1. Focus on Central Line Bloodstream Infection Reduction Expanding Prevention Hospital Wide
Ghinwa Dumyati, MD, FSHEA
Associate Professor of Medicine
University of Rochester Medical Center

2. 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

3. Why Expand CLABSI Prevention Hospital Wide?
CLABSI rates outside the ICU are similar or higher than the ICU
Range: 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 fold (95% CI 1.15–4.46) increased risk of mortality
0.9 per 1,000 pt days from 2011 NHSN
Since there are more patients outside the ICU the burden is higher.
Cost in the literature $3,700-39,000
Climo M, et al. ICHE 2003; 24: Marshalls J, et al ICHE 2007;28:
Son CH, et al. ICHE 2012:33; Stevens V, et al. CMI 2013;20: O319-O324

5. CLABSI Outside the ICU Device utilization ratio varies
In ICU:
Non-ICU: Medical-surgical:
Specialties:
Step down:
Length of catheterization prior to infection
Median days
Type of central lines differ
Dumyati G, et al. AJIC 2014; 42: Tedja R, et al. ICHE 2014; 35:
Rhee Y, et al ICHE 2015; 36:424– Son CH, et al. ICHE 2012:33;

6. Type of Central Venous Catheter by Unit Type
Also mention that hospital used different type of needleless access device
Data from the Rochester CLABSI Prevention Collaborative

7. Avoid unnecessary use of central venous catheters
CLABSI Prevention
Insertion
Maintenance
Removal
Avoid unnecessary use of central venous catheters

8. 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
Also reduced patient to nurse ratio in ICU
Marschall J, et al. ICHE 2014;35:
Concannon C, et al. ICHE 2014;35: 8

9. CLABSI Prevention Focuses on Prevention of Bacterial Colonization of Insertion Site and Catheter Hub
Contaminated
catheter hub
Contamination at
the insertion site
Organisms present on the patient’s skin or from health care worker’s hands, travel along the outside of the lumen of the catheter and adhere to a fibrin sheath where they multiply.
<10 days:
Extraluminal colonization more common
Origin of organisms: SKIN
>10 days-30 days:
Intraluminal colonization > extraluminal colonization
Origin of organisms HUB of catheter contaminated by HCW hands
This is the most common source of catheter colonization when catheters are in place for less than 10 days and occurs during insertion or shortly after
Bacteria present on the surface of the catheter’s needleless access device or transferred by health care workers’ hands are introduced to the catheter when accessed. Organisms migrate along the inside lumen of the line, and attach to the fibrin sheath
Contamination of the inside lumen of the catheter is more common with catheters in place for a longer period, such as tunneled catheters

11. The “Technical” Aspects of CLABSI Prevention
Insertion Best Practices
Maintenance Best Practices
Hand hygiene
Maximum barrier precautions
Chlorhexidine prep
Optimal site selection avoid femoral site in obese patients
Ultrasound guided insertion
Hand Hygiene
Aseptic access of needleless device
Proper dressing change technique
Regular IV tubing change
Regular assessment of CVC necessity with prompt removal when no longer needed

12. 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 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

13. 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, 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: e

14. Special “Technical” Approaches for Preventing CLABSI
To be used if “basic” prevention unsuccessful in reducing CLABSI rate
Antiseptic or antimicrobial-impregnated catheters
Use chlorhexidine-impregnated sponge
Use an antiseptic-containing hub/connector protector to cover needleless access device
Use antibiotic locks
Chlorhexidine Bathing

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

16. Use of Antiseptic-Containing Hub Protector
Wright MO et al. American Journal of Infection Control 41 (2013) 33-8

17. Chlorhexidine Bathing
Most study support bathing in ICU
Meta-analysis of 12 ICU studies:
Pooled odds ratio: 0.44 (95%CI ; 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:
Climo MW, et al. N. Engl J Med 2013;368:533-42
Huang SS, et al. NEJM 2013;368:
Noto MJ, et al. JAMA 2015; 313:369-78

18. Multicenter Study of CHG Bathing In ICU and BMT
P=0.006
P=0.004
53%
6 hospitals, 9 ICU including bone marrow. 30% reduction of primary BSI and 53% reduction of CLABSI. By cox proportional hazard the risk of acquiring primary BSI was lower. There was no interaction between the type of unit and the development of BSI suggesting that it is beneficial in any setting.
Important to note that the effect was greater among patients with longer length of stay on the unit.
Climo MW, et al. N. Engl J Med 2013; 368:533-42

19. Targeted versus Universal Decolonization with CHG and Mupirocin to Prevent ICU Infection
44% reduction
P<0.001
1% reduction
22% reduction
Huang SS, et al. NEJM 2013; 368:2255

20. 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
Used 4% Hibiclens aqueous solution. Intervention staggered for 3 cohorts and continued for 19 months followed by discontinuation for 4 months.
For bed bound patients routine bed bath, for patients taking showers, asked to scrub 4 oz the 4% solution and allow to dwell for 1 minute before rinsing.
Adherence was 90% in critical care and 58% in non critical care units, low in hem onc and pediatrices (46% and 37%). Most likely related to ICU pt not able to refuse bathing, unit specific culture, staffing level and effectiveness of protocol–related communication.
This study looked at all HAI and found an effect on C. diff rates but not CLABSI rates.
Rupp ME, et al. Infect Control and Hosp Epidemio 2102;33(11):

21. 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

22. IMPLEMENTATION CLABSI PREVENTION HOSPITAL WIDE
Where To Start?

23. Implementation Framework
Engage
Educate
Execute
Evaluate

24. Implementing CLABSI Prevention Hospital Wide Where to Start?
Engage
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

25. Identify one or two non-ICU wards with
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)

26. Implementing CLABSI Prevention Hospital Wide
Educate
Assessment:
Current policies for catheter insertion and maintenance hospital wide
Consolidate if multiple policies exist
The knowledge of front line staff of the CLABSI prevention policies
Compliance with the current policies
Point prevalence of CVC dressing observations
Documentation of CVC insertion and maintenance procedures/checklist

27. Identifying “Gaps” in Central Line Maintenance
Survey of 200 Nurses
Rochester CLABSI Prevention Collaborative

28. Implementing CLABSI Prevention Hospital Wide
Educate
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

29. On Line Education: example of dressing change
Educational module

30. Implementing CLABSI Prevention Hospital Wide
Execute
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
Be aggressive with your target goals

31. Implementing CLABSI Prevention Hospital Wide
Execute
Assess location and services inserting CVC in non ICU patients
Ensure 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)

32. Key drivers for the CCHMC CA-BSI QIC
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.
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. The aim statement was developed by using specific, measurable, attainable, relevant, and time-bound (SMART) goals20 and states the primary objective of the project. The key drivers are the elements believed to be crucial for achieving that goal. CHG indicates chlorhexidine; LOR, level of reliability.
Derek S. Wheeler et al. Pediatrics 2011;128:e995-e1007
©2011 by American Academy of Pediatrics

33. Implementing CLABSI Prevention Hospital Wide
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

34. Observation of nurses practice (n=200)
Evaluate
Audits
Observation of nurses practice (n=200)
Needleless access device scrubbing
CVC dressing change
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 guidelines
82% compliance with scrubbing the needless access device
Rochester CLABSI Prevention Collaborative

35. Checklist- Alternative to Observation

36. Electronic Medical Record Documentation
Slide courtesy of Janet Taylor, RN- Highland Hospital

37. CLABSI Rate Feedback
Your unit
CLABSI rate per 1,000 line days

38. Feedback

39. 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?

41. The Tale of Two Units Unit #1 Unit #2 Nurse Champion Efforts:
One on one education
Observations of compliance with maintenance bundle
Incentives for no CLABSI events

42. The tale of two units cont’d
Multidisciplinary team
New nurse manager
Open discussion of all adverse events
Audits, nurse bedside rounding
Success celebrated

44. Management “Bundle” for CLABSI Prevention Interventions
Aggressive goal setting and support: getting to zero CLABSI
Strategic alignment/communication and information sharing: CLABSI rate shared at executive/board level meetings
Systematic education: Structured and part of a patient safety education
Inter-professional collaboration: physicians and nursing collaboration
Meaningful use data: Share data regularly with everyone, strive toward automation
Recognition for success: incentive compensation linked to the CLABSI prevention goals

45. Dumyati G, et al. AJIC 2014; 42:

46. Sustainability

47. Easy to move to other priorities,

48. 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 success
Pronovost PJ, et al.; BMJ, 2010; 340:c309

49. Questions?