Hospital Acquired Catheter-Related Hospital Acquired Catheter-Related Bloodstream InfectionsBloodstream Infections

(CR-BSI)(CR-BSI)

MED INF 406 - Decision Support Systems and Health Care

BackgroundBackground

More than 5 million Central vascular catheters used annually in US.

250,000 cases of CVC-associated BSIs occur annually in the US

ICU related CVC-associated BSIs occuring annually in the US: 80,000

Attributable mortality for these BSIs : upto 28,000 deaths

Attributable average cost per infection : $ 56000

Financial Impact!

Annual cost of CVC-associated BSIs – upto $2.3 billion• http://www.firstdonoharm.com/HAC/CRBSI/

DefinitionDefinition

Bacteremia / fungemia in a patient with an intravascular catheter with:

at least one positive blood culture obtained from a peripheral vein

clinical manifestations of infection (i.e., fever, chills, and/or hypotension)

and no apparent source for the bloodstream infection except the catheter. 

Bloodstream infections are considered to be associated with a

central line if the line was in use during the 48-hour period before the development of the bloodstream infection.

http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Measures/CatheterRelatedBloodstreamInfectionRate.htm

Impact!Impact! Common in healthcare, especially in ICU Morbidity (risk for local and systemic infectious complications) LOS Mortality Cost - in term of morbidity and financial resources

As of Oct, 2008

CMS New Rule – No Pay for Never Events

Cannot Bill Patient for HAIs

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm

Why Address it ?Why Address it ?

EtiologyEtiology

Sources of InfectionSources of Infection

Skin organisms

Environmental contamination

Post-placement subcutaneous tract infection

Intraluminal contamination

Hematogenous seeding

Risk FactorsRisk Factors

The incidence of CRBSI varies considerably by:

type of catheter frequency of catheter manipulation patient-related factors

underlying disease

acuity of illness

.By

Type of Vessel it occupies

-peripheral venous-central venous-arterial

By Catheter

pathway from skin to vessel -tunneled -nontunneled

By the site of insertion •femoral•subclavian•internal jugular•peripheral•peripherally inserted central catheter [PICC

By the intended life span of Catheter

- temp or short-term

-permanent or long-term

or by some special characteristic of the catheter, e.g.:- presence or absence of a cuff- impregnation with heparin• antibiotics or antiseptics• and the number of lumens

By Catheter

Physical Length

- long -short

CLASSIFYING THE

CATHETERS

Peripheral venous catheters• most frequently used devices for vascular access • Low incidence of associated infections

BUT

Higher frequency of such catheters used

SO It adds up! Serious infectious complications produce considerable annual morbidity

Central venous catheters (CVCs)• majority of serious catheter-related infections associated

with CVCs - especially those that are placed in patients in ICUs

Risk FactorsRisk Factors1. Type of Catheter

Risk Factors Risk Factors 2. Setting / frequency of catheter manipulationRisk Factors Risk Factors 2. Setting / frequency of catheter manipulation

• In the ICU setting, the incidence of infection is often higher:• central venous access needed for extended periods of time• Patient colonization with hospital-acquired organisms• Catheter can be manipulated multiple times per day

contamination clinical infection• Catheter insertion in urgent situations with sub-optimal aseptic

precautions

Risk Factors Risk Factors 3. Patient Related Factors

• Diabetic or high blood glucose levels• Immuno-compromised• Cancer patients• Age - elderly

- pediatric population

To improve patient outcome

reduce health-care costs

strategies should be implemented to reduce the incidence of these

infections

The Keystone ICU Project The Keystone ICU Project #:Evidence-based recommendations from CDC for

preventing CR-BSI• A care bundle of best practices in terms of CRBSIs that

individually improve care, but when applied together result in substantially greater improvement.  The science supporting the bundle components is sufficiently established to be considered standard of care.

•  

(1) Hand Hygiene

(2) Full Barrier Precautions during insertion of CVC

(3) Cleaning the skin with 2% Chlorhexidine

(4) Appropriate site and line selection

(5) Remove Unnecessary Catheters

# Pronovost P, Needham D, Berenholtz S et al. An Intervention to Decrease Catheter Related Bloodstream Infections in the ICU. N Engl J Med 2006;355:2725-32.

