New Jersey Hospital Improvement Innovation Network (NJHIIN)

CLABSI Prevention

HAI TAP WorkshopMarch 12, 2019

Central line-associated Bloodstream infections (CLABSI)

Source: https://gis.cdc.gov/grasp/PSA/HAIreport.html

New Jersey CLABSI Rates

Central Line Associated Bloodstream Infections (CLABSI) Facts

• 30,000 HAI CLABSI occur in US hospitals each year• Serious infections, causing prolonged hospital stay, increase risk of

mortality• More Common cause:

• Pathogen migration along external surface, more common early (< 7 days)• Hub contamination with intraluminal colonization, more common (> 10 days)

• Less Common• Hematogenous seeding from another source• Contaminated infusates

4. http://www.cdc.gov/hai/pdfs/toolkits/CLABSItoolkit_white020910_final.pdf

PresenterPresentation NotesAn estimated 30,000 CLABSIs occur in U.S. hospitals each year. Specifically, these are primary bloodstream infections that are associated with the presence of a central line or an umbilical catheter in neonates at the time of or before the date of the infection event. Primary bloodstream infections are usually serious infections that typically cause a prolonged hospital stay, increased cost and risk of mortality.

CLABSI can be prevented through proper insertion and management of the central line.

Central Line-Associated Bloodstream Infection

5

PresenterPresentation NotesAs with all invasive devices there are risks associated with central line use. If you are not familiar with central line insertion, maintenance, and the types of central line, it would benefit you to research this medical device. This picture illustrates the possible routes of infection associated with an IV line.

Target

CLABSI: Measures to Target

• CLABSI Infections rate, SIR, CAD• Device utilization rate, SUR• Unit-level or facility-level• Pathogen patterns• Process related data

• Central line insertion bundle compliance

CLABSI: TAP Report

Source: https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/ref-guide/TAP-Reports_Facility_CLABSI.pdf

Monitor Trends: Provide Feedback

Chart1

Days without CAUTIDays without CAUTIDays without CAUTIDays without CAUTI

6 East

2 North

4 West

8 South

Unit Locations

Number of Days

CLABSI Free Days by Unit Location

89

267

111

56

Sheet1

6 East2 North4 West8 South

Days without CAUTI8926711156

Category 22.54.42

Category 33.51.83

Category 44.52.85

Assess

CLABSI: Assessment

• Use tools to identify gaps in CLABSI prevention practices

• Tools can be used to assess practice through:• Observational auditing• Understanding staff perception• Competency based training tools• Monitoring trends

CLABSI TAP Facility Assessment Tool

New Jersey CLABSI Assessment Feedback Results

Prevent

CLABSI Prevention

Central Line

Insertion

Maintenance

Removal

General Infrastructure, Capacity & Processes

• Identification of Champions• Nurse• Physician• Support personnel

• Competency-based training• Audits and feedback• Use of bundles

Source: https://www.cdc.gov/hai/prevent/tap/preventionchampions.html

https://www.cdc.gov/hai/prevent/tap/preventionchampions.html

CLABSI Prevention: Basic

• Provide evidence-based list of indications for CVC use to minimize unnecessary CVC placement

• Assess the ongoing need for the CVC on a daily basis through multidisciplinary rounding

• Require education of healthcare personnel involved in insertion, care, and maintenance of CVCs about CLABSI prevention

Source: Marschall, J., et al, ICHE, 2014;

ICU Rounding

decreases mortality among

ICU patients

ICU rounds with multidisciplinary teams

Kim MM, et al. Arch Intern Med, 2010

ICU Rounds with Daily Goals

• Do not use as “just” a checklist!• Use explicit language during discussions on Daily Goals• Address important questions

• Does this patient have an ongoing need for the central line?• What will we do today?• What is the patient’s greatest safety risk?• Complete during rounds• Nurse should read back to ensure agreement• Modify to fit your unit

Source: AHRQ, Daily Goals During Interdisciplinary Rounds: Facilitator Guide , 2017

Appropriate Use of CVCs

• Documenting indication for use• Prompt removal

Proper Insertion Practices

• Hand hygiene• Aseptic technique

• Removal when lapses identified• Skin antisepsis

• >0.5% chlorhexidine with alcohol• Suture-less securement • Checklist fatigue ?

Source: https://www.cdc.gov/hai/pdfs/bsi/checklist-for-CLABSI.pdf

PresenterPresentation Noteshttps://www.cdc.gov/hai/pdfs/bsi/checklist-for-CLABSI.pdf

https://www.cdc.gov/hai/pdfs/bsi/checklist-for-CLABSI.pdf

Central Line Insertion Practices

• Hand hygiene• Skin preparation with chlorhexidine/alcohol

based solution• Standardized insertion tray or cart• Maximal sterile barrier precautions• Optimal site selection- avoid femoral site for

obese patients• Use of an insertion checklist

2003 Michegan Keystone ICU Project: up to 66%

reduction in CLABSI rates maintained throughout the 18-month project

period.Provonost, P. et al. NEJM,

2006

Marschall, J., et al, ICHE, 2014;

PresenterPresentation Notes One of the most well known CLABSI reduction studies, the 2003 Michegan Keystone ICU project demonstrated a 66% reduction in CLABSI rates over an 18 month period. The study intervention targeted clinicians' use of five evidence-based procedures recommended by the CDC and identified as having the greatest effect on the rate of catheter-related bloodstream infection and the lowest barriers to implementation.1 The recommended procedures are hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters.

Proper Maintenance Practices

•Dressing Changes•CHG•Skin prep•Intervals

•Injection Safety•Scrub hub•Blood culture collection

CLABSI- CHG Training Tools• Observed CHG Bathing Practices

• Please circle your answer:

• Y N Cleanses entire neck area well including skin folds and around lines.

• Y N Massages skin firmly with CHG cloth to ensure adequate cleansing.

• Y N States rationale for not using soap below jaw line at any time.

• Y N Uses all six cloths and more if needed.

• Y N Cleans armpit and back of knee well.

• Y N Cleans in between toes and fingers.

• Y N Cleans between all folds in perineal and gluteal area.

• Y N Wipes occlusive and semi-permeable dressing with CHG cloth.

• Y N Cleans tubing, lines, and drains closest to body (after emptying drains).

• Y N Bathing is completed with no skin below jaw line missed.

• Y N N/A Uses CHG on superficial wounds, rash, and stage 1 & 2 decubitus ulcers.

• Y N N/A Uses on closed surgical wounds.

• Y N Allows to air dry/does not wipe off CHG.

• Y N CHG bathing documented.

Source:https://www.ahrq.gov/professionals/systems/hospital/universal_icu_decolonization/universal-icu-apf.html

Central Prevention: Device Maintenance

• Nurse to patient ratio (at least 1 to 2 in ICU)• Disinfect access points prior to access

• vigorously apply mechanical friction with an alcoholic chlorhexidine preparation, 70% alcohol, or povidone-iodine

• Dressing change• 5-7 days for transparent dressings• Every 2 days for gauze dressings

Marschall, J., et al, ICHE, 2014;

Universal Decolonization

• “Bathe ICU patients over 2 months of age with a chlorhexidine preparation on a daily basis (quality of evidence: I)

• Universal Decolonization consists of:

• Daily chlorhexidine bathing which replaces soap and water bath.

• 5 days of nasal mupirocin.

Marschall, J., et al, ICHE, 2014;

REDUCE MRSA Trial (Randomized Evaluation of Decolonization vs. Universal