Reducing Central Line-Associated Bloodstream Infections

1. Reducing Central Line-Associated Bloodstream Infections Implementing Central Line Care Bundle Mary Eschete, MD IC Committee Chairman Peggy Glanders, RN Infection Control Coordinator Marleen C. Michael, RN CIC Infection Control Coordinator

2. Central Line-Associated Bloodstream Infection (CLABSI) Facts • CDC reports an estimated 250,000 CLABSI’S occur each year • Attributable mortality is an estimated 12-25% per infection • Prolongs hospital stays by an average of 7 days • Attributable cost per infection is an estimated $29,156.

3. Central Line-Associated Bloodstream Infection Risk Factors • Prolonged hospitalization prior to insertion • Prolonged duration of catheter • Heavy bacterial colonization at insertion site and catheter hub • Neutropenia • Internal jugular and femoral catheterization • Substandard care of the catheter and insertion site

4. Infection Prevention Guidelines • Centers for Disease Control (CDC) • Infectious Disease Society of America (IDSA) • Society for Healthcare and Epidemiology (SHEA) • Association for Professionals in Infection Control (APIC) • Institute for Healthcare Improvement (IHI) • The Joint Commission (TJC) National Patient Safety Goals

5. Goals and Plan • Significantly reduce rate of central line infections, increase patient safety and reduce morbidity/mortality in addition to realizing a cost savings. • Perform risk assessment and evaluate CLABSI data • Utilize best practices by implementing Central Line Bundle • Comply with TJC National Patient Safety Goal • Continually re-evaluate CLABSI data and provide feedback of outcomes down to the unit level • Meet or be below benchmark data from NHSN

6. What is the Central Line Bundle? • Group of evidence-based interventions and best practices for patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually. • Must be used as an all or none strategy for optimal results.

7. Central Line Bundle Core Components • Hand Hygiene • Before and after touching catheter or site • Maximal Barrier Precautions • Mask, cap, sterile gown and gloves • Large sterile full body drape • Skin Antisepsis • Chlorhexidine prior to insertion and for site care • Optimal Site Selection • Subclavian vein • Avoid femoral and internal jugular

8. Central Line Bundle Core Components • Catheter Hub Disinfection • Scrub the hub for at least 15 seconds with alcohol • CHG Site Dressings

9. Additional Measures to Bundle • Staff education via web-based modules • Patient education • Patient Safety Handbook – UMC • Patient education sheet - LJC • Central Line Insertion/Safety Checklists • Daily chlorhexidine baths for ICU patients • Policy Development • All-inclusive central line kits and supplemental barrier precautions kits • Daily line necessity review - UMC

11. Central Venous Catheter Line Days

12. Central Line Bundle Compliance • Masking of procedure assistants along with site selection have been most common reason for compliance failures. • Site selection has improved.

13. Increasing Bundle Compliance • Extensive education to physicians and nurses. Including new, incoming physicians • Physician noncompliance reported to Infection Control, Medical Executive and Executive Steering Committees • Taped insertion checklist to catheter kits • Infection Control makes rounds daily on inpatient units

14. 2006-2010 ICU Infection Rates

15. Estimated Mean ICU CLABSI Cost *Based on estimated mean cost of $29,156 per infection

16. Areas for Improvement • Increase compliance for daily reviewing of line necessity • Catheter hub disinfection • Increase compliance with checklist completion • Hand hygiene compliance

18. ICU/NICU Central Venous Catheter Line Days

19. Central Line Safety Checklist Compliance • Compliance with utilizing the checklist at LJC has increased from 53.8% in December 2009 to 86.6% in December 2010.

20. Compliance with Bundle Components • Compliance with using CHG antiseptic for skin prep increased from 48.1% in January to 100% in December. • Compliance with using Maximum Barrier precautions increased from 77.8% in January to 100% in December. • Compliance with Femoral Vein avoidance has increased from 88.9% in January to 100% in December. • Compliance with using a CHG dressing has increased from 55.6% in January to 100% in December. • Compliance with documentation of patient education has increased from 18.2% in January to 60.9% in December.

21. 2009-2010 ICU/NICU Infection Rates • The ICU/NICU annual rate decreased from 5.69/1000 device days in 2009 to 1.72/1000 device days in 2010.

22. 2009-2010 Hospital-Wide CLABSI’s By Number of Infections • The 2010 Hospital-wide annual rate is 2.04/1000 device days which is lower than the ICU/NICU 2009 rate of to 5.69/1000 days. • There were no central line-associated bloodstream infections for 8 consecutive months following the practice change. The two infections that occurred in October were related to lines that were inserted under sub-optimal conditions. One line was inserted in a femoral vein at another facility secondary to trauma. The other line was inserted emergently in a patient that coded in the Ultrasound department.

23. Estimated Mean ICU/NICU CLABSI Cost *Based on estimated mean cost of $29,156 per infection

24. Areas for Improvement • Increase compliance with documentation of patient education. • Increase compliance with checklist completion. • Increase compliance with documentation of Hand hygiene compliance. • Educate staff to re-insert lines that are inserted under sub-optimal conditions as soon as feasible. • Increase compliance by daily reviewing of line necessity.