Decision Tree: Decision Tree: Appropriate Site and Line Appropriate Site and Line

Selection Selection

Does patient have peripheral access? YesNo

Patient will need one of the following:Vesicant medicationVasopressorTPNFuild bolus

Patient needs hemodynamic monitoringYesNo

Anticipate IV therapy greater than 5 daysYesNo

Workflow engine Alert to clinicianWorkflow engine Alert to clinician

Central line AlertPatient does not meet criteria:

No peripheral accessIV vesicantHemodynamic monitoringIV therapy greater than 5 days

Decrease the risk of a hospital acquired central line infection by PLACING A PERIPHERAL LINE

Populates database with patient names

who had the alert associated with

them

Daily Documentation To Justify Daily Documentation To Justify Keeping A Central LineKeeping A Central Line

High volume IVFHi volume bloodMultiple dripsTPNLimited accessLong term accessHemodynamic monitoringVasopressor/vesicant meds

Populates database to track reasons for keeping central lines etc.

Workflow engine Alert to clinicianWorkflow engine Alert to clinician

Central line Dwelling Time AlertDwelling time of central line catheter is greater than 5 days

Decrease the risk of a hospital acquired central line infection

consider discontinuation of Central line

Populates database with patient names

who had the alert associated with

them

Outcome and Process MeasuresOutcome and Process Measures

• Outcome measures– CRBSI/1000 central line days– Average length of central catheter dwelling

time

• Process measures– Justification of central line– # of alerts rendered and response to them

Average Central Line DaysAverage Central Line Days

.

CDSS Design CDSS Design

Guided by the AMIA Roadmap for National Action on CDS vision:

“optimal, usable and effective clinical decision support is widely available to providers, patients, and individuals where and when they need it to make health care decisions.”

AMIA RoadMap PillarsAMIA RoadMap Pillars

1. Best Knowledge Available when Needed

2. High Adoption and Effective Use

3. Continuous Improvement of Knowledge and CDS Methods

CDSS FrameworkCDSS Framework

Service-oriented Architecture (SOA):• An SOA infrastructure allows different

applications to exchange data with one another as they participate in business processes.

• Core business capabilities are encapsulated within independent software services, and these services are leveraged by various front-end applications to fulfill business requirements.

CDSS ArchitectureCDSS Architecture

DemographicsAllergiesClinical

DocumentationPhysician

DocumentationOrders

Laboratory ResultsRadiology Reports

Clinical Information System (CIS)

Data Repository

CIS Action Broker

HL7 message

Web Service`

ClinicianReference Database(s)

KeystoneKnowledge Module

SOAP

XML

XML

XML

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90

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Surveillance Reports -Performance Measures

How did we do ?How did we do ?

• Design – Provides a good foundation to build additional

CDSS– Reusable, separates knowledge from code– Based on standards

• Information availability– Data repository provides robust reporting

capabilities – Ability to monitor clinician responses to alert

against patient outcomes

What are the Limitations?What are the Limitations?

• Design requires technical resources

• Clinician workflow is critical– Be reasonablereasonable in expectation of CDSS use

SummarySummary

• Information is powerful!Information is powerful! Use it to influence clinician practice to positively impact patient outcomes

• Performance measures should be monitored to reflect effectiveness

• CDSS Design must be re-usablere-usable and based on standards

• Must lay foundation for additional CDSS

Resources Resources 1. CDC Guidelines

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm

2. Clinical study - An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU http://content.nejm.org/cgi/reprint/355/26/2725.pdf

3. Clinical study -Prevention of Intravascular Catheter–Related Infections. Leonard A. Mermel, DO, ScM, AM(Hon)

http://www.annals.org/cgi/reprint/132/5/391.pdf

4. http://www.journals.uchicago.edu/doi/pdf/10.1086/377265?cookieSet=1

5. A Roadmap for National Action on Clinical Decision Support. Osheroff, MD, Teich, MD, PhD, Middleton, MD, Steen, MA, Wright, Detmer, MD, MA

6. Proposal for Fulfilling Strategic Objectives of the U.S Roadmap for National Action on Decision Support through a Service-oriented Architecture Leveraging HL7 Services – Kawamota, PhD, Lobach, MD, PhD, MS

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