2011 CLABSI Master Class Monitoring of CVC-associated bloodstream infections in Victorian hospitals

1. 2011 CLABSI Master ClassMonitoring of CVC-associated bloodstream infections in Victorian hospitals VICNISS Coordinating Centre

2. Outline • VICNISS CLABSI surveillance module • NHSN CLABSI surveillance – revisions • CLABSI rates in Victoria – how do we compare? • Prevention of CLABSI – what does the literature say? • CLIP surveillance – VICNISS pilot results • Ensuring accuracy & reproducibility • Case studies for discussion

3. VICNISS & the CLABSI module

4. VICNISS • Coordinating Centre • commenced collecting hospital acquired infection data in 2002 • Quarterly data submission • large & small acute public hospitals • private hospitals • CDC – NHSN (NNIS) • Collate, analyse & report ‘hospital rates vs. State rate’; notify CEOs and DoH if significantly high rates identified

5. VICNISS surveillance modules • SSI • ICU CLABSI • ICU VAP • Haemodialysis • Surgical prophylactic antibiotics • + Type 2 process & outcomes

6. CLABSI – a significant outcome • Mortality • attributable mortality 12-25% • Increased LOS • 2.4 ICU days • 6.1-7.5 hospital days • Healthcare costs • US $11-25000 Higuera F et al. ICHE 2007 Warren DK et al. Crit Care Med 2006 Posa PJ et al. AACN Adv Crit Care 2006 Siempos II et al. Crit Care Med 2009 Tacconelli E et al. J Hosp Infect 2009

7. CLABSI case definitions: clinical • Numerous • Applications: diagnostic dilemmas, clinical trials • Specialised laboratory testing methods: • catheter tip cultures • quantitative blood and catheter tip cultures • differential time to positivity

8. Clinical definitions: heterogeneity Fatkenheuer G, et al. Ann Hematol. 2003

9. CLABSI case definition: surveillance • Uniform & standardised • Applications: • public health reporting • IC monitoring • Feasible to apply across range of healthcare facilities • Laboratory and clinical criteria

10. NHSNCLABSI surveillance definition for benchmarking Edwards JR, et al. Am J Infect Control 2009

11. Monitoring in infection controlCLABSI surveillance definition to monitor an intervention Pronovost PJ, et al. N Engl J Med 2006

12. NHSN CLABSI surveillance – revisions

13. The question of definition* *case-definition for CLABSI, adult patients

14. NNIS/NHSN CLABSI rates* NNIS Report, Am J Infect Control 2004 Edwards JA, et al. Am J Infect Control 2007 Edwards JA, et al. Am J Infect Control 2008 *published pooled mean rates

15. CLABSI rates - Victoria Updated NHSN definition: 1 July 2008 pooled mean: 6.05/1000 CVC days pooled mean: 2.06/1000 CVC days

16. CLABSI aetiology following definition change • VICNISS reporting period 2002-2008 • CNS 36.6% • MRSA 17.4% • enterococci 9.6% • VICNISS reporting period 2008-2011 • CNS 12.3% • MRSA 11.3% • enterococci 26.2%

17. NHSN CLABSI definitionmodifications: June 2011 • ‘skin contaminants’ → ‘common commensals’ • revised & expanded organism list • Relatedness of infecting organisms • susceptibility profile not required • genus/species sufficient

18. Modifying a case-definitionconsiderations for a surveillance strategy • Comparison with historical data • Establishing a new baseline for trend analysis • Confidence intervals • Evidence for prevention & treatment strategies • Consider as ‘new’ infection

19. CLABSI rates in Victoria – how do we compare?

20. National trends: CLABSI Currently available reports: • WA • 7 contributing hospitals • peripherally- and centrally-inserted devices reported separately • SA • 12 contributing hospitals • all bloodstream infections; denominator ‘bed days’

21. Healthcare Infection Surveillance WA (HISWA) Aggregate ICU CLABSI rate = 0.77/1000 CVC days (Q1 2011) http://www.public.health.wa.gov.au/

22. SA Healthcare associated BSI report www.health.sa.gov.au

23. International data: CLABSINHSN rates by ICU type Edwards JR, et al. Am J Infect Control 2009

24. Prevention of CLABSI – what does the literature say?

25. Prevention of CLABSIinterventions with proven efficacy • Education • physicians & nursing staff • Anatomical site • subclavian < jugular < femoral • Skin asepsis • alcoholic chlorhexidine gluconate • Maximal barrier precautions Lobo RD, et al. Am J Infect Control 2005 Eggimann P, et al. Ann Intern Med 2005 Hamilton HC, et al. Cochrane database Syst Rev 2007 Pratt RJ, et al. J Hosp Infect 2007 Raad II, et al. infect Control Hosp Epidemiol 1994

26. Impregnated & coated devices • Chlorhexidine-silver sulfadiazine and minocycline-rifampicin impregnated devices reduce colonisation & CLABSI • CDC guidelines recommend if CLABSI rates are high • Threshold CLABSI rates not proposed (cost-benefit demonstrated for use of chlorhexidine-and-silver-sulfadiazine–impregnated catheters if CLABSI > 2%). Hockenhul JC, et al. Crit Care Med 2009 Casey AL, et al. Lancet Infect Dis 2008 Maki DG, et al. Ann Intern Med 1997

27. The ‘beneficial bundle’ • Strategy/intervention consisting of a series of components • each component evidence-based & demonstrated impact • process measures • Implementation • feasible • achieved by multi-faceted strategy – education, credentialing, product selection

28. Bloodstream infections in ICUUS experience with ‘bundle intervention’ • Bloodstream infections associated with CVCs are preventable • Bundle comprised of 5 interventions: • maximal barrier precautions • hand washing • avoidance of femoral site • removal of unnecessary devices • chlorhexidine for skin asepsis • Significant & sustained impact in reducing rates of infection at multiple US centres Pronovost PJ, et al. N Engl J Med 2006

29. Zero tolerance? • Proposal for zero tolerance of CLABSI rates – simple hospital performance indicator • Modification in case-definition will reduce CLABSI rates • Other contributing factors: • barrier precautions, hand-hygiene, skin preparation, removal of unnecessary devices, avoidance of femoral site • education, simulator training, credentialing of HCW

31. CLIP surveillance – VICNISS pilot results

32. ICU ‘bundle intervention’a lesson for Victorian centres • Variable uptake of ICU bundle in Australian centres • Victorian centres with high rates of infection - bundle components used by VICNISS as basis for recommendations • VICNISS literature review of evidence-based bundle components (2009) • Australian & NZ Intensive Care Society (ANZICS) collaboration & support for implementation

33. CLABSI: process monitoring • Central line insertion practices (CLIP) • HICPAC CVC insertion guidelines • Surveillance module: NHSN • Reporting commenced 2008 • CLABSI prevention bundle • hand hygiene • appropriate skin asepsis • dry antiseptic before skin puncture • maximal barrier precautions (cap, sterile gown, gloves, mask, full drape)

34. NHSN CLIP datapreliminary findings • Mar 2008 – Sep 2009 • 72,216 CVC insertions, 744 healthcare facilities • Majority in ICU (84%), and upper extremity devices (62%) • 6,356 (8.8%) did not adhere to bundle: • 16% did not perform hand hygiene • 20% did not use appropriate skin antiseptic • 21% did not allow antiseptic to dry • 60% did not adhere to maximal barrier precautions • cap omitted in 63% • full patient drape omitted in 34% Allen-Bridson K, et al. SHEA 2010, abstract 686

35. CLIP data: Victorian experience • Pilot study, Jan – June 2011 • 4 Victorian centres participating in CLABSI surveillance • Audit of CVC insertion practices in ICU • Minimum 3 month continuous audit period • Assessment of compliance with NHSN bundle • Evaluation of feasibility of data collection

37. CLIP data: Victorian experience

38. A role for CLABSI process monitoring in Victoria? • Following pilot – ongoing participation requested • Proposed scope for CLABSI process monitoring in Victoria: • Optional surveillance module for healthcare facilities currently participating in CLABSI surveillance (periodic/continuous) • If higher than expected CLABSI rates at a single centre • Monitoring in non-ICU environments, where CLABSI may be less frequent or more difficult to monitor (interventional radiology, ward, other) • CLIP module available 10/2011

39. Ensuring accuracy & reproducibility

40. Validation of CLABSI data (VICNISS) • Accuracy of data important for benchmarking & longitudinal analysis, but few validation studies performed by non-US centres • Review of hospital medical records comparing reported surveillance data with gold standard • 6 Victorian centres, Jan-Dec 2006 • Gold standard = blinded assessment by trained VICNISS ICC • NNIS case-definition McBryde ES, et al. Infect Control Hosp Epidemiol 2009

41. Outcomes • Total 398 bacteraemias, 81 reported as CLABSI. Sample set of 46 reported CLABSIs and 62 not reported as CLABSIs • 67% inter-rater agreement with VICNISS review • PPV 59% (43-73%), NPV 73% (60-83%) • Sensitivity 35% (23-48%), specificity 87% (82-92%) • Hypothetical sensitivity 50% [NHSN]

42. Reproducibility of CLABSI dataVICNISS • Questionnaire review of Victorian ICCs assessing reproducibility of case-definition when compared to international gold standard • 18/21 VICNISS centres, 2006 • 11-item questionnaire, classification of clinical cases (CLABSI/not CLABSI) • NNIS case-definition • Gold standard = blinded CDC staff specialist Worth LJ, et al. Am J Infect Control 2009

43. Assessment tool: an example A patient with sub-arachnoid haemorrhage is admitted to hospital directly into ICU and a CVC is inserted. The patient becomes febrile after 24 hrs, with no localising symptoms or signs. Blood culture taken at 24 hrs isolates Staphylococcus aureus, and treatment with intravenous flucloxacillin is commenced: ⃞ this is an ICU-acquired CLABSI ⃞ this is not an ICU-acquired CLABSI

44. Outcomes • Overall concordance with external comparator 57.1% (range 16.7-94.4%) • Mean concordance higher for 1A hospitals compared with non-1A (60.6 vs. 55.3%) • Proportion of congruently classified cases, by NNIS criteria: criterion 1, 52.8%; criterion 2a, 83.3%; criterion 2b, 58.3% • Hypothetical concordance 62.5% [NHSN]

45. Enhancing CLABSI surveillance • Credentialing tool for IC staff • on-line, periodic, rotation of content • VICNISS website • FAQs, case studies • Other • education opportunities • multi-disciplinary engagement; collaboration with ANZICS ‘CLAB’ project

46. Case studies for discussion

47. Scenario 1 • Trauma patient, day 18 post MVA • Blood cultures collected at the same time: • from PICC - Enterobacter gergoviae • from peripheral site – no growth

48. Scenario 2 • Patient with 60% burns. • After prolonged hospital stay, central line in situ, • blood culture: Enterobacter spp. • On same day as blood culture - patient had clinically infected burns with tissue cultures growing multiple organisms (not Enterobacter).

49. Scenario 3 • Patient admitted 5 days ago following head injury. • Central line in situ. • Single blood culture from central venous line - Pseudomonas spp. • No peripheral blood culture taken. • The patient was not febrile or septic at the time of the culture and was not commenced on antibiotics.

50. Scenario 4 28 Apr Admitted to hospital 1 May Admitted to ICU 2 CVC inserted (2200) 3 Blood culture (0600) - Acinetobacterspp Tracheal aspirate - MSSA • Notes: "febrile, ? Source GNB on blood culture” 7 ID documented “Acinetobacter cause of line sepsis” CXR essentially clear 3 - 7 May 8 CXR increasing consolidation, collapse in the LLL & increasing consolidation R) lung base Acinetobacterspp isolated from tracheal aspirate