Protocols and Definitions Central Line Associated Bloodstream Infection Neonatal Intensive Care Michelle Littlejohn RN,

1. Protocols and DefinitionsCentral Line Associated Bloodstream InfectionNeonatal Intensive CareMichelle Littlejohn RN, CIC This portion of today�s training will describe the protocols and definitions for the Device-associated Module of the Patient Safety Component of the NHSN.This portion of today�s training will describe the protocols and definitions for the Device-associated Module of the Patient Safety Component of the NHSN.

2. Objectives Describe the NHSN NICU protocols and definitions used in reporting CLABSI. While CLABSI surveillance in the NICU follows the same event defintion as CLABSI in the adult population, there are changes particular to the NICU. These include reporting of Umbilical lines in addition to the usual central lines and reporting the CLABSI rate within the five Birth Weight Categories The reporting of the CLABSI is reported in the category of the baby�s Birth Weight no matter what the current weight is on the day of the event.While CLABSI surveillance in the NICU follows the same event defintion as CLABSI in the adult population, there are changes particular to the NICU. These include reporting of Umbilical lines in addition to the usual central lines and reporting the CLABSI rate within the five Birth Weight Categories The reporting of the CLABSI is reported in the category of the baby�s Birth Weight no matter what the current weight is on the day of the event.

3. Who Must Report NHSN NICU CLABSI? All hospitals with Perinatal Centers approved to provide care in the following Neonatal Intensive Care Units (NICU) must report CLABSI into NHSN. Level III Nursery Level ll/lll Nursery Level ll E Nursery (NHSN Location ll/lll )

4. Who Must Report NHSN NICU CLABSI? Currently: Greenville Hospital System, McLeod Regional Medical Center, MUSC , Palmetto Health, Spartanburg Regional, Palmetto Health Baptist, Self Regional Health, Piedmont Medical Center, PLUS any hospital approved by DHEC in the future to provide care in the reportable nursery category.

5. CLABSI Central Line-Associated Bloodstream Infection (CLABSI) is a primary bloodstream infection (BSI) in a patient that had a central line within the 48-hour period before the development of the BSI If the BSI develops in a patient within 48 hours of discharge from a location, indicate the discharging location on the infection report In collecting surveillance data, we always want to make sure that the things we count and the data we compare are exactly the same. Otherwise, our data has little or no meaning. For this reason, we�ll spend a good deal of time during this training defining terms. Let�s begin with the definition of CLABSI. [read slide]In collecting surveillance data, we always want to make sure that the things we count and the data we compare are exactly the same. Otherwise, our data has little or no meaning. For this reason, we�ll spend a good deal of time during this training defining terms. Let�s begin with the definition of CLABSI. [read slide]

6. Central Line Next, we�ll define Central Line. [read slide]Next, we�ll define Central Line. [read slide]

7. An introducer is considered an intravascular catheter In neonates, the umbilical artery and vein is considered a great vessel Neither the location of the insertion site nor the type of device may be used to determine if a line qualifies as a central line Pacemaker wires and other non-lumened devices inserted into central blood vessels or the heart are not considered central lines, because fluids are not infused, pushed, nor withdrawn through such devices. [read slide][read slide]

8. Types of Central Lines Temporary� A central line that is nontunneled (ex.- PICC, Broviac, Umb) Permanent� Includes Tunneled catheters, including certain dialysis catheters Implanted catheters (including ports) In NHSN, a central lines is distinguished by whether it�s temporary or permanent. [read slide] In NHSN, a central lines is distinguished by whether it�s temporary or permanent. [read slide]

9. Infusion Introduction of a solution through a blood vessel via a catheter lumen Continuous infusions such as nutritional fluids or medications, or May include intermittent infusions such as flushes or IV antimicrobial administration, or blood, in the case of transfusion or hemodialysis Infusion means the introduction of a solution through a blood vessel via a catheter lumen. This may include continuous infusions such as nutritional fluids or medications, or it may include intermittent infusions such as flushes or IV antimicrobial administration. Infusion also includes the administration of blood or blood products in the case of transfusion or hemodialysis You don�t stop counting it as a line day just because you have Hep Welled it.Infusion means the introduction of a solution through a blood vessel via a catheter lumen. This may include continuous infusions such as nutritional fluids or medications, or it may include intermittent infusions such as flushes or IV antimicrobial administration. Infusion also includes the administration of blood or blood products in the case of transfusion or hemodialysis You don�t stop counting it as a line day just because you have Hep Welled it.

10. Collecting CLABSI Data Specific types of BSI Lab Confirmed Bloodstream Infection (LCBI) can be used for all age groups- Including NICU! The first step in collecting CLABSI data is to identify patients on the unit who meet the criteria for BSI who have a central line. A Primary Bloodstream Infection form is completed for each patient with a BSI. There are two specific types of BSIs. Laboratory Confirmed BSI, or LCBI can be used for any patient including adults, children, infants and neonates.. All the definitions that we talk about are found in the NHSN Users Manual (Patient Safety Protocol). You should always have a copy of these definitions available when doing surveillance just to make sure that you have exactly the elements of the criteria required. Let�s look now at these definitions individually. The first step in collecting CLABSI data is to identify patients on the unit who meet the criteria for BSI who have a central line. A Primary Bloodstream Infection form is completed for each patient with a BSI. There are two specific types of BSIs. Laboratory Confirmed BSI, or LCBI can be used for any patient including adults, children, infants and neonates.. All the definitions that we talk about are found in the NHSN Users Manual (Patient Safety Protocol). You should always have a copy of these definitions available when doing surveillance just to make sure that you have exactly the elements of the criteria required. Let�s look now at these definitions individually.

11. LCBI Any patient The LCBI definition is pretty straightforward. The blood culture must show a pathogen and it must be clear that the pathogen is not related to an infection from another site. This is the most commonly used criteria for BSI. If you are ruling out a CLABSI on the basis that the symptoms are due to infection at another site, you must be able to meet that infection per the NHSN definition. For example, if you have a blood sepsis with e faecalis and say you are ruling it out due to NEC, you must have documented evidence of signs and symptoms of NEC in the patient record.The LCBI definition is pretty straightforward. The blood culture must show a pathogen and it must be clear that the pathogen is not related to an infection from another site. This is the most commonly used criteria for BSI. If you are ruling out a CLABSI on the basis that the symptoms are due to infection at another site, you must be able to meet that infection per the NHSN definition. For example, if you have a blood sepsis with e faecalis and say you are ruling it out due to NEC, you must have documented evidence of signs and symptoms of NEC in the patient record.

12. Laboratory Confirmed BSI (LCBI)* Any Patient This is the second criteria that can be used for LCBI. Basically, it says you can have a fever, chills or hypotension which cannot be related to an infection at another site. Additionally, you must have either two blood cultures that grow a common skin contaminant or one blood culture that grows a skin contaminant plus the patient must have an intravascular line and the doctor institutes appropriate antimicrobial therapy. Notice the definitions use the words �and� and �or� frequently. When the word �and� is used, it means that both of the elements of the criteria must be present. When the word �or� is used, it means that you may choose one or the other. This is the second criteria that can be used for LCBI. Basically, it says you can have a fever, chills or hypotension which cannot be related to an infection at another site. Additionally, you must have either two blood cultures that grow a common skin contaminant or one blood culture that grows a skin contaminant plus the patient must have an intravascular line and the doctor institutes appropriate antimicrobial therapy. Notice the definitions use the words �and� and �or� frequently. When the word �and� is used, it means that both of the elements of the criteria must be present. When the word �or� is used, it means that you may choose one or the other.

13. Notes: 1. In criterion 1, the phrase �one or more blood cultures� means that at least one bottle from a blood draw is reported by the laboratory as having grown organisms (i.e., is a positive blood culture). 2. In criterion 1, the term �recognized pathogen� does not include organisms considered common skin contaminants (see criteria 2 and 3 for a list of common skin contaminants). A few of the recognized pathogens are S. aureus, Enterococcus spp., E. coli, Pseudomonas spp., Klebsiella spp., Candida spp., etc.

14. Notes continued: 3. In criteria 2 and 3, the phrase �two or more blood cultures drawn on separate occasions� means: 1) that blood from at least two blood draws were collected within two days of each other (e.g., blood draws on Monday and Tuesday or Monday and Wednesday would be acceptable for blood cultures drawn on separate occasions, but blood draws on Monday and Thursday would be too far apart in time to meet this criterion), and 2) that at least one bottle from each blood draw is reported by the laboratory as having grown the same common skin contaminant organism (i.e., is a positive blood culture). (See Note 4 for determining sameness of organisms.)

15. Notes: 3 continued a. For example, an adult patient has blood drawn at 8 a.m. and again at 8:15 a.m. of the same day. Blood from each blood draw is inoculated into two bottles and incubated (four bottles total). If one bottle from each blood draw set is positive for coagulase-negative staphylococci, this part of the criterion is met. b. For example, a neonate has blood drawn for culture on Tuesday and again on Saturday and both grow the same common skin contaminant. Because the time between these blood cultures exceeds the two-day period for blood draws stipulated in criteria 2 and 3, this part of the criteria is not met. c. A blood culture may consist of a single bottle for a pediatric blood draw due to volume constraints. Therefore, to meet this part of the criterion, each bottle from two or more draws would have to be culture-positive for the same skin contaminant.

