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Impact of a National Multimodal Intervention to Prevent Catheter-Related Bloodstream Infection in the ICU: The Spanish Experience

Palomar, Mercedes MD, PhD1; Álvarez-Lerma, Francisco MD, PhD2; Riera, Alba RN3; Díaz, María Teresa RN4,†; Torres, Ferrán MD, PhD5; Agra, Yolanda MD, PhD6; Larizgoitia, Itziar MD, MPH, PhD4; Goeschel, Christine A. ScD, MPA, MPS, RN7; Pronovost, Peter J. MD, PhD7

doi: 10.1097/CCM.0b013e3182923622
Clinical Investigations

Objective: Prevention of catheter-related bloodstream infection is a basic objective to optimize patient safety in the ICU. Building on the early success of a patient safety unit-based comprehensive intervention (the Keystone ICU project in Michigan), the Bacteremia Zero project aimed to assess its effectiveness after contextual adaptation at large-scale implementation in Spanish ICUs.

Design: Prospective time series.

Setting: A total of 192 ICUs throughout Spain.

Patients: All patients admitted to the participating ICUs during the study period (baseline April 1 to June 30, 2008; intervention period from January 1, 2009, to June 30, 2010).

Intervention: Engagement, education, execution, and evaluation were key program features. Main components of the intervention included a bundle of evidence-based clinical practices during insertion and maintenance of catheters and a unit-based safety program (including patient safety training and identification and analysis of errors through patient safety rounds) to improve the safety culture.

Measurements and Main Results: The number of catheter-related bloodstream infections was expressed as median and interquartile range. Poisson distribution was used to calculate incidence rates and risk estimates. The participating ICUs accounted for 68% of all ICUs in Spain. Catheter-related bloodstream infection was reduced after 16–18 months of participation (median 3.07 vs 1.12 episodes per 1,000 catheter-days, p < 0.001). The adjusted incidence rate of bacteremia showed a 50% risk reduction (95% CI, 0.39–0.63) at the end of the follow-up period compared with baseline. The reduction was independent of hospital size and type.

Conclusions: Results of the Bacteremia Zero project confirmed that the intervention significantly reduced catheter-related bloodstream infection after large-scale implementation in Spanish ICUs. This study suggests that the intervention can also be effective in different socioeconomic contexts even with decentralized health systems.

Supplemental Digital Content is available in the text.

1Intensive Care Unit, Hospital Universitari Arnau de Vilanova, Lleida, Universitat Autònoma de Barcelona, Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), Barcelona, Spain.

2Intensive Care Unit, Parc de Salut Mar, Universitat Autònoma de Barcelona, SEMICYUC, Barcelona, Spain.

3Intensive Care Unit, Hospital Universitari Vall d´Hebron, Barcelona, Spain.

4Patient Safety Programme, World Health Organization, Geneva, Switzerland.

5Statistics and Methodology Support Unit (USEM), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.

6Quality Agency of the National Health System, Spanish Ministry of Health, Social Policy and Equality, Madrid, Spain.

7Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine, Johns Hopkins University School of Medicine, Bloomberg School of Public Health, and School of Nursing, Baltimore, MA.

† Deceased.

