Prevention of Central Line Associated Bloodstream Infection CLABSI

1. Prevention of Central Line Associated Bloodstream Infection (CLABSI) Kati Hodge, R.N., Robby Hutson, R.N., & Amy Jamison, R.N. Northeastern State University

2. Central Venous Catheters Central venous catheters (CVC) are integral part of modern-day healthcare. They are used to administer drugs and fluids, and for hemodynamic monitoring. Approximately 48% of patients in ICU have central line. There are 15 million central line days per year in the U.S. (Casey & Elliot, 2010)

3. Central Line Associated Bloodstream Infection (CLABSI) CLABSI are common, costly and potentially lethal. CLABSI affects more than 250,000 ICU patients per year in the United States. Average cost of treating CLABSI ranges from $3,700 to $29,000 per incident. Estimated mortality rate as high as 18%. Approximately 5.3 central line infections per 1,000 central line days. (Krein, et. al, 2007) (Earsing, et. al, 2005)

4. Pathogens Coagulase Negative Staphylococci Staphylococcus epidermidis Candida albicans Methicillin Resistant Staphylococcus aureus (MRSA) Pseudomonas aeruginosa Escherichia coli Klebsiella pneumoniae (Center for Disease Control and Prevention, 2010)

5. Risk Factors Placement of CVC in the jugular or femoral vein. Catheter insertion with less than maximal sterile barrier precautions Heavy colonization of insertion site Contamination of the catheter hub Duration of CVC placement more than 7 days Difficult insertion (Center for Healthcare Related Infection Surveillance and Prevention, 2009)

6. Risk Factors Nurse to patient ratio Established remote infection Increased frequency of catheter manipulation Use of total parenteral nutrition (TPN) Catheter management Contaminated equipment Lack of compliance with written guidelines (Center for Healthcare Related Infection Surveillance and Prevention, 2009)

7. The Joint Commission Hospital Requirements - To conduct periodic risk assessments - Measure CLABSI rates - Monitor compliance with best practices - Evaluate effectiveness of prevention efforts - Provide rate data and outcome measures to key stakeholders - Evaluate all CVCs routinely and remove nonessential catheters. (Pennsylvania Patient Safety Authority, 2010)

8. The Institute of Healthcare Improvement (IHI) Is a non-profit organization leading the improvement of health care throughout the world. Led the national initiative, “The 5 Million Lives Campaign” (Institute of Healthcare Improvement, 2008)

9. The Central Line Bundle Is a group of evidence-based practice interventions for patients with CVC that, when implemented together, result in better outcomes than when implemented individually.

10. PICO Population: ICU patients with CVC Intervention: Compliance with Central Line Bundle Comparison: Increased compliance with central line bundle versus the current rate of compliance Outcome: Decreased risk of CLABSI

11. PICO QUESTION For the patients in ICU with CVC, will increased compliance with central line bundle interventions, as compared to the current rate of compliance, decrease the occurrence of CLABSI ?

12. Five Components of Central Line Bundle Hand Hygiene: When caring for CVC, appropriate times for hand hygiene includes: - Before and after palpating catheter insertion sites - Before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter - When hands are obviously soiled or if contamination is suspected - Before and after invasive procedure - Between patients - Before donning and after removing gloves - After using the bathroom (Institute for Healthcare Improvement, 2008)

13. Maximal Barrier Precautions on Insertions: For the provider: Hand hygiene, non-sterile cap and mask, all hair under cap, mask covering nose tightly, and sterile gown and gloves For the patient: Cover patient’s head and body with a large sterile drape (Institute for Healthcare Improvement, 2008)

14. Chlorhexidine Skin Antisepsis Prepare skin with antiseptic detergent chlorhexidine 2% in 70% isopropyl alcohol by saturating pad, pressing it against the skin. Apply chlorhexidine solution using back-and-forth friction scrub for at least 30 seconds. Do not blot or wipe. Allow antiseptic solution time to dry completely before puncturing the site. (Institute for Healthcare Improvement, 2008)

15. Optimal Catheter Site Selection Femoral site: greatest risk of infection, especially in overweight patients (Institute for Healthcare Improvement, 2008)

16. Optimal Catheter Site Selection Subclavian site: lower risk of CLABSI than internal jugular vein. (Institute for Healthcare Improvement, 2008)

17. Daily Review of Line Necessity Goal: reduce central line days Avoid routine replacements of central lines All lines should be removed ASAP (Institute for Healthcare Improvement, 2008)

18. Outcome Measure: CLABSI per 1000 Central Line Days CLABSI rate per 1000 central-line days Numerator: Number of CLABSI x 1000 Denominator: Number of central line-days (total number of days of exposure to CVC by all patients in the selected population during the selected time period). (Institute for Healthcare Improvement, 2008)

19. Evidence of Bundle Compliance Central line insertion checklist Should be used to confirm compliance with the elements of the bundle that are specific to the time of initial insertion. Daily goals sheet Should be used to confirm compliance for that day with the element of “daily review of line necessity with prompt removal of unnecessary lines.” (Institute for Healthcare Improvement, 2008)

20. EBP Supports Central Line Bundle Application of the central line bundle has demonstrated shrinking reductions in the rate of CLABSI in many hospitals. Provost P., Needhan D., Berenholtz S., et. al (2006)

21. Summary Central line infections are common. Proven strategies exist to decrease the incidence of CLABSI. Using central line checklist, most bundle elements are implemented. Daily goals sheet verify necessity of central lines daily. Thousands of lives and millions of dollars can be saved with reliable adherence and bundle execution (Institute for Healthcare Improvement, 2008)