Focus on Central Line Bloodstream Infection Reduction

Expanding Prevention Hospital Wide

Ghinwa Dumyati, MD, FSHEAAssociate Professor of Medicine

University of Rochester Medical Center

Agenda

• Review the burden of central line associated bloodstream infections (CLABSI) outside the ICU

• Describe the components of a central line maintenance bundle

• Review the methods for implementing and sustaining CLABSI prevention hospital wide

• Questions

Why Expand CLABSI Prevention Hospital Wide?

• CLABSI rates outside the ICU are similar or higher than

the ICU

Range: 0.9-5.2 per 1,000 line days

• Excess variable cost ~ $ 33,000

• Crude in-hospital mortality: up to 28%

after controlling for confounders: CLABSI is associated with

2.27-fold (95% CI 1.15–4.46) increased risk of mortalityClimo M, et al. ICHE 2003; 24:942-945 Marshalls J, et al ICHE 2007;28: 905-909Son CH, et al. ICHE 2012:33; 869-874 Stevens V, et al. CMI 2013;20: O319-O324

CLABSI Outside the ICU• Device utilization ratio varies

In ICU: 0.52-0.77

Non-ICU: Medical-surgical: 0.08-0.27

Specialties: 0.25-0.53

Step down: 0.26-0.73

• Length of catheterization prior to infection

Median 10-17 days

• Type of central lines differ

Dumyati G, et al. AJIC 2014; 42:723-30 Tedja R, et al. ICHE 2014; 35: 164-168Rhee Y, et al ICHE 2015; 36:424–430 Son CH, et al. ICHE 2012:33; 869-874

Type of Central Venous Catheter by Unit Type

Data from the Rochester CLABSI Prevention Collaborative

CLABSI Prevention

Insertion Maintenance Removal

Avoid unnecessary use of central venous

catheters

Risk Factors for CLABSI

Patient factors: • Severity of underlying illness• Prolonged duration of

hospitalization prior to central line insertion

• Prolonged hospitalization• Immuno-suppression• Prematurity• Total parenteral nutrition

Catheter Factors (modifiable):• Prolonged duration of

catheterization• Heavy bacterial colonization at

insertion site • Heavy bacterial colonization at the

catheter hub• Insertion in jugular area, femoral

area (in adults)• Excessive manipulation of catheter• Presence of multiple catheters

Marschall J, et al. ICHE 2014;35:753-771Concannon C, et al. ICHE 2014;35:1140-1146

CLABSI Prevention Focuses on Prevention of Bacterial Colonization of Insertion Site and Catheter Hub

Contaminated catheter hub

Contamination at the insertion site

The “Technical” Aspects of CLABSI Prevention

Insertion Best Practices

1. Hand hygiene

2. Maximum barrier precautions

3. Chlorhexidine prep

4. Optimal site selection avoid femoral site in obese patients

5. Ultrasound guided insertion

Maintenance Best Practices

1. Hand Hygiene

2. Aseptic access of needleless device

3. Proper dressing change technique

4. Regular IV tubing change

Regular assessment of CVC necessity with prompt removal when no longer needed

Central Line Maintenance Bundle• Wash hands with soap and water or alcohol based hand rub before

accessing line or changing dressing Hand Hygiene

• Clean before accessing with chlorhexidine, iodine, or 70% alcohol using twisting motion for 10-15 sec*

• Change aseptically no more frequently than every 72 hrs and with tubing change

Needleless access device

• Assess dressing integrity, change if loose or soiled • Change transparent dressing every 7 days • Gauze dressing every 2 days • Clean site with >0.5 % chlorhexidine/alcohol for 30 sec

Dressing change

• Change no more frequently than every 96 hours but at least every 7 days

• Change every 24 hours for TPN containing lipids and blood and after each chemotherapy infusion

Administration Sets

• Assess central line necessity daily• Promptly remove CVC when no longer necessary

CVC need assessment

* CLABSI Guidelines “for no less than 5 seconds” Rochester CLABSI Prevention Collaborative

Examples of Central Line Maintenance Bundles

• The joint Commission. Preventing Central Line-Associated Bloodstream Infection: Useful tools. An International Perspective, Nov 20,2013. Accessed June 17, 2015. http://www.joint comission.org/CLABSI toolkit

