Strategies to prevent central-line associated bloodstream infections (CLABSI) in acute care hospitals were recently published in a supplement to Infection Control and Hospital Epidemiology, October 2008, Vol. 29, Supplement 1 S22-S30. Authors are: Marschall J, Mermel LA, Classen D, Arias KM et.al.
The article’s purpose was not to serve as an in depth discussion of recommendations for detecting and preventing central line-associated bloodstream infection (CLABSI) but rather to offer a concise and practical listing of recommendations to assist acute care hospitals in implementing CLABSI prevention strategies. The article also gives criteria for grading the strength of recommendations and the quality of evidence described.
The following is a brief summary of the article’s five major sections. For complete discussion and references visit the website of the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America: http://www.shea-online.org/about/compendium.cfm
Section 1: Rationale and Statements of Concern
In this section the authors discuss the occurrence, outcomes and risk factors associated with CLABSI.
Occurrence: They noted that the Intensive Care Unit (ICU) population is at a high risk of developing CLABSI because of the need for frequent insertion of multiple catheters, e.g. arterial line as well as CVCs. Many of these catheters are inserted under emergency conditions and need to be indwelling for extended periods of time. Even though the primary focus of CLABSI has been directed towards critically ill patients, many non-ICU patients, which are the largest patient population receiving central lines, are also at a substantial risk for developing CLABSI.
Outcomes: Any patient who develops a CLABSI will typically experience an increase in the length of hospital stay as well as costs associated with treatment. Costs vary from $3700 to $29,000 per episode.
Risk factors: Factors contributing to the development of CLABSI include but are not limited to: prolonged hospitalization prior to catheterization, prolonged duration of catheterization, heavy microbial colonization at the insertion site and the catheter hub, and substandard general care of the catheter.
Section 2: Strategies to Detect CLABSI
To utilize benchmark data effectively for comparison the authors suggest the use of consistent surveillance methods and definitions. They refer the reader to the NHSN (National Healthcare Safety Network) Manual: Patient Safety Component Protocol for appropriate surveillance methodology and definitions, and list specific sections as to their relevance to CLABSI.
Section 3: Strategies to Prevent CLABSI
In this section the authors identify several resources, infrastructure requirements and the practical side of implementing suggestions to prevent CLABSI.
The practitioner should utilize guidelines and or recommendations from the Healthcare Infection Control Practices Advisory Committee, The Institute for Healthcare Improvement and Making Health Care Safer, Agency for Healthcare Research and Quality. The focus of these documents is central venous access in general and is not necessarily all inclusive of other intravascular devices.
The authors note that it is important to have an adequate infrastructure in place. Infrastructure elements include: adequate infection prevention techniques, control staff responsible for identifying CLABSI, and the institution’s ability to use information technology to collect and calculate catheter-days and patient-days for evaluation of appropriate infection rates. Appropriate staff education and adequate laboratory support are imperative to support these endeavors.
From a practical standpoint, healthcare professional education regarding key CLABSI topics, including insertion, daily care and maintenance should be offered, followed by post education testing. A checklist for catheter insertion should be available and utilized. In addition, the Organization should establish specified carts and kits containing all necessary items for catheter insertion.
Section 4: Recommendations for Implementing Prevention and Monitoring Strategies
This section discusses the recommendations for preventing and monitoring CLABSI. These recommendations are grouped into categories of: before insertion, at insertion, after insertion, and accountability. Special approaches to prevention and approaches that should not be considered a routine part of CLABSI prevention are also presented. A table that categorizes and grades the strength of the recommendations and the quality of evidence that currently exist is included.
I. Basic Practices
- Before Insertion
- Sufficient education of all healthcare personnel involved, to ensure competency
- At Insertion
- Use a catheter checklist
- Perform hand hygiene
- Avoid femoral vein in adults
- Use an all inclusive catheter cart and/or kit
- Use maximal sterile barrier precautions
- Use a chlorhexidine-based antiseptic for skin prep (patients aged 2 months or older)
- After Insertion
- Before accessing catheter, disinfect
- Remove nonessential catheters
- Change dressings and disinfect insertion site as needed
- Replace administration sets at appropriate intervals (depending on therapies)
- Perform surveillance for CLABSI
- Use antimicrobial ointments for hemodialysis catheter insertion sites only
- Accountability: The hospital’s chief executive officer and senior management team need to be accountable to ensure that the healthcare system effectively supports a program to prevent CLABSI. The authors also identify other levels of hospital employees that should be involved and describes their roles in preventing CLABSI.
II. Special Approaches: This section discusses approaches to be used for prevention of CLABSI in patient populations or areas of the hospital that have unacceptably high rates of CLABSI despite implementation of basic prevention strategies.
- Bathe ICU patients daily with chlorhexidine (patients age 2 months or older)
- Use antiseptic or antimicrobial-impregnated CVCs for adult patients
- Use chlorhexidine-containing sponge dressings for CVCs in adults or infants 2 months or older
- Use antimicrobial locks for CVCs for high risk patients
Approaches that should not be considered a routine part of CLABSI prevention are:
- Use of antimicrobial prophylaxis for short-term or tunneled catheter insertion or while catheters are in situ (systemic antimicrobial prophylaxis is not recommended)
- Routine replacement of CVCs or arterial catheters
- Routine use of positive-pressure needleless connectors with mechanical valves without a thorough assessment of the specific technology
- Nurse-to-patient ratio and use of float nurses in ICUs
- Use of intravenous therapy teams for reducing CLABSI rates
- Surveillance of other types of catheters (eg. peripheral arterial catheters)
- Estimating catheter-days for determining incidence density of CLABSI
Section 5: Performance Measures
In this section performance measures and compliance calculations are discussed. These measures are derived from published guidelines, relevant literature and author opinion. The measures and compliance calculations are intended to support hospital quality improvement efforts and do not necessarily address external reporting needs. These outcomes should be reported to hospital and nursing leadership, as well as to the other clinicians who care for patients at risk for CLABSI.
The four techniques included in the performance measure, in rank order from highest to lowest are:
- Compliance with CVC insertion guidelines checklist
- Compliance with documentation of daily assessment regarding the continuing need for CVC access
- Compliance with cleaning of catheter hubs and injection ports before being accessed
- Compliance with avoiding the femoral vein site for CVC insertion in adult patients
Process (performance) Measures:
- Preferred measure of the above assessment of compliance
- Number of CVC insertions that have documented the use of all 3 interventions (hand hygiene, maximal barrier precautions, and chlorhexidine-based cutaneous antiseptic use) performed at the time of CVC insertion;
- Number of patients with a CVC for whom there is documentation of daily assessment;
- Number of times that a catheter hub or port is observed to be cleaned before being accessed;
- Number of patients with a CVC in the femoral vein.
- Number of all CVC insertions;
- Number of patients with a CVC;
- Number of times a catheter hub or port is observed to be accessed;
- Total number of patients with a CVC in unit population being assessed.
- Multiply by 100 so that the measure is expressed as a percentage.
Use the National Healthcare Safety Network CLABSI definitions for numerator, denominator and multiply by 1,000 so that the measure is expressed as number of CLABSIs per 1,000 catheter days. Risk adjustment is made dependent upon type of patient unit. Comparisons are based on National Healthcare Safety Network data and historical national data.
The document contains recommendations for public reporting of healthcare-associated infections which have been provided by the Healthcare Infection Control Practices Advisory Committee, the Healthcare-Associated Infection Working Group of the Joint Public Policy Committee, and the National Quality Forum. Hospitals that participate in any type of external reporting must collect and report the data that is required and in the format requested. Contact the specific agency or state or local health department for specific criteria.
A list of 106 references completes the document.
Institute of Healthcare Improvement
5 million lives campaign
The 5 Million Lives Campaign is a voluntary initiative to protect patients from five million incidents of medical harm over the next two years (December 2006 – December 2008).
- CDC Guidelines for the Prevention of Intravascular Catheter-related Infections
- CDC Hand Hygiene in Healthcare Settings
- CDC Surveillance Systems
- Products Designed to Help Reduce HAC's
- CDC Guidelines for Prevention of Intravascular Catheter-related Infections
- CDC Biofilms and Device-Associated Infections
- Maximal Sterile Barrier Precautions to Prevent Infections
- Unfolding the Maximal Barrier Precautions Drape
- Chloraprep® - Chlorhexidine Skin Antisepsis In-Service Materials
- Effectiveness of a Hospital-wide Hand Hygiene Compliance Program
- Association of Vascular Access - Save That Line! Program