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Patient Safety Issues
I
RATES IN
INTENSIVE CARE UNITS
BY ELECTROCARDIOGRAPHIC
LEAD WIRE TYPE:
DISPOSABLE VS REUSABLE
NFECTION
By Nancy M. Albert, PhD, CCNS, CHFN, CCRN, NE-BC, Ellen Slifcak, RN, BA,
Joel D. Roach, BA, James F. Bena, MS, Gregory Horvath, RN, BA, MBA, Sue Wilson,
RN, BSN, Rosslyn Van Den Bossche, RN, BSN, MBA, Nemy Vargas, RN, MSN, CCRN,
CEN, Victoria Rhoades, RN, BSN, CCRN, Katrina M. Hartig, RN, BSN, MS, NE-BC,
Heather Lachiewicz, RN, MSN, CCRN, CNML, and Terri Murray, RN, MSN
CNE
1.0 Hour
Notice to CNE enrollees:
A closed-book, multiple-choice examination
following this article tests your understanding of
the following objectives:
1. Compare infection rates of patients in intensive
care units who received disposable electrocardiographic (ECG) leads vs reusable ECG leads.
2. Identify sources of microorganisms that may
promote hospital-acquired infections.
3. State the role of disposable ECG leads in a
bundled infection control program.
To read this article and take the CNE test online,
visit www.ajcconline.org and click “CNE Articles
in This Issue.” No CNE test fee for AACN members.
©2014 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2014362
460
Background It is unknown if disposable electrocardiographic
lead wires (ECG-LWs) reduce infection rates compared with
cleaned, reusable lead wires.
Purpose To compare infection rates in intensive care unit
(ICU) patients receiving disposable versus reusable ECG-LWs.
Methods Matched adult ICUs were randomly assigned to
disposable or reusable ECG-LWs. Outcomes were bloodstream
infection, ventilator-associated pneumonia, and chest surgical
site infections. Patients’ characteristics and infections were
collected from hospital databases. Event rates were described
by using total counts and rates per 100 patient days and were
compared between groups by using generalized linear mixedeffect models weighted by patients’ ICU length of stay.
Results Overall, 4056 patients from 6 ICUs received disposable
and 3184 patients from 5 ICUs received reusable ECG-LWs. The
characteristics of the 2 groups were similar, except patients
receiving disposable ECG-LWs were less likely to be discharged
home (P = .03) and had more comorbid conditions (P = .002).
Overall infection rates did not differ between ECG-LW groups,
between groups in matched ICUs, between groups by infection
type, or when only patients with ICU stays longer than 48 hours
were considered (2578 cases). In multivariate analyses, infection
rates did not differ between all patients in ECG-LW groups or
for patients with ICU stays beyond 48 hours (both P = .10).
Conclusions No difference was observed in infection rates of
ICU patients receiving disposable versus reusable ECG-LWs.
(American Journal of Critical Care. 2014;23:460-468)
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2014, Volume 23, No. 6
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H
ospital-acquired infections (HAIs) have been a long-standing source of
complications for patients. Compared with patients without HAIs, patients
with HAIs had longer hospital length of stay, increased cost of care, more
morbidity, and higher mortality.1-4 Decreasing the occurrence of HAIs, which
are considered preventable, is a primary goal of many hospital-based quality
improvement and patient safety programs.
Infection control practices, such as hand hygiene,
isolation precautions, environmental cleaning, and
antimicrobial bathing, are the major focus of efforts
to decrease HAI occurrence. Despite infection control
practices surrounding cleaning techniques by hospital personnel, bacteria can remain latent on inanimate surfaces such as door knobs, identification
badges, stethoscopes, bath basins, sharps containers, tourniquets,5-11 and electrocardiographic lead
wires (ECG-LWs),13,14 and may be a source of crosscontamination and nosocomial infection, especially
in patients who are immunocompromised.12,13
Although it is known that ECG-LWs are a
reservoir source for microorganisms, it is unknown
if disposable ECG-LWs would lead to a decrease in
infection rates compared with cleaned, reusable
ECG-LWs. Disposable ECG-LWs do not require adherence to optimal cleaning procedures because they are
discarded after one use. Because disposable ECGLWs are not expected to harbor latent bacteria when
packaged, they may offer advantages beyond reusable
ECG-LWs that are cleaned after each use. In this
comparative effectiveness research trial, the primary
objective was to determine whether disposable
ECG-LWs caused a reduction of cross-contamination
risk and led to the following outcomes compared
with cleaned, reusable ECG-LWs: lower rates of
bloodstream infection (BSI) and
ventilator-associated pneumonia
(VAP) in adults treated in medical,
cardiovascular surgery, general surgery, and neurological intensive care
units (ICUs) and lower rates of sternal wound-surgical site infections
(SSIs) in adults cared for in cardiovascular surgery ICUs. Specific aims
were to examine between-group differences in overall infection rates,
infection rates by ICU environment, infection rates
by infection type (BSI, VAP, and SSI), infection rates
for each infection type by ICU environment, and
time to first infection in all ICU patients and in
patients treated in the ICU for at least 48 hours, after
adjusting for patients’ length of stay in the ICU.
Disposable ECG
lead wires are
not expected to
harbor latent
bacteria when
packaged.
Methods
About the Authors
Nancy M. Albert is the associate chief nursing officer,
Office of Research and Innovation–Nursing Institute and
a clinical nurse specialist, Kaufman Center for Heart
Failure–Heart and Vascular Institute at Cleveland Clinic
in Cleveland, Ohio. She is also an adjunct professor at
Aalborg University in Aalborg, Denmark, and an adjunct
associate professor at Case Western Reserve University,
Francis Payne Bolton School of Nursing in Cleveland,
Ohio. Ellen Slifcak is a research nurse, Joel D. Roach is
a research coordinator, James F. Bena is a statistician,
Gregory Horvath was a nurse manager in the medical
intensive care unit, Sue Wilson is a nurse manager in the
surgical intensive care unit, Rosslyn Van Den Bossche
is assistant nursing director of the Heart and Vascular
Institute, Nemy Vargas is a nurse manager in the medical
intensive care unit, Victoria Rhoades is a nurse manager
in the neuroscience intensive care unit, Katrina M. Hartig
was a nurse manager in the cardiovascular intensive
care unit, Heather Lachiewicz is a nurse manager in the
cardiovascular intensive care unit, and Terri Murray is a
nurse manager in the cardiovascular stepdown/telemetry unit at Cleveland Clinic.
Corresponding author: Nancy M. Albert, RN, PhD, CCNS, CHFN,
CCRN, NE-BC, Cleveland Clinic, 9500 Euclid Avenue, J3-630
(J3-4), Cleveland, OH 44195 (e-mail: [email protected]).
www.ajcconline.org
The trial used a cluster, randomized controlled
design. Matched ICUs were randomized to nonsterile,
disposable ECG-LWs (intervention) versus cleaned,
reusable ECG-LWs (usual care). This study received
approval from the Cleveland Clinic’s institutional
review board before initiation.
Setting and Sample
The unblinded trial was completed at the Cleveland Clinic, a quaternary-care medical center with
more than 1200 beds in Northeast Ohio. Adult
patients being treated in a medical, cardiovascular
surgery, general surgery, or neurological ICU were
included if their assigned ICU was 1 of a minimum
of 2 matching units that had the same population
of patients, leadership team, health care providers
(physicians, acute care nurse practitioners, respiratory therapists, and in some ICUs, clinical nurses),
and policies and procedures. Four cardiovascular
ICUs, 3 general surgery ICUs, 2 medical ICUs, and
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2014, Volume 23, No. 6
461
Enrollment
Assessed for eligibility (n = 7939 cases)
Randomized by intensive care unit (ICU) assignment (n = 7939)
Allocation
Cases allocated to reusable
ECG-LW (n = 3463)
Cases allocated to disposable
ECG-LW (n = 4476)
• Excluded from analysis:
• In hospital or ICU > 2 days
before study start date
(n = 104)
• On study unit < 24 hours
(n = 120)
• Extended stay on study unit
after enrollment stop date
(n = 52)
• Other (n = 3)
• Excluded from analysis:
• In hospital or ICU > 2 days
before study start date (n = 31)
• On study unit < 24 hours
(n = 189)
• Extended stay on study unit
after enrollment stop date
(n = 74)
• Patient off assigned ECG-LW
(n = 21)
• Other (n = 5)
Analysis
Analyzed (n = 3184 cases)
Analyzed (n = 4056 cases)
Figure 1 Usual-care and intervention cases for electrocardiographic lead wires (ECG-LW) trial.
