Other studies have demonstrated an association between prolonged catheterization and increased risk of CR‐BSI2,3,34. The increased risk of infection associated with longer CVC duration may be attributed to risk factors being greater in CVCs that remain in situ for a relatively long time. However, this was not the case in the study cohort, except for CVCs used for TPN (17.8% of TPN CVCs in situ for over 14 days compared with 8.7% of other CVCs). This study had the following limitations. CVC that were inserted when patients were experiencing a bacteraemia were excluded. The risk factors for CR‐BSI in a CVC in a bacteraemic patient may differ from the ones in the surveillance population, and the rate may have been higher if these CVCs had been included. The hospitals in this study participated because they were aware of the risk of CVC use and were keen to prevent CR‐BSI; as such, these hospitals may not be widely representative. The participating hospitals diagnosed the infections themselves and this may have led to differences in interpretation of the infection criteria. However, with validation visits from PREZIES, annual meetings for participants, a clear protocol and case histories on the PREZIES website, this is unlikely to have been a major source of bias. Participating hospitals received benchmark reports with adjusted rates. The authors adjusted the rates for risk factors that hospital staff cannot substantially influence, and which were significantly associated with the risk of CR‐BSI in the study data. Based on earlier analyses, rates were adjusted for the distribution of CVC applications in three categories: TPN, dialysis and other applications. Feedback reports were used to evaluate CVC insertion procedures, CVC care and general infection prevention practices. From 2009 onwards, participation increased as Dutch hospitals committed themselves to reduce CR‐BSI rates as part of a national patient safety initiative (www.vmszorg.nl). CR‐ BSI rates are monitored, as is adherence to a bundle of best practices, based on those recommended by the Centers for Disease Control and Prevention and selected by Pronovost et al.35 This bundle consists of: subclavian access as the preferred insertion site, followed by the jugular vein (another vein can be chosen instead of the subclavian, e.g. in the case of expected increased risk of mechanical complications, but this should be documented). The current guideline of the Dutch Associaton of Intensive Care does not routinely advise ultrasound guidance of CVC insertion. skin antisepsis with alcohol‐based chlorhexidine; hand hygiene (all people actively involved with CVC insertion must disinfect their hands); maximal barrier precaution measures at CVC insertion (sterile gloves, cap, gown and a large drape); 52 Chapter 3
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