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Tony Burrell

CLABSI. Tony Burrell. Healthcare associated infections. 2009 – 175,153 estimated HAIs (5% admissions) cost Australian healthcare system 850,000 lost bed days Increasing concerns about HAIs with emphasis on: MROs and Antimicrobial Stewardship (AMS) Hand Hygiene

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Tony Burrell

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  1. CLABSI Tony Burrell

  2. Healthcare associated infections • 2009 – 175,153 estimated HAIs (5% admissions) cost Australian healthcare system 850,000 lost bed days • Increasing concerns about HAIs with emphasis on: • MROs and Antimicrobial Stewardship (AMS) • Hand Hygiene • Vascular access devices common cause • CLABSI • Attributable mortality – 12-25% • Significant increase in ICU LOS • Largely preventable

  3. ANZICS/ACSQHC initiative • Acknowledges work in various states and individual ICUs • Aims to develop standardised approach nationally • Consistent surveillance definition and national database using ANZICS CORE • Partnership between ANZICS and ACSQHC

  4. Evidence CLAB is preventable • Good evidence base going back 15 years • Raad II, Hohn DC, Gilbreath BJ et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiology. 1994; 15:231-8 • Eggimann P Prevention of intravascular catheter infection. Curr Opin Infect Dis 2007; 20:360-369 • Berenholtz et al 2004. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 32 (10) 2014-2020. • Quality not research

  5. Major Collaboratives • CLABSI rate was reduced to: • 1.36/1000 line days over a 4 year period in 69 ICUs in South Western Pennsylvania • CDC MMWR reported in JAMA 2006; 269-270 • 1.44/1000 line days in 46 ICUs in New York State • Koll BS, Straub TA, Jalon HS et al Jt Comm J Qual Patient Saf 2008; 34:713-723 • 1.7/1000 line days in 9 VA Hospitals, Midwest, US • Bonello RS, Fletcher CE, Becker WK et al. Jt Comm J Qual Patient Saf 2008; 34:639-645 • 1.4/1000 (mean) line days in 103 ICUs in Michigan • Pronovost et al NEJM 2006 • 0.6/1000 line days (down from 1.5/1000) in 20 ICUs in Hawaii • Lin DM et al Am J Med Qual 2011 epub • ‘Matching Michigan’

  6. NSW CLAB-ICU • ‘Top down/bottom up’ project – NSW Intensive Care Coordination & Monitoring Unit and Clinical Excellence Commission • 38 ICUs • Methodology modelled on the work of Pronovost et al. • The project promoted a standardised insertion technique including: • Hand washing • Full barrier precautions during insertion • Cleaning skin with chlorhexidine • Avoiding femoral site if possible • Removing unnecessary catheters • Burrell et al MJA 2011

  7. Method • Central Line Insertion Guidelines developed • Emphasis on aseptic technique • Insertion checklist • Data management established • Completed checklist faxed to CEC • Teleform methodology • Central Line Insertion Pack developed • ICCMU Nursing management guideline

  8. Checklist detail

  9. Checklist Compliance –– 10,890 line insertions July 07 – Dec 08

  10. For further analysis data from checklist divided into: • ‘Clinician bundle’ • Undertake competency assessment • Clean hands • Sterile gloves/gown • Hat, mask, protective eyewear • ‘Patient bundle’ • Prep with 2% chlorhexidine & dry 2 mins • Large sterile drape • Maintain sterile technique • No multiple passes • Confirm catheter position

  11. Results

  12. Culture • Apathy • ‘We don’t have CLABS’ • Infection control reporting independently • Impact of clinical leadership and support readily apparent and vice versa • ‘I don’t believe the evidence’ • Mistake promoting one high profile study • 4 ICUs refused to wear hats • Why fully drape the patient? • Excuse for not changing • Data collection/reporting requirements – ‘Where’s the money? – excuse for not engaging in project, other ICUs used checklist but didn’t follow up lines or submit data

  13. HATS!!! • ‘As in OT’ argument didn’t work • Not a lot in literature but found: • Hair reservoir for organisms in proportion to length, oiliness & curliness • Clinicians acquire transient flora in hair • Fletcher et al J Bone & Joint Surg 2007 • Owers et al J Hosp Inf 2004 • Nicolay Int J Surg 2006 • Studies linking hair to surgical site infection: • Mastro et al New Engl J Med 1990 • Dineen, Drusin Lancet 1973 • Summers et al J Clin Path 1965 • Studies linking max sterile barrier precautions to CLAB less clear: • Raad et al Inf Control & Hosp Epid 1994 • Carrer et al Minerva Anesth 2005 Marghie Murgo, Eda Calabria CEC

  14. Impact of compliance • Non compliance with the ‘clinician bundle’: • relative risk of CLABSI was RR 1.62 (95% CI 1.1-2.4, p=0.0178) • For central lines RR 1.99 (95% CI 1.2-3.2 , p=0.0037) • For PICC RR 5.08 (95% CI 1.03-25 , p=0.059) • Dialysis catheters – no difference • If compliant with both ‘clinician bundle’ and ‘patient bundle’ then risk of CLAB was RR 0.6 (95%CI 0.4-0.9, p=0.0103)

  15. Survival analysis • In non-referral ICUs lowest probability of CLABSI (1 in 100) was at day 3 in first 12 months – this was extended to day 8 in last 6 months • In referral ICUs the lowest probability of CLABSI was extended from day 7 to day 9 • 75% central lines in place for less than 7 days • ‘Zero-risk’ (<1/1000 line days) is possible • McLaws, Burrell Crit Care Med 2011 epub Oct • Many ICUs do not have CLABSIs for months at a time • Other strategies ie BioPatch, coated catheters best reserved for longterm lines, ICUs where CLABSI is a continuing problem

  16. Improvement multi-factorial • Increased awareness of need for scrupulously aseptic insertion • Increasing compliance with clinician bundle (if non hat wearers excluded) • Not due to ↓femoral lines or ↓time in situ • Significantly better communication between intensive care & infection control • Greater understanding of surveillance definition • Increasing ownership by intensive care clinicians following reporting of individual ICU CLABSI data

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