1. Hospital Acquired Catheter-Related Bloodstream Infections (CR-BSI)
MED INF Decision Support Systems and Health Care

2. More than 5 million Central vascular catheters used annually in US.
Background
More than 5 million Central vascular catheters used annually in US.
250,000 cases of CVC-associated BSIs occur annually in the US
ICU related CVC-associated BSIs occuring annually in the US: 80,000
Attributable mortality for these BSIs : upto 28,000 deaths
Attributable average cost per infection : $ 56000
Financial Impact!
Annual cost of CVC-associated BSIs – upto $2.3 billion
CR-CSI are important cause of

3. Definition
Bacteremia / fungemia in a patient with an intravascular catheter with:
at least one positive blood culture obtained from a peripheral vein
clinical manifestations of infection (i.e., fever, chills, and/or hypotension)
and no apparent source for the bloodstream infection except the catheter. 
Bloodstream infections are considered to be associated with a central line if the line was in use during the 48-hour period before the development of the bloodstream infection.
Defined by NNIS

4. Impact! Common in healthcare, especially in ICU
 Morbidity (risk for local and systemic infectious complications)
 LOS
 Mortality
 Cost - in term of morbidity and financial resources
As of Oct, 2008
CMS New Rule – No Pay for Never Events
 Cannot Bill Patient for HAIs
CR_BSI is classified by CMS as a Never Event – One of the 3 serious conditions deemed to be ‘reasonably preventable’ based on the existence of evidence-based guidelines for preventing their occurrence
Beginning October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) will no longer provide reimburse for the never events. When the DRG code (Diagnosis Related Group code) indicates that one of these conditions is secondary and the condition was not present on admission, the increased costs associated with the treatment of these conditions will not be covered by Medicare. Hospitals also will not be permitted to bill patients for additional costs related to these infections.
three serious preventable events (sometimes called “never events”)
CMS has selected those conditions it deems to be "reasonably preventable" based on the existence of evidence-based guidelines for preventing their occurrence

5. Why Address it ? 50% of these infections are preventible by the
implementation of strategies
Evidence Based Interventions!
This effort should be multidisciplinary:
involving
health-care professionals who insert and maintain IV catheters
health-care managers who allocate resources
patients capable of assisting in the care of their catheters

6. Etiology

7. Sources of Infection
 Skin organisms  Environmental contamination  Post-placement subcutaneous tract infection  Intraluminal contamination  Hematogenous seeding

8. Risk Factors The incidence of CRBSI varies considerably by:
type of catheter
frequency of catheter manipulation
patient-related factors
 underlying disease
 acuity of illness

9. CLASSIFYING THE CATHETERSBy
Catheter pathway from skin to vessel
-tunneled
-nontunneled By
Type of Vessel
it occupies
-peripheral venous
-central venous
-arterial .
CLASSIFYING THE CATHETERS By
Catheter Physical Length
- long
-short
By the site of insertion
femoral
subclavian
internal jugular
peripheral
peripherally inserted central catheter [PICC
Check out!
I made this from info from CDC website.
By the intended life span of Catheter
- temp or short-term
-permanent or long-term
or by some special characteristic of the catheter, e.g.:
- presence or absence of a cuff
- impregnation with heparin
antibiotics or antiseptics
and the number of lumens

10. Risk Factors 1. Type of Catheter
Peripheral venous catheters
most frequently used devices for vascular access
Low incidence of associated infections
BUT
Higher frequency of such catheters used
SO It adds up!
Serious infectious complications produce considerable annual morbidity
Central venous catheters (CVCs)
majority of serious catheter-related infections associated with CVCs - especially those that are placed in patients in ICUs

11. Risk Factors 2. Setting / frequency of catheter manipulation
In the ICU setting, the incidence of infection is often higher:
central venous access needed for extended periods of time
Patient colonization with hospital-acquired organisms
Catheter can be manipulated multiple times per day  contamination  clinical infection
Catheter insertion in urgent situations with sub-optimal aseptic precautions

12. Risk Factors 3. Patient Related Factors
Diabetic or high blood glucose levels
Immuno-compromised
Cancer patients
Age - elderly
- pediatric population

13. Multifaceted Approach
To  improve patient outcome
 reduce health-care costs
strategies should be implemented to
reduce the incidence of these infections

14. The Keystone ICU Project #: Evidence-based recommendations from CDC for preventing CR-BSI
A care bundle of best practices in terms of CRBSIs that individually improve care, but when applied together result in substantially greater improvement.  The science supporting the bundle components is sufficiently established to be considered standard of care.
(1) Hand Hygiene
(2) Full Barrier Precautions during insertion of CVC
(3) Cleaning the skin with 2% Chlorhexidine
(4) Appropriate site and line selection
(5) Remove Unnecessary Catheters
# Pronovost P, Needham D, Berenholtz S et al. An Intervention to Decrease Catheter Related Bloodstream Infections in the ICU. N Engl J Med 2006;355:

15. Decision Tree: Appropriate Site and Line Selection
Patient needs IV access
Patient has peripheral access
IV medications (vein irritating or vesicant ) need to be administered
Definite Central Line
Vein irritating or vesicant IV medications do not need to be administered
Patient needs hemodynamic monitoring
Definite central line
Patient does not hemodynamic monitoring
Length of therapy greater than 5 days
Length of therapy less than 5 days
Definite Peripheral Line
Patient does not have peripheral access

16. Does patient have peripheral access?
Yes No
Patient will need one of the following:
Vesicant medication
Vasopressor
TPN
Fuild bolus
Patient needs hemodynamic monitoring
Yes No
Anticipate IV therapy greater than 5 days
Yes No

17. Workflow engine Alert to clinician
Central line Alert
Populates database with patient names who had the alert associated with them
Patient does not meet criteria:
No peripheral access
IV vesicant
Hemodynamic monitoring
IV therapy greater than 5 days
Decrease the risk of a hospital acquired central line infection by PLACING A PERIPHERAL LINE

18. Daily Documentation To Justify Keeping A Central Line
High volume IVF
Hi volume blood
Multiple drips
TPN
Limited access
Long term access
Hemodynamic monitoring
Vasopressor/vesicant meds
Populates database to track reasons for keeping central lines etc.

19. Workflow engine Alert to clinician
Central line Dwelling Time Alert
Dwelling time of central line catheter is greater than 5 days
Decrease the risk of a hospital acquired central line infection consider discontinuation of Central line
Populates database with patient names who had the alert associated with them

20. Outcome and Process Measures
Outcome measures
CRBSI/1000 central line days
Average length of central catheter dwelling time
Process measures
Justification of central line
# of alerts rendered and response to them

21. Average Central Line Days.

22. CDSS Design
Guided by the AMIA Roadmap for National Action on CDS vision:
“optimal, usable and effective clinical decision support is widely available to providers, patients, and individuals where and when they need it to make health care decisions.”

23. AMIA RoadMap Pillars Best Knowledge Available when Needed
High Adoption and Effective Use
Continuous Improvement of Knowledge and CDS Methods

24. CDSS Framework Service-oriented Architecture (SOA):
An SOA infrastructure allows different applications to exchange data with one another as they participate in business processes.
Core business capabilities are encapsulated within independent software services, and these services are leveraged by various front-end applications to fulfill business requirements.

25. CDSS Architecture

26. How did we do ? Design Information availability
Provides a good foundation to build additional CDSS
Reusable, separates knowledge from code
Based on standards
Information availability
Data repository provides robust reporting capabilities
Ability to monitor clinician responses to alert against patient outcomes

27. What are the Limitations?
Design requires technical resources
Clinician workflow is critical
Be reasonable in expectation of CDSS use

28. Summary
Information is powerful! Use it to influence clinician practice to positively impact patient outcomes
Performance measures should be monitored to reflect effectiveness
CDSS Design must be re-usable and based on standards
Must lay foundation for additional CDSS

29.  Resources  1. CDC Guidelines
2. Clinical study - An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU
3. Clinical study -Prevention of Intravascular Catheter–Related Infections. Leonard A. Mermel, DO, ScM, AM(Hon) 4.
5. A Roadmap for National Action on Clinical Decision Support. Osheroff, MD, Teich, MD, PhD, Middleton, MD, Steen, MA, Wright, Detmer, MD, MA
6. Proposal for Fulfilling Strategic Objectives of the U.S Roadmap for National Action on Decision Support through a Service-oriented Architecture Leveraging HL7 Services – Kawamota, PhD, Lobach, MD, PhD, MS

31. Bea Dhanoa
Marla Husch
MariJo Rugh