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19. Notes continued 5. For patients < 1 year of age, the following temperature equivalents for fever and hypothermia may be used: Fever: 38�C rectal/tympanic/temporal artery = 37�C oral = 36�C axillary Hypothermia: 37�C rectal/tympanic/temporal artery = 36�C oral = 35�C axillary.

20. LCBI Neonates / Infants Criterion 3 is very much like Criterion 2, but the signs and symptoms are those that you would use for an infant or neonate. Please note, however, that Criterion 1 or 2 may be used for a neonate or infant as well. If, for example, a newborn has a blood culture that is positive with a pathogen as noted in Criterion 1, it is a valid LCBI.Criterion 3 is very much like Criterion 2, but the signs and symptoms are those that you would use for an infant or neonate. Please note, however, that Criterion 1 or 2 may be used for a neonate or infant as well. If, for example, a newborn has a blood culture that is positive with a pathogen as noted in Criterion 1, it is a valid LCBI.

21. CLABSI Denominator Data for NICU Use Denominators for NICU form At the same time each day, count for each birthweight category: # patients (i.e., patient days) # patients with one or more central lines (i.e., central line-days) separated into central lines and umbilical catheters* Enter the totals within 30 days of the end of the month When collecting denominator information in the NICU, use the Denominators for NICU form. At the same time each day, count and record the number of patients on the unit and the number of patients with one or more central lines separated into central line catheters and umbilical catheters. If a patient has both a central line and an umbilical line, count it as one patient with an umbilical line for that day. In the NICU, both patient days and line days are further stratified into 5 birthweight categories.When collecting denominator information in the NICU, use the Denominators for NICU form. At the same time each day, count and record the number of patients on the unit and the number of patients with one or more central lines separated into central line catheters and umbilical catheters. If a patient has both a central line and an umbilical line, count it as one patient with an umbilical line for that day. In the NICU, both patient days and line days are further stratified into 5 birthweight categories.

22. NICU Birthweight Categories = 750 grams 751-1000 grams 1001-1500 grams 1501-2500 grams >2500 grams These are the 5 birthweight categories that are used in NHSN to risk stratify patients. The Baby�s birthweight doesn�t change! Any CLABSI event is reported in the Baby�s BIRTH WEIGHT category, not the current weight of the baby at the time of the CLABSI event.These are the 5 birthweight categories that are used in NHSN to risk stratify patients. The Baby�s birthweight doesn�t change! Any CLABSI event is reported in the Baby�s BIRTH WEIGHT category, not the current weight of the baby at the time of the CLABSI event.

23. Example of Completed Denominators for NICU Form And here is an example of a partially completed Denominator form for a NICU, separating devices into those patients with umbilical catheters and those with central lines in each of the 5 birthweight categories. Remember, if a neonate has both an umbilical line and a central line, when counting device days, the patient is counted as having only an umbilical line.And here is an example of a partially completed Denominator form for a NICU, separating devices into those patients with umbilical catheters and those with central lines in each of the 5 birthweight categories. Remember, if a neonate has both an umbilical line and a central line, when counting device days, the patient is counted as having only an umbilical line.

24. Analysis: CLABSI Rate Stratify by: Type of ICU/Other Location SCA Temporary central line Permanent central line NICU Birthweight category Catheter type (umbilical or central) To determine the CLABSI Rate for a given location in your facility, you take the number of Central Line-associated BSIs identified on the unit and divide by the number of central line days for that unit then multiply by 1000. The numerator and the denominator in this formula are both stratified by location, and in Specialty Care areas, they�re further stratified by temporary and permanent central lines. In the NICU, the numerator and denominator are stratified by both birthweight category and by catheter type � umbilical or central.To determine the CLABSI Rate for a given location in your facility, you take the number of Central Line-associated BSIs identified on the unit and divide by the number of central line days for that unit then multiply by 1000. The numerator and the denominator in this formula are both stratified by location, and in Specialty Care areas, they�re further stratified by temporary and permanent central lines. In the NICU, the numerator and denominator are stratified by both birthweight category and by catheter type � umbilical or central.

25. Analysis:Device Utilization (DU) Ratio The Device Utilization Ratio gives us a measure of the proportion of patient days in which central lines s are used on a given unit. DU ratios are generated in NHSN output whenever CLABSI rates are calculated. They�re also available in the the NNIS/NHSN Report that you can use for comparison. The DU ratio is calculated by dividing the number of central line days by the number of patient days. There is no multiplier used for this. The Device Utilization Ratio gives us a measure of the proportion of patient days in which central lines s are used on a given unit. DU ratios are generated in NHSN output whenever CLABSI rates are calculated. They�re also available in the the NNIS/NHSN Report that you can use for comparison. The DU ratio is calculated by dividing the number of central line days by the number of patient days. There is no multiplier used for this.

26. Questions about CLABSI? Peds CLABSI Contact- Michelle Littlejohn, mlittlejohn2@ghs.org