2 neurological ICUs participated. Each of the matched
units was randomly assigned to usual care or intervention ECG-LWs by having nurse managers associate
a specific ICU to a sealed envelope with an ECG-LW
assignment written inside. The surgical ICU had 3
matched units, so 4 envelopes were available, 2 of
each labeled with disposable and reusable ECG-LWs.
Of 11 participating ICUs, 6 were
assigned to disposable ECG-LWs
and 5 were assigned to reusable
ECG-LWs. Some patients had multiple ICU stays during 1 episode of
care; thus, each ICU stay was considered a case if inclusion criteria
were met. On the first day of study
enrollment, patients who were currently in a study ICU were included
if they had been previously admitted to the unit within 48 hours. On
the day the study stopped enrollment, patients were
included if they were discharged within 48 hours of
the enrollment stop date. The enrollment stop date
was dictated by inability to provide disposable
ECG-LWs to newly admitted ICU patients, because
the supply was depleted. Patients were excluded
from analysis if they were admitted after midnight
but were not in the ICU the following midnight,
Data collection for
1 year would provide 80% power to
detect differences
of at least 25%
between groups.
462
reflecting less than a 1-day stay according to billing
criteria, received the wrong ECG-LW per random
assignment, or had ECG-LWs removed (Figure 1).
Sample size was determined on the basis of the
following assumptions: randomization of matched
units, not individual patients, required a much larger
difference between groups in the primary outcome
(overall infection rate), matched units would have
a ρ of 0.5 (50% level of correlation among the like
units), and usual care ICU BSI rate would be approximately 0.9 per 100 ICU days. Thus, to detect a 50%
reduction in BSI, using 80% power in BSI infections,
and assuming 10 beds per unit per day per group
enrollment, cases would need to be enrolled to the
matched units for a 1-year period. Sample size for
SSI among cardiothoracic surgical ICU cases was based
on an SSI rate of 2.4% among patients in the cleaned,
reusable ECG-LW group. With an expected enrollment per group of 60 patients/month (total 420),
there would be 80% power to detect a reduction of
90% or greater in the SSI rate in the disposable ECGLW group relative to the reusable ECG-LW group.
After 4 months of data collection, a data review
revealed 2 findings: the number of cases enrolled
was nearly 2 times (double) what was anticipated,
and ICU BSI rates were much lower than previous
annual reports (BSI rate was approximately 0.15
per 100 ICU days). To evaluate the impact of the
observed results on sample size requirements, an
update of the previous sample size analysis was
performed by using the methods described by Hayes
and Bennett.14 Assuming the rate of enrollment of
cases and all other effects remained the same, data
collection for a 1-year period would provide 80%
power to detect differences of at least 25% between
groups. With low rates of BSI and other HAIs, a 25%
difference between groups would provide clinical
significance of group differences.
Usual-Care and Intervention ECG-LW Groups
Units assigned to usual care maintained standard-of-care procedures related to ECG-LW attachment, removal, cleaning, and storage when not in
use. For all except the cardiovascular surgery ICUs,
environmental service workers cleaned ECG-LWs
after patients were discharged from the ICU, using
standard wipes (Clorox Healthcare Germicidal Wipes,
which effectively kill Clostridium difficile spores in 3
minutes and 50 other bacteria in 30 seconds or less)
and procedures (wiped the entire length of each
wire to clean visible and invisible debris and contaminants). For the cardiovascular ICUs, after patients
were discharged, ECG-LWs were sent to the cardiovascular operating room for ultrasound cleaning
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2014, Volume 23, No. 6
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and reuse, per long-standing usual-care procedures.
Nurses and other health care workers completed
usual-care activities related to ECG monitoring for
both groups.
After random assignment was determined, units
allocated to the intervention group were oriented to
disposable ECG-LW cable-to-monitor connection,
patient connection, and supply storage site. Nonsterile, disposable ECG-LW sets were wrapped in a clear
plastic bag. The supply of ECG-LWs that were not in
use was maintained in the sealed shipping box and
stored in an office of the principal investigator. When
patients were discharged from the ICU, disposable
ECG-LWs were discarded. During the study enrollment
period, all reusable ECG-LW sets were removed from
the intervention group ICUs. One research nurse and
1 research coordinator made daily rounds to each
study ICU to assess use of ECG-LWs per random assignment and ensure an adequate supply of disposable
ECG-LWs. On the day that the study started, staff
nurses switched all patients in intervention group ICUs
from reusable to disposable ECG-LWs.
Outcomes
Rates of hospital-acquired BSI and VAP were
retrieved from a database in the infection control
department and included the date of the infection,
type of bacteria, central-catheter BSI determination,
and primary and secondary sources. All data retrieved
were reviewed by researchers to ensure that the date
of infection coincided with the ICU stay of record.
Rates of SSIs were retrieved from data collected routinely for the Society of Thoracic Surgeons registry. An
SSI was defined as 1 of 3 sternal infections, a sternal
superficial wound infection, a deep sternal wound infection, or mediastinitis. Medical records of all cases were
reviewed by researchers to ensure that the sternal infection had occurred during the current ICU admission
and was not associated with a previous event or surgery.
Patients’ data on age, sex, race, marital status,
insurance type, discharge disposition, ICU length of
stay, and hospital length of stay were retrieved from
a billing database. Electronic medical records were
reviewed for presence of 17 chronic medical conditions before hospital admission by using the Charlson
Comorbidity Index (CCI). The CCI was developed to
classify comorbid conditions that might change the
risk of mortality.15-20 The score was categorized into 3
groups (score of 1-2 = 1; 3-4 = 3; 5 or more = 5), with a
higher score reflecting greater morbidity and risk of
mortality. In a study18 of 33 940 patients with
ischemic heart disease, the index grouping demonstrated a strong relationship to mortality rate. In our
study, the CCI was used to reflect patients’ acuity.
www.ajcconline.org
Data Collection
Researchers identified cases daily by completing
ICU rounds and by assessing patient admissions via
the electronic medical record. Infection data and
patients’ demographics were requested in batches,
and valid cases were entered into an SPSS database
(v19, IBM/SPSS) with CCI data that were retrieved
retrospectively. Data retrieved from the billing database were merged with SPSS data by a statistician.
Data Analysis
Categorical factors were described by using frequencies and percentages, rates were described by
using total counts and rate per 100 patient days,
and continuous measures were described by using
means and standard deviations. To compare infection rates across all unit types, generalized linear
mixed-effect models were used, treating the counts
as coming from a Poisson distribution. We used the
generalized linear mixed-effect model because it
was reported to perform better in situations that
involved a small number of clusters
(ICUs). Analysis was performed
under assumptions of nonmatching
within ICU type and also matching
within each of the 4 ICU types
(medical, cardiothoracic surgical,
surgery, and neurological). For
analysis within ICU type, traditional
Poisson regression models were
used. Models were fit by using the
GLIMMIX and GENMOD procedures
within SAS software (version 9.2).
ECG-LW groups were compared by
using mixed models for continuous measures and
logistic regression with generalized estimating equations for binary measures. All models except the
model comparing unit length of stay were weighted
by the patient’s length of stay in the unit. Time-toevent analyses were performed by using KaplanMeier estimates of survival and Cox proportional
hazards models. Analyses corrected for the correlation within patients by using adjustments within
the Cox proportional hazards model. Models were
fit by using the LIFETEST and PHREG procedures
within SAS software. A significance level of .05 was
considered statistically significant.
One research
nurse and one
research coordinator made daily
rounds to assess
use of ECG
lead wires.
Results
In a 12-month period, 7240 cases were enrolled
with 1484 cases from 2 matched medical ICUs,
3260 cases from 4 matched cardiovascular surgery
ICUs, 1540 cases from 3 matched general surgery ICUs
(2 randomized to disposable and 1 randomized to
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2014, Volume 23, No. 6
463
Table 1
Demographics of 7240 patients in the study
A. Continuous factors
Mean (95% CI)
Factor
Reusable
Days in intensive care unit
Age, y
Charlson Comorbidity Index
Days in hospital
Disposable
Difference
P
3.61 (3.44-3.77)
3.62 (3.47-3.76)
0.01 (-0.21-0.23)
.94
62.83 (62.30-63.36)
62.29 (61.82-62.76)
-0.54 (-1.25-0.17)
.13
2.48 (2.40-2.55)
2.63 (2.56-2.70)
0.15 (0.05-0.25)
.002
21.79 (21.02-22.57)
22.06 (21.41-22.72)
0.27 (-0.75-1.28)
.60
B. Categorical factors
Probability (95% CI)
Reusable
Disposable
Discharge disposition
Home
Not home
.38 (.36-.41)
.62 (.59-.64)
.35 (.32-.37)
.65 (.63-.68)
Sex
Male
Female
.55 (.52-.58)
.45 (.42-.48)
.56 (.53-.59)
.44 (.41-.47)
Insurance type
Government/self-pay
Commercial
.47 (.44-.50)
.53 (.50-.56)
.46 (.43-.49)
.54 (.51-.57)
Marital status
Other
Married
.48 (.45-.51)
.52 (.49-.55)
.46 (.43-.49)
.54 (.51-.57)
Race
White
Nonwhite
.79 (.76-.81)
.21 (.19-.24)
.77 (.74-.79)
.23 (.21-.26)
No. of infections per 100 patient days
Factor
.03
.69
.62
.21
.33
2.0
1.5
1.0
0.5
P = .48
P = .47
P = .47
Cardiovascular
Medical
Surgical
P = .72
0.0
Neurological
Type of intensive care unit
Disposable
Reusable
Figure 2 Comparison of rate of infection between disposable
and reusable electrocardiography lead wire by type of intensive
care unit (N = 7240). Infections included bloodstream infections
and ventilator-associated pneumonia for all types of intensive
care units, with sternal surgical site wound infections also
included for cardiovascular intensive care units.
464
P
cleaned, reusable ECG-LWs), and 956 cases from
the 2 matched neurological ICUs. Patients’ demographics were similar for most factors studied, except
for discharge disposition and mean CCI score.
Patients randomized to the disposable ECG-LW
group were less likely to be discharged home and
had a moderately higher CCI, both of which reflected
higher acuity in patients randomized to disposable
ECG-LWs (Table 1).
Overall, the infection rate remained very low
throughout the trial period, with only 86 BSIs, cases
of VAP, or SSIs among 74 patients. Thus slightly
more than 1% of the study population had an infection develop as defined by the research protocol.
Of 61 BSIs, 16 (26%) were determined to be BSIs
associated with a central catheter. A total of 19 cases
of VAP and 6 cases of SSI occurred. No difference in
total infection rate (BSI + VAP + SSI) was apparent
between disposable and reusable ECG-LW groups
based on 100 patient days; paired unadjusted relative risk (95% CI) was 1.35 (0.99-1.83; P = .06).
Per matched ICUs, total infection rates per group
did not differ by type of ICU (Figure 2). In addition,
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Table 2
Multivariate analyses of infection rates between electrocardiographic lead
wire groups after adjusting for discharge disposition and comorbidity index
Infection type
Disposable, No. (rate/100)
Reusable, No. (rate/100)
Paired, relative risk (95% CI)
Paired P
Full sample of cases (N = 7240)
Alla
BSI
BSI + SSI
56 (0.379)
41 (0.277)
45 (0.304)
30 (0.260)
20 (0.173)
22 (0.191)
1.35 (0.94-1.95)
1.40 (0.91-2.16)
1.49 (0.97-2.29)
.10
.12
.07
28 (0.313)
19 (0.213)
20 (0.224)
1.43 (0.93-2.19)
1.43 (0.89-2.30)
1.59 (0.97-2.61)
.10
.14
.07
Sample with length of stay > 48 hours; n = 2578
Alla
BSI
BSI + SSI
a
55 (0.479)
40 (0.349)
44 (0.383)
Bloodstream infection (BSI) + ventilator associated pneumonia + sternal surgical site infection (SSI).
each type of infection per group did not differ by
type of ICU: BSI (P values, .61-.72), VAP (P values,
0.38-0.91), and SSI (P = .36; cardiovascular surgery ICU only). In the 2578 cases that involved
an ICU stay longer than 48 hours, no difference in
total infection rate based on 100 patient days was
found between disposable and reusable ECG-LW
groups (paired unadjusted relative risk [95% CI],
1.43 [0.97-2.12], P = .07), and no differences per
group were apparent for each paired ICU environment, (P values, .39-.51).
In multivariate analyses, after discharge disposition and CCI were adjusted for, no differences
in total infection rates were apparent between
ECG-LW groups for the full sample or for cases
where the ICU stay was greater than 48 hours
(Table 2). When just BSI rates and BSIs and SSIs
combined were assessed, the relative risk of infection between groups remained relatively unchanged.
Time to first infection was compared between
groups to determine if disposable ECG-LWs would
lengthen time to infection occurrences. Total
infection rates, BSI, or BSI plus SSI did not differ
between groups (P values, .26-.97). After discharge
disposition and CCI were controlled for between
groups, no differences were found in time to first
infection. The disposable ECG-LW versus reusable
ECG-LW hazard ratio (95% CI) for all infections
was 1.21 (0.87-1.69; P = .25); for BSI, it was 1.45
(0.68-3.09; P = .34); and for BSI plus SSI, it was
1.40 (0.81-2.43; P = .23). Similar to the full sample, no differences in time to first infection were
apparent between groups for the 2578 cases with
ICU stays longer than 48 hours; P values were
from .26 to .97. After discharge disposition and
comorbid conditions were controlled for, hazard
ratios for total infection, BSI, and BSI plus SSI
were similar to hazard ratios for the full sample
with P values of .23 to .33.
www.ajcconline.org
Discussion
In this randomized controlled trial, the overall
infection rate throughout the 1-year period was very
low and stable over time, and infection rates did
not differ between patients receiving nonsterile
disposable ECG-LWs and patients receiving cleaned,
reusable ECG-LWs. Before the start of the study, a
much higher infection rate (0.9 per 100 ICU days)
was seen among the hospital’s adult ICUs. Implementation of infection control practices drastically
reduced the infection rate during the study. In the
literature, clinicians suggested that reusable ECG-LWs
might lead to cross-contamination of microorganisms, including resistant bacteria,
and be a culprit in HAIs.15,21,22 Our
findings represent new knowledge
and provide evidence that reusable
ECG-LWs are not more likely to be a
source of pathogens that lead to HAIs.
Further, our cardiovascular surgery
ICUs cleaned reusable ECG-LWs by
ultrasound. Previously, ultrasound
cleaning of ECG-LWs was hypothesized to be the reason why fewer
bacteria grew on ECG-LWs in ICUs.12
In this study, both the disposable and
reusable cardiovascular surgery ICU ECG-LW groups
had fewer HAIs than patients in other ICU environments; however, no between-group differences in the
rate of HAIs were found. Thus, ultrasound cleaning
of reusable ECG-LWs did not offer benefit over the
cleaning practices used in the other adult ICUs and
did not provide an explanation for the lower incidence of HAIs among the cardiovascular ICUs.
Some hypotheses may explain our results. First,
once clean, disposable ECG-LWs are removed from
their original packaging, the risk of contamination
with resistant microorganisms via handling and
exposure to environmental factors (including health
The groups did
not differ in total
infection rates
for cases with
an intensive care
unit stay longer
than 48 hours.
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2014, Volume 23, No. 6
465
care providers’ hands, airborne particulates associated with coughing or sneezing, and open wounds)
is the same as the risk for cleaned, reusable ECGLWs. Risk of cross-contamination may be reduced
initially, but the period of risk reduction might be
very short, depending on environmental cleanliness
and hand-washing practices of staff. In this research,
we found no differences between groups in time to
infection development based on the type of ECGLWs used. The first assessment was at 3 days after
ICU admission. Therefore, any possible advantage
of disposable ECG-LWs based on the assumption
that reusable ECG-LWs would have a heavier burden of microorganisms from inefficient disinfection
during cleaning was negated fairly quickly if it was
a factor at all. Because disposable ECG-LWs are not
sterile before use, it is unknown if microorganisms
were present before patient contact, due to handling during packaging.
Second, clinicians should not assume that exposure to resistant bacteria and other microorganisms
found on ECG-LWs, no matter if the burden is heavy
or light, automatically increases the occurrence of
HAIs. Bacteria grow on many inanimate objects
found in hospital ICU environments,23 and common nosocomial pathogens may survive or persist
on surfaces for months,24 yet HAIs
do not develop in most patients
who are not immunocompromised.
In this study, 3 of the 4 ICU environments included patients with
surgical wounds, exposed incisions,
and drains or catheters across the
chest and abdomen that could
have come in contact with the
ECG-LWs. Because the infection
rates did not differ between groups among matched
ICUs, the rate of exposure of ECG-LW to open incisions and wounds was probably equal among disposable and reusable ECG-LWs and was not a factor
in the risk of HAI.
Finally, many hospitals have a bundled infection
control program, especially in ICUs. Bactericidal
solutions are used to bathe patients and clean equipment; adherence to optimal hand-washing techniques
is monitored; intravenous, urinary, and other catheters
are removed as soon as possible to stop infection;
VAP prevention protocols are commonly used; and
early mobility and extubation are encouraged. The
combination of efforts that may have also included
use of nonsterile disposable ECG-LWs, could have
resulted in a reduction in the rate of HAI. For most
bundled programs, it is difficult to determine the
components that are truly effective in achieving
Infection rates were
very low and stable
with no differences
between disposable
and reusable wires.
466
outcomes. In a review of the literature on transmission of methicillin-resistant Staphylococcus aureus,
risk factors varied, but the most commonly reported
factor was carriage from poor infection control/hand
hygiene practices among health care workers. Other
less common factors were patients’ comorbid conditions and recent use of antibiotics. One of 4 risk
factors for persistence of transmission despite eradication included environmental contamination; the
others were patient-centric factors such as comorbid
conditions, mupirocin resistance, and sites of colonization.25 Thus, transmission of microorganisms to
patients was most likely from personnel and patient
factors, not environmental contamination. Based
on results of this study, ECG-LW type alone may
not provide HAI risk reduction. A bundled approach
may be a more effective strategy for reducing HAIs
related to BSI, VAP, or sternal SSI; however, hand
hygiene is the most important intervention to prevent
pathogen spread and reduce the occurrence of HAIs.
This research has limitations. The research setting was a single center; however, it was uniquely
suited to the study design because it is one of very
few hospitals in the United States with multiple
matched ICU environments near one another. The
rate of HAIs from BSIs, VAP, and sternal wound
SSIs was much lower than originally assumed when
the study was powered; thus, the confidence intervals surrounding the relative risk and hazard ratios
are wide. Methods of cleaning reusable ECG-LWs
varied by unit, and health care providers were not
blinded to interventions because the disposable
ECG-LWs were a different color than the reusable
ECG-LW system. However, the study was conducted
for a long period, and the risk of bias due to various cleaning techniques and nonblinding was minimal, especially because use of ECG-LWs was the
standard of care. Reusable ECG-LWs were occasionally discarded, so patients in the reusable ECG-LW
group who were recipients of a newly opened
reusable ECG-LW set mimicked patients in the disposable ECG-LW group. Our large sample size of
more than 7000 cases minimized this limitation.
Conclusion
Disposable ECG-LWs may offer advantages to
patient care in an ICU, including a reduction in initial exposure to microorganisms that are found on
cleaned, reusable ECG-LWs; however, HAI rates
did not differ between patients who received clean,
reusable ECG-LWs and patients who received nonsterile, disposable ECG-LWs. Nurses must assess
other cross-contamination pathways that might
minimize or eliminate HAIs.
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2014, Volume 23, No. 6
www.ajcconline.org
FINANCIAL DISCLOSURES
The study was partially supported by a research grant
from Covidien in Mansfield, Massachusetts.
eLetters
Now that you’ve read the article, create or contribute to an
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SEE ALSO
For more about disposable vs reusable electrocardiography leads, visit the Critical Care Nurse Web site,
www.ccnonline.org, and read the article by Brown,
“Disposable vs Reusable Electrocardiography Leads
in Development of and Cross-contamination by
Resistant Bacteria” (June 2011).
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2. Song X, Chen Y, Li X. Differences in incidence and outcome of ventilator associated pneumonia in surgical and
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794-801. doi:10.1001/archsurg.2011.41.
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Bloodstream Infections: A Global Challenge, a Global Perspective. Oak Brook, IL: Joint Commission Resources;
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_monograph.pdf. Accessed July 29, 2014.
5. Johnson D, Lineweaver L, Maze LM. Patients’ bath basins
as potential sources of infection: a multicenter sampling
study. Am J Crit Care. 2009;18(1):31-38.
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What’s hanging around your neck? Pathogenic bacteria on
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8. Runner JC. Bacterial and viral contamination of reusable
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infection in the orthopedic operating theater? Acta Orthop.
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e73-80. doi:10.4037/ajcc2010304.
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Outbreak of vancomycin-resistant enterococci in a burn
unit. Infect Control Hosp Epidemiol. 2000;21:575-582.
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To purchase electronic or print reprints, contact the
American Association of Critical-Care Nurses, 101
Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712
or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail,
[email protected].
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2014, Volume 23, No. 6
467
CNE Test Test ID A1423063: Infection Rates in Intensive Care Units by Electrocardiographic Lead Wire Type: Disposable vs Reusable
Learning objectives: 1. Compare infection rates of patients in intensive care units who received disposable electrocardiographic (ECG) leads vs reusable
ECG leads. 2. Identify sources of microorganisms that may promote hospital-acquired infections. 3. State the role of disposable ECG leads in a bundled
infection control program.
1. Which of the following trial designs is used in the study?
a. Nonrandomized, comparative
b. Qualitative, ethnography
c. Cluster randomized, controlled
d. Cross-sectional, descriptive
2. The unblinded trial was completed in Ohio in which
type of site?
a. A secondary-care community center
b. A quaternary-care urban medical center
c. A Veterans Affairs medical center
d. A primary and home care health system
3. How many neurological intensive care units (ICUs)
were included in the study?
a. 2
c. 3
b. 4
d. 5
4. Out of all units in the study, which of the following
units did not have environmental service workers clean
the reusable electrocardiographic (ECG) leads?
a. General surgery
c. Neurological ICU
b. Medical ICU
d. Cardiovascular ICU
5. Rates of surgical site infections were retrieved from
data routinely collected for which of the following
organizations?
a. Society of Thoracic Surgeons
b. Society of Critical Care Medicine
c. Society for Neuroscience
d. Society of General Internal Medicine
6. In the study, the Charlson Comorbidity Index was
used as a surrogate for which of the following?
a. Infection burden
c. Mortality rate
b. ICU readmission
d. Patient acuity
7. How long was the data collection period?
a. 3 months
c. 9 months
b. 6 months
d. 12 months
8. How many total cases were enrolled in the study?
a. 1484
c. 1540
b. 7240
d. 3260
9. In this study, patient characteristics differed between
groups for which of the following?
a. Insurance type and marital status
b. Marital status and discharge disposition
c. Discharge disposition and Charlson Comorbidity Index
d. Charlson Comorbidity Index and insurance type
10. In the review of literature on transmission of
methicillin-resistant Staphylococcus aureus, the most commonly reported risk factor was which of the following?
a. Environmental contamination
b. Poor hand hygiene practices
c. Comorbid conditions
d. Recent use of antibiotics
11. Of the study sample, what was the mean hospital
length of stay (days) for patients?
a. 2.6
c. 63
b. 3.6
d. 22
12. According to Figure 1, which of the following was the
most common reason for being excluded from analysis?
a. Did not receive assigned ECG lead wires
b. On unit more than 48 hours before the study start date
c. On study unit for less than 24 hours
d. On unit for multiple days after enrollment stopped
Test ID: A1423063 Contact hours: 1.0; pharma 0.0 Form expires: November 1, 2017. Test Answers: Mark only one box for your answer to each question.
1. ❑ a
❑b
❑c
❑d
2. ❑ a
❑b
❑c
❑d
3. ❑ a
❑b
❑c
❑d
4. ❑ a
❑b
❑c
❑d
5. ❑ a
❑b
❑c
❑d
6. ❑ a
❑b
❑c
❑d
7. ❑ a
❑b
❑c
❑d
8. ❑ a
❑b
❑c
❑d
9. ❑ a
❑b
❑c
❑d
10. ❑ a
❑b
❑c
❑d
11. ❑ a
❑b
❑c
❑d
12. ❑ a
❑b
❑c
❑d
Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Category: CERP A Test writer: Darlene Pileski, ACNP
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