Authors belonging to the Bacteremia Zero Working Group: Mercedes Palomar, Francisco Álvarez-Lerma, Juan José Otal, Cristobal León, and Alba Riera (SEMICYUC); Yolanda Agra, Eduardo Sierra, Mar Fernández, and Enrique Terol (now with the European Commission) (Quality Agency of the National Health System, Spanish Ministry of Health, Social Policy and Equality); Itziar Larizgoitia and Maria Teresa Díez (Patient Safety Programme, World Health Organization); Rafael Sierra, Maria Aranzazu Isastola, Lourdes Benítez, Carmen Díaz Marisa Dotor, Concepción Barrera, and Enrique Fernández (Andalucía); Isabel Gutiérrez, Sonia Delgado, Teresa Giménez, and Carlos Aibar (Aragón); Armando Blanco, Manuel Valledor, Carmen Martínez, and Belén Suárez (Asturias); Marcio Sa-Gorges and Carlos Campillo (Baleares); Manuel Sánchez, Pablo Jadraque, Carlos Agustín Cruz, and Paloma Garcia de Carlos (Canarias); Jose Luis Teja, Lourdes Gómez, Ana Rosa Díaz, Francisco Antolín, Henar Rebollo, and Trinidad Valle (Cantabria); Enriqueta Muñoz, Llanos Soriano, María Ángeles Arrese, and Sonia Cercenado (Castilla-La Mancha); Maria Jesus López Pueyo, Celia Díaz Tobajas, Sonsoles Paniagua Tejo, and María José Pérez Boíllos (Castilla-León); Mercedes Palomar, Francisco Álvarez-Lerma, Alba Riera, Rosa María Balaguer, Milagros Calizaya, Elisabet Gallart, Pilar Latre, María Isabel Quintana, Jordi Vallés, Juan Carlos Yebenes, Magdalena Campins, Joan María Ferrer, and Josep Davins (Catalunya); Marta Montans, Isabel María Román, Nieves García, and Carmen Gómez (Extremadura); Ana María Díez, Concepción Miralles, Dolores Martin, and Mercedes Carreras (Galicia); Ángel Caballero and Mª Jesús Navaridas (La Rioja); Joaquín Álvarez, Mercedes Nieto, Susana Sánchez, María Jesús Luengo, María del Mar García, Francisco Javier Morón, and Juan Carlos Ansande (Madrid); Juan Antonio Martínez and Susana Valbuena (Murcia); Eduardo Layana (Navarra); Pedro Olaechea, Ana María Sánchez, David Cantero, and Marbella García (País Vasco); and Paula Ramírez, Josefina Monzón, Rafael Zaragoza, Roberto Reig, Cristina Huertas, and Ricard Meneu (Valencia), Health Region Coordinators, Spanish National Health System.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Supported, in part, by the Spanish Ministry of Health, Social Policy and Equality through a contract with SEMICYUC (Number 2008/0273−227−06) and specific contracts with the Health Regions during 2009 and 2010.

Dr. Palomar received grant support from the Vall Hebron Hospital (funding from Conselleria de Salut de Catalunya) and Pfizer, support travel from the Sociedad Española de Medicina Intensiva and Critica y Unidades Coronarias, lectured for Pfizer and 3M, and received support for travel from Novartis. Dr. Álvarez-Lerma received grant support from Conselleria de Salut de Catalunya, Astra Zeneca, Novartis, and Gilead; support for travel from Sociedad Española de Medicina Intensiva and Critica y Unidades Coronarias; consulted for Gilead and Novartis; lectured for Pfizer, Astellas, Novartis, and MSD; received payment for manuscript preparation from Gilead; and received support for travel from Pfizer and Novartis. Dr. Riera consulted for SEMiCyUC (coordination). Dr. Agra is employed by the Spanish Ministry of Health (SMoH), received grant support from the European Commission (budget to the SMoH to participate in European projects where Dr. Agra is the coordinator for Spain), lectured for Escuela Nacional de Sanidad and Universidad Nacional de Educación a Distancia, received support for development of educational presentations from Escuela Nacional de Sanidad, received support for travel from the European Commission, and received other funding from the Spanish Ministry of Health. Dr. Larizgoitia consulted for, received support for travel, and is employed by the World Health Organization and disclosed that her contribution to this study was part of his work as staff member to the World Health Organization (WHO). Dr. Goeschel received grant support from The John Hopkins University (funding from World Health Organization to help support this project); consulted for The University of Lelcester; received grant support from DaVita Corporation, US Agency for Healthcare Research and Quality, and VHA; and lectured for various agencies and healthcare provider organizations. Dr. Pronovost received grant support from AHRQ and the National Institutes of Health, consulted for APIC and Hospitals and Health Care Systems, served as a board member for the Cantel Medical Group, lectured for Leigh Bureau, and received royalties from Penguin Group. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Dr. Mercedes Palomar, MD, PhD, Intensive Care Unit, Hospital Universitari Arnau de Vilanova, Av Alcalde Rovira Roure 80, E-250080 Lleida, Spain. E-mail:

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins