Central Line Associated Blood Stream Infection (CLABSI) Prevention
Central Line Associated Bloodstream Infections (CLABSI) pose a significant risk to patients in New York hospitals. From our work and the reports of others, we know that the rates of CLABSI outside the ICU setting are similar to those found in the ICU. Since most patient stays are outside the ICU, and approximately 20% of these patient days include a central line, the burden of disease is greater outside the ICU. A focus on CLABSI surveillance and prevention outside the ICU therefore has the potential to significantly impact and reduce CLABSI rates among NY hospitals. This will require an approach that is different from ICU prevention methods by focusing on post insertion line care and nurse education. The purpose of the study is to improve central line care practices and to reach a sustained reduction in the overall burden of CLABSI in NY hospitals.
Goals and Objectives
Initial goals of the project were to measure the burden of CLABSI outside the ICU and track the rate of CLABSI after feedback of these rates to the unit staff and hospital administration.
Develop and implement a Line Care Protocol (LCP) of best practices, educate staff regarding the protocol, and determine the rate of CLABSI after implementation of the LCP.
Assess the effect of interventions on processes related to line care.
Develop a practical measure to sustainably monitor CLABSI by establishing the reliability of the once weekly device use ratio (DUR) in estimating central line-days.
Thirty-seven non-intensive care units in six hospitals in the Rochester, NY region providing data to calculate infection rates from April 2008 – February 2013. These 37 units represent a range of patients, from medical and surgical to oncology and transplant.
Previous prevention efforts have focused on central line insertion, and more specifically, central lines in the intensive care unit. Our Collaborative is unique in that it spans six hospitals in unrelated hospital systems, and focused entirely on the care and maintenance of central lines after insertion.
After an initial period of data collection, we began our first phase of intervention; the dissemination of rates to the participating units. Each unit received their current CLABSI rate on a quarterly basis, and was encouraged to share the rates with their staff. Additionally, nursing leadership from each facility received rate information for all participating units.
The second phase of intervention was a series of Nursing Grand Rounds, held at each facility. All nurses from the hospital were invited and given information about the burden of CLABSI outside the ICU; comparisons of their hospital’s rate with national averages and the importance of preventing infections. The Grand Rounds is also where we rolled out the Central Line Maintenance Bundle, which would provide the framework for all future interventions. The Bundle was comprised of recommendations on the proper care and maintenance of central lines, that when used together, would reduce central line infections.
Phase three of our interventions consisted of a computer based training module that reiterated all of the information provided in the Grand Rounds. Each hospital mandated the view of the module by all of their nurses by the end of 2009. To date, more than two dozen facilities across New York as well as other states are using this training module, which fulfills the CMS National Patient Safety goal to provide all nurses with training to reduce this hospital acquired infection.
The fourth phase of interventions was the effort to audit both the integrity of the central line dressing as well as nursing practice when changing the central line dressing. Observing the central line maintenance bundle in action provides a teaching opportunity and reinforcement of proper technique.
Nurses were surveyed as to their knowledge and practice prior to and after the intervention, and dressing change practices were audited. The collaborative was expanded in the third year to include vascular team members, safety & education nurses and other identified champions. This collaborative model was effective in reducing CLABSI outside the ICU.
Where Are We Now?
The generous funding we received from New York State Department of Health concluded in February, 2013. Over the five years of this Collaborative, we served as a resource for all facilities striving to reduce their infection rates. We have robust data that can be provided to anyone in the Collaborative for purposes such as Magnet application, practice change or quality improvement. Additionally, our Preventing CLABSI Outside the ICU online training module (see link below) is available at no cost to any interested facility.
Thompson ND, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Godine D, Maloney M, Kainer M, Ray S, Thompson D, Wilson L, Magill SS. "Estimating central line-associated bloodstream infection incidence rates by sampling of denominator data: A prospective, multicenter evaluation." American journal of infection control. 2015 Aug; 43(8):853-6. Epub 2015 May 21.
Concannon C, van Wijngaarden E, Stevens V, Dumyati G. "The effect of multiple concurrent central venous catheters on central line-associated bloodstream infections." Infection control and hospital epidemiology. 2014 Sep; 35(9):1140-6. Epub 2014 Jul 28.
Dumyati G, Concannon C, van Wijngaarden E, Love TM, Graman P, Pettis AM, Greene L, El-Daher N, Farnsworth D, Quinlan G, Karr G, Ward L, Knab R, Shelly M."Sustained reduction of central line-associated bloodstream infections outside the intensive care unit with a multimodal intervention focusing on central line maintenance." American journal of infection control. 2014 Jul; 42(7):723-30. Epub 2014 May 23.
Stevens V, Geiger K, Concannon C, Nelson RE, Brown J, Dumyati G. "Inpatient costs, mortality and 30-day re-admission in patients with central-line-associated bloodstream infections." Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. 2014 May; 20(5):O318-24. Epub 2013 Nov 06.
Central Line Maintenance Tools: