Team-based prevention of catheter-related infections.

About half the days patients spend in ICUs (ICU days) are associated with the use of a central venous catheter and therefore with a risk of subsequent bloodstream infection (five infections per 1000 catheter-days). Each year, 36 million patients are admitted to acute care hospitals in the United States, staying for 164 million days.1 Eleven percent (18 million days) of these hospitalizations are spent in intensive care units (ICUs). For 54% of the days (9.7 million) that patients are in ICUs, central venous catheters remain in place for the infusion of medications and fluids. Regrettably, the use of these devices results in 48,600 associated bloodstream infections (5 per 1000 catheter-days).2 The leading pathogens, in descending order, are coagulasenegative staphylococci, Staphylococcus aureus, enterococcus species, and candida species. Morbidity is significant with bloodstream infections. At least 5% of patients whose condition meets the criteria for sepsis will have the acute respiratory distress syndrome, and at least 15 to 20% will have disseminated intravascular coagulation, acute renal failure, or shock, alone or in combination, while in the hospital. The epidemiologic concept of attributable mortality has been advanced to distinguish deaths directly due to catheter-related bloodstream infection from those due to the underlying disease. In historical cohort studies in which infected patients are tightly matched to noninfected control subjects, estimates of excess (attributable) deaths in ICUs have been as high as 35% (17,000 deaths yearly).3 These figures represent the portion of the total deaths that can be maximally influenced by the use of effective antimicrobial agents or maximally prevented (Fig. 1). Cumulative data on pathogenesis focus on the role of contamination by organisms residing on the hands of health care workers and the skin of patients. Microorganisms gain access to the bloodstream intraluminally through the connecting ports of the catheter or extraluminally at the exit site, at the interface between the catheter and the patient’s skin. Since bacteria and yeast can traverse both the inner and outer surfaces of the catheter, the use of chemically bonded materials has been recommended to reduce infection rates. On the basis of current data on pathogenesis, prevention strategies have become a major issue in the quality of care. In 1966, Avedis Donabedian elegantly defined the architecture of quality-assurance programs as having three platforms: structure, process, and outcome.4 This seminal partition influenced medical care worldwide. Early quality-assurance