream infection data to a state health department. Am J Infect Control. 2010;38:832–838
29. Olaechea PM, Álvarez-Lerma F, Palomar M, et al.ENVIN Study Group. “Mortality attributable to primary and catheter-related nosocomial bacteremia. A case control study.” 22nd Annual Congress of European Society of Intensive Care Medicine. Vienna 11–14 October 2009. Intensive Care Med. 2009:S1–269
APPENDIX: HOSPITALS PARTICIPATING IN THE PROJECT
ANDALUCIA: Hospital de Valme, Hospital Virgen de la Macarena, Hospital de la Merced, Hospital San Juan de Dios del Aljarafe, Hospital Comarcal de la Axarquía, Hospital General Básico de la Serranía de Ronda, Hospital Universitario Virgen de la Victoria, Hospital Costa del Sol, Hospital Univer, Médico Quirúrgico (Compl. Hosp. de Jaén), Hospital San Juan de la Cruz, Hospital Neurotraumatológico de Jaén, Hospital Alto Guadalquivir, Hospital Médico Quirúrgico Virgen de las Nieves (UCI), Hospital General Básico de Baza, Hospital General Básico Santa Ana, Hospital Médico Quirúrgico Vírgen de las Nieves (UC y UCC), Hospital Universitario Puerta del Mar, Hospital del SAS de Jerez, Hospital Universitario de Puerto Real, Hospital Punta Europa, Hospital de Antequera, Hospital de Montilla, Hospital Reina Sofía, Hospital Valle de los Pedroches, Hospital Infanta Margarita, Hospital General de Huelva Juan Ramón Jiménez, Hospital General Básico de Riotinto, Hospital Torrecárdenas, Hospital de Poniente, Hospital Comarcal La Inmaculada, Hospital de La Línea. ARAGON: Hospital Clínico Universitario Lozano Blesa, Hospital Royo Villanova, Hospital General San Jorge, Hospital Obispo Polanco. ASTURIAS: Hospital Central de Asturias (UCI 1), Hospital Central de Asturias (UCI pediátrica), Hospital Central de Asturias (UCI HGA), Hospital Central de Asturias (UCI INS), Hospital de Cabueñes, Hospital de San Agustín, Hospital Valle del Nalón. BALEARES: Hospital Son Dureta, USP Clínica Palmaplanas, Hospital Son Llàtzer, Fundación Hospital Manacor, Clínica Rotger Hospita, Hospital Mateu Orfila, l Can Misses, Eivissa. CANARIAS: Hospital Universitario Insular de Gran Canaria, Hospital Universitario de Gran Canaria Dr. Negrín (U. Cardiología), Hospital Universitario de Gran Canaria Dr. Negrín (U. Neurotrauma), Hospital General de Lanzarote, Hospital General de Fuerteventura, Hospital Universitario de Canarias, Hospital Ntra. Sra. de Candelaria, Hospital General de La Palma. CANTABRIA: Hospital Marqués de Valdecilla (UCI 1), Hospital Marqués de Valdecilla (UCI 2 Politrauma), Hospital Marqués de Valdecilla (UCI 3). CASTILLA-LA MANCHA: Hospital Sierrallana (URCE), Hospital Virgen de la Salud, Hospital Nacional de Parapléjicos, Hospital Virgen de la Salud (U.C. Críticos Cirugía Cardíaca), Hospital Provincial de la Misericordia, Hospital Nuestra Señora del Prado, Hospital General Universitario de Albacete, Hospital General Universitario de Albacete, Hospital General de Ciudad Real, Hospital Universitario de Guadalajara, Hospital Virgen de la Luz. CASTILLA LEON: Hospital Universitario Río Hortega, Hospital Clínico Universitario de Valladolid, Hospital Virgen de la Vega, Hospital Clínico de Salamanca, Complejo Hospitalario de Soria, Hospital General de Segovia, Hospital Ntra. Sra. de Sonsoles, Hospital General Yagüe, Hospital de León (UCI polivalente), Complejo Hospitalario de Palencia, Hospital Virgen de la Concha. CATALUNYA: Hospital General Hospitalet (Unidad de semi-intensivos), Capio Hospital General de Catalunya, Hospital General Vall Hebron (UCI), Hospital de Traumatología Vall Hebron, Hospital General Vall Hebron (UPCC), Hospital Clínic i Provincial (UCI Quirúrgica), Hospital Asepeyo. Sant Cugat del Vallés, Hospital de Sant Pau (UCI Polivalente), Centro Médico Delfos. Barcelona, Hospital del Mar, Hospital Dos de Maig, Hospital Plató, Hospital Universitari Sagrat Cor, Hospital de Barcelona (SCIAS), Hospital General Hospitalet, Hospital de Traumatologia Vall Hebron (U. Quemados), Clínica Corachán, Hospital Universitario Mutua Terrassa, Hospital de Terrassa, Hospital Parc Tauli, Hospital de Mataró. Consorci Sanitari del Maresme, Hospital Sant Joan de Deu de Manresa, Hospital de Igualada, Hospital General de Granollers, Clínica Girona, Hospital Universitari de Girona Doctor Josep Trueta, Hospital Universitari Arnau de Vilanova de Lleida (UCI), Hospital de Santa María de Lleida, Hospital Universitari Joan XXIII, Hospital Universitari de Sant Joan, Hospital Verge de la Cinta. EUSKADI: Hospital Santiago de Vitoria, Hospital de Txagorritxu, Vitoria, Hospital Donostia (Ntra. Sra. de Aranzazu), Hospital de Basurto, Hospital de Galdakao. EXTREMADURA: Hospital de Mérida, Hospital San Pedro de Alcántara, Hospital San Pedro. GALICIA: Complexo Hospitalario Universitario Juan Canalejo (Reanimación), Complexo Hospitalario Universitario Juan Canalejo (Quemados), Complexo Hospitalario Universitario A Coruña (UCI 6), Complexo Hospitalario Universitario de A Coruña (UCI 5ª), Hospital Clínico Universitario de Santiago (UCI), Hospital Arquitecto Marcide, Complexo Hospitalario de Ourense, Hospital Montecelo, Hospital Povisa, Hospital Meixoeiro—C. Hosp. Universitario de Vigo (UCI Médica). MADRID: Hospital Clínico Univer. San Carlos (U. Médico-Quirúrgica), Hospital Clínico Univer. San Carlos (U. Neuro-Politrauma), Hospital La Paz (Unidad de Quemados), Hospital La Paz (UCI polivalente), Fundación Jiménez Díaz, Clínica Puerta de Hierro, Hospital Ramón y Cajal, Hospital Clínico Universitario San Carlos (U. Cardiovascular), Hospital Universitario Fundación Alcorcón, Hospital Gregorio Marañón, Clínica Moncloa, Hospital Universitario 12 de Octubre, Hospital Universitario 12 de Octubre (UCI Traumatología), Hospital Príncipe de Asturias, Hospital General. Móstoles, Hospital Severo Ochoa. Leganés, Hospital del Henares, Hospital de Getafe (UCI Polivalente), Hospital Infanta Cristina, Hospital Universitario 12 de Octubre (UCP), Hospital de la Princesa, Hospital Universitario de Fuenlabrada, Hospital del Sureste, Hospital del Tajo, Hospital Infanta Sofía, Hospital Infanta Leonor. MURCIA: Hospital Virgen de la Arrixaca, Hospital Universitario J. Mª Morales Meseguer, Hospital Santa María del Rosell, Hospital General Universitario Reina Sofía. NAVARRA: Hospital de Navarra, Hospital Virgen del Camino, Hospital García Orcoyen, Clínica San Miguel. VALENCIA: Hospital Universitario La Fe (U. Reanimación), Hospital Universitario La Fe, Hospital Arnau de Vilanova de Valencia, Hospital Clínico Universitario de Valencia (U. Polivalente), Hospital General Universitario de Valencia (UPCC), Hospital General de Requena, Hospital Doctor Peset, Hospital de Sagunto, Valencia, Hospital de la Ribera, Hospital Francesc de Borja de Gandía, Hospital Marina Baixa de Villajoyosa—departamento 16 AVS, Hospital Lluís Alcanyís de Xàtiva, Hospital de Torrevieja Salud, Hospital General Universitario de Alicante (UCI), Hospital General Universitario de Elche, Hospital de Sant Joan, Hospital General de Castellón, Consorcio Hospitalario Provincial de Castellón, Hospital Comarcal de Vinaròs.