• Wheeler DS, et al. A Hospital-wide Quality-Improvement Collaborative to Reduce Catheter-Associated Bloodstream Infections. PEDIATRICS 2011; 128:e995-e997

• Bundy DG, et al. Preventing CLABSI among pediatric hematology/oncology inpatients: National collaborative results. PEDIATRICS 2014; 134: e1678-1685

Special “Technical” Approaches for Preventing CLABSI

1. Antiseptic or antimicrobial-impregnated catheters

2. Use chlorhexidine-impregnated sponge

3. Use an antiseptic-containing hub/connector protector to cover needleless access device

4. Use antibiotic locks

5. Chlorhexidine Bathing

To be used if “basic” prevention unsuccessful in reducing CLABSI rate

Chlorhexidine-Containing Dressing

non CHG sponge

CHG sponge0

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Timsit JF, et al Am J Respir Crit Care Med. 2012; 186(12):1272-1278Meta-analysis: Safdar N, et al. Crit Care Med. 2014;42:1703–1713

Use of Antiseptic-Containing Hub Protector

Wright MO et al. American Journal of Infection Control 41 (2013) 33-8

Chlorhexidine Bathing

• Most study support bathing in ICU– Meta-analysis of 12 ICU studies:

• Pooled odds ratio: 0.44 (95%CI 0.33-0.59; p<0.0001)

– 2 large multicenter studies showed reduction of bloodstream infections

• 1 single center study showed no benefit

O’horo JC, et al. ICHE 2012;33:257-267Climo MW, et al. N. Engl J Med 2013;368:533-42 Huang SS, et al. NEJM 2013;368:2255-2265Noto MJ, et al. JAMA 2015; 313:369-78

Multicenter Study of CHG Bathing In ICU and BMT

Climo MW, et al. N. Engl J Med 2013; 368:533-42

Primary BSI per 1000 pt-days

CLABSI per 1000 catheter days

0

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Rate

P=0.006

P=0.004

53%

Targeted versus Universal Decolonization with CHG and Mupirocin to Prevent ICU

Infection

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Huang SS, et al. NEJM 2013; 368:2255

44% reductionP<0.00122% reduction1% reduction

CHG Bathing Hospital-Wide• Compliance with bathing:

– 90% in ICU – 58% in non-ICU

• Effect on CLABSI rates could not be demonstrated possibly due to – Low baseline rates– Enforcement of the CL insertion and maintenance

bundles

Rupp ME, et al. Infect Control and Hosp Epidemio 2102;33(11):1094-1100

CHG Bathing Outside the ICU• Active Bathing to Eliminate Infection (ABATE

Infection) – Cluster randomized trial to reduce multidrug

resistance organisms and healthcare associated infections in non-ICU

– Decolonization with CHG bathing and nasal mupirocin for MRSA +

– Results pending

https://clinicaltrials.gov/ct2/show/NCT02063867

WHERE TO START?

IMPLEMENTATION CLABSI PREVENTION HOSPITAL WIDE

Implementation Framework

Engage

Educate

Execute

Evaluate

http://www.ahrq.gov/professionals/education/curriculum-tools/clabsitools/index.html

Implementing CLABSI Prevention Hospital WideWhere to Start?

• Obtain senior and nursing leadership support and buy-in– Approve time for oversight of the intervention– Approve cost for additional products– Provide accountability– Demonstrate that CLABSI prevention is a priority

Engage

• Identify one or two non-ICU wards with– High central venous catheter use– High CLABSI rate

• Identify and engage local champions on the ward– Front line nursing staff that can partner with infection

preventionist and/or IV access team– The champion will educate others, perform

observations, assess all nursing staff competency • Establish a CLABSI prevention multidisciplinary

team (or expand the ICU team)

Engage

Implementing CLABSI Prevention Hospital Wide

Assessment:• Current policies for catheter insertion and

maintenance hospital wideConsolidate if multiple policies exist

• The knowledge of front line staff of the CLABSI prevention policies

• Compliance with the current policiesPoint prevalence of CVC dressing observationsDocumentation of CVC insertion and maintenance

procedures/checklist

Educate

Identifying “Gaps” in Central Line Maintenance

Change access port every 96 hrs

Change transparent dressing every 5-7 days

Clean insertion site with >5% Chlorhexidine

Scrub access port for 10-15 sec

0 10 20 30 40 50 60 70 80 90

Survey of 200 Nurses

Rochester CLABSI Prevention Collaborative

Implementing CLABSI Prevention Hospital Wide

• Use multiple approaches for education:– Lectures– On-line course– One on one education– Assessment of staff competency

• Repeat education regularly and with any new products or change in policies

Educate

On Line Education: example of dressing change

1 of 6 2 of 6 3 of 6

4 of 6 5 of 6 6 of 6

Educational module https://www.urmc.rochester.edu/community-health/research/communicable-disease-surveillance/healthcare-associated-infections/clabsi/central-line-education.aspx

Implementing CLABSI Prevention Hospital Wide

• Identify your target goals:– CLABSI rate or SIR (unit level and hospital wide)

– Percent compliance with insertion and maintenance bundles

• Make your hospital wide CLABSI rate information a part of the organization score card

• Share at executive and board meetings

Execute

Be aggressive with your target goals

• Assess location and services inserting CVC in non ICU patientsEnsure that all staff inserting CVC are educated

Insertion checklist implemented outside the ICU setting, e.g. radiology, ED

• Assess the availability of supplies Insertion cart Supplies for dressing change (bundle into one package)Chlorhexidine sponge, securement device, alcohol caps (if used)

Implementing CLABSI Prevention Hospital Wide

Execute

Key drivers for the CCHMC CA-BSI QIC. Shown is the learning structure of our quality-improvement project, including the aim statement, key drivers, and the change strategies to

be tested or implemented during the project.

Derek S. Wheeler et al. Pediatrics 2011;128:e995-e1007

©2011 by American Academy of Pediatrics

• Evaluate Process– Compliance with the insertion bundle– Compliance with the maintenance bundle

• Evaluate outcome– CLABSI rate– Number of patients affected each month– Days since last infection

Implementing CLABSI Prevention Hospital Wide

Audits1. Observation of nurses practice

(n=200)– Needleless access device scrubbing– CVC dressing change

2. Status of dressing and administration sets (n=800)– CVC dressing integrity– Documentation of CVC dressing

assessment, tubing and needleless access device date change

Results of audits>90% compliance with all the recommended line maintenance guidelines82% compliance with scrubbing the needless access device

Evaluate

Rochester CLABSI Prevention Collaborative

Checklist- Alternative to Observation

Electronic Medical Record Documentation

36Slide courtesy of Janet Taylor, RN- Highland Hospital

CLABSI Rate Feedback

37

CLA BSI on monitored floors outside ICU, April-June

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Bringing Prevention to the Patient Level

• Establish a Team to Brainstorm about each CLABSI case:– Nurses– Infection Preventionist– Intravenous access team– Unit nurse manager– Physicians

• Review:• WHY did it happen?

• WHAT can be done to prevent harm to the next patient?

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The Tale of Two Units

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Nurse Champion Efforts:1. One on one education2. Observations of compliance with maintenance bundle3. Incentives for no CLABSI events

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Multidisciplinary teamNew nurse managerOpen discussion of all adverse events Audits, nurse bedside roundingSuccess celebrated

Management “Bundle” for CLABSI Prevention Interventions

1. Aggressive goal setting and support: getting to zero CLABSI2. Strategic alignment/communication and information

sharing: CLABSI rate shared at executive/board level meetings

3. Systematic education: Structured and part of a patient safety education

4. Inter-professional collaboration: physicians and nursing collaboration

5. Meaningful use data: Share data regularly with everyone, strive toward automation

6. Recognition for success: incentive compensation linked to the CLABSI prevention goals

Dumyati G, et al. AJIC 2014; 42:723-710

SUSTAINABILITY

Sustainability

• Improvement in safety culture• Ensure that all changes are included in policies and daily

work flow• Continue to repeat education due to staff turn over• Continue feedback of CLABSI data• Continued involvement of senior leadership

– Review of infection data and

– provide teams with the resources needed

• Alignment of the prevention project with the organizational goals

• Continue to support local champions and celebrate successPronovost PJ, et al.; BMJ, 2010; 340:c309

QUESTIONS?