Central Line Associated Blood Stream Infection Prevention Project Gabrielle Hanlon, Project Manager...

Central Line Associated Blood Stream Infection Prevention Project

Gabrielle Hanlon, Project ManagerTony Burrell, Chair ANZICS Steering Committee

Background• ~ 300 ICU CLABSI/yr in Australia• Costs $14,000 per case

extra $AU4.3 million

• 3,000 extra bed days• Attributable mortality 4-20%• CLABSI preventable

BackgroundCLABSI reduction projects• Pronovost (2006) & others (15yrs)• NSW CLAB ICU (2007-08) 3.0 → 1.2/1,000• WA Safety and Quality Investment for Reform

(SQuIRe) Program 2006 → 0.55/1000

This project

• ACSQHC funded ANZICS• National project• Adult & paed ICU• Public & private• Build on existing work

Objectives• Decrease rate of CLABSI in Australian ICUs to

<1/1000 line days• Accurately and consistently measure the rate

of CLABSI in ICUs throughout Australia• Timely reporting to clinicians• Benchmarking

Preparation• Review current practice (April/May 2010)

• Surveillance– Definition– Reporting method & timeframe

• ICU– CVL insertion– Knowledge of surveillance

SurveillanceAcross Australia• Majority data collected by ICPs• A few ICUs collected some data• Not all jurisdictions did CLABSI surveillance• Inconsistent definitions, reporting (method &

timing), benchmarking• Variable practises in private sector• No national reporting or benchmarking

ICU practice ICU Directors/Nurse Managers Survey• 53/100 ICUs: 24 doctors, 39 RNs (not NSW, ACT)

• Variable knowledge of surveillance processes• Some did not know CLABSI rate “but it’s low”• Variable compliance with “best practice” re

CVL insertion

ICU practiceCVL insertion – total 51 ICUs• have trolley/pack 76%• wear hats 43%• wear masks 43%• Chlorhex handwash 88%• sterile gown & gloves 100%• Chlorhex & alcohol skin prep 100%• full body draping 41%

Clinical practice

CVL insertion & maintenance• Chlorhex patch 20%• Impregnated CVC 59%• Chlorhex body-wash 25%

Schedule First • Outcome assessment & national reporting

both require– national definition – implementation/interpretation guide

Then• improve CVL insertion practises

National definition • minimise change if possible• numerator - NHSN 2008• denominator - line days • implementation guide inc “other infection”

definitions

National definition

Am J Infect Control 2008:36;309-32

National definition

• All jurisdictions adopting as able• New surveillance commencing

National reporting • No duplication at any step• Jurisdictions forward data to ANZICS if they

already collect it (hospital-level data only) • Some individual public & private hospitals

forward data to ANZICS (if above n/a)

National reporting • ANZICS generate reports

– Self vs other SA ICUs– Self vs other in same CICM level/other PICUs nationally– Self vs all in Australia

• Secure log-in• Access:

– ICU director & NUM – Inf Cont

– ? other

Monthly reportingICU CLABSI rate compared to other CICM Level I

0

1

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Janu

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Febru

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Time period: 2010

CL

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ays

Max-Q3

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Q1-min

0-min

CLABSI rate of Identified ICU

Mean

Annual reportYearly CLABSI rate summary for <insert name of hospital & ICU ID>

2.5 1 3 2 10

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Mean Identified ICUannual CLABSI rate

Mean CICM Level 1annual CLABSI rate

Mean <Jurisdiction>annual CLABSI rate

Mean national annualCLABSI rate

Benchmark CLABSI rate

Time period: January - December 2010

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rate

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Interim goals Foundations• National definition √• Implementation (interpretation) guide √• National reporting √

Now• Improve CVL insertion practises

Improving Central Line Insertion

Quality not research

However....• Based on evidence derived from research• Focus on

– sustainable practice vs short intervention– process & outcomes – ongoing measurement

Method - Clinical Practice Improvement

Too complex & time-consuming ...

MethodKeep It Simple• Measure CLABSI• Incorporate change into usual practise • Measure CLABSI• Review individual cases (ICU & IC +/- ID)• Check compliance with insertion process• Keep measuring CLABSI & review

Approach• Assumptions relevant to Australia

– multidisciplinary clinical team– ward rounds occur twice/day

• Establish multi-disciplinary project teams– ICU director & nurse manager or senior dr & ns– Infection Control/ID support– Others as appropriate

Intervention • Joint medical & nursing responsibility• Insertion & maintenance guideline based on

– NHMRC/ACSQHC Guidelines– CDC– Expert group– Core items– Optional items

Insertion Maximum barrier precautions• Hat• Mask• CHG handwash • Sterile gloves & gown• CHG & ETOH skin prep & allow to dry• Full-body drape• Maintain aseptic technique

Checklist

“Reminder”

Proceduralist acknowledges he/she would like to be reminded if he/she misses one of the steps below; eg. “ I would like you to watch me and if you see that I forget an important step in the procedure I want you to tell me”

Other suggestions• CVC (inc swan & vascath) trolley• Appropriate site• Options if rate higher than goal

– chlorhexidine patch at insertion site– impregnated CVC– daily chlorhexidine body wash

• Maintenance– Very limited re-wiring of existing lines– Replace lines with a blocked lumen– No disconnection & re-connection of lines (inc HF)

Guideline contents• Scope• Definitions• Selecting a central line• Selecting a site• Aseptic technique • Maximum barrier precautions• Stopping the procedure if asepsis breached• Daily review

– local infection– need for line

Guideline contents• Line replacement inc re-wiring• Blocked lumens• Changing fluids & administration sets• Needleless connectors• Dressings• CHG patches• Drug administration (CHG & ETOH swabs)• CHG body wash

Support Website • CVC insertion & maintenance guideline • References• Audit tools/checklist• Line day calculator• Secure discussion forum

ANZICS CLABSI Reporting Program

What now? • Establish CLABSI reporting process• Form the team - Dr, Ns, ICP, ?other• Review your protocol• Identify changes required & materials needed (eg.

trolley, big drapes, ?culture)

• Develop education strategies for all staff• Implement changes• Check compliance• Review CLABSI rate & compliance

Counting line-daysLine day counts should be done• 3 times a week, eg. Mon, Wed, Fri• At the same time • By asking the question: Does this patient have a

central line, PA catheter/swan, swan sheath, vascath (or other haemofiltration catheter), or a PICC?

This job does not require nursing/technical knowledgeThis is done by Infection Control in Vic & WA public ICUs

Counting line-daysMon Tues Wed Thurs Fri Sat Sun

Bed 1 1 0 0

Bed 2 0 1 1

Bed 3 0 1 1

Bed 4 1 1 0

Total 2 3 2

1 means the patient in that bed has at least 1 central line0 means either the bed is empty, or the patient doesn’t have a central line

Thankyou

gabrielle.hanlon@anzics.com.auwww.clabsi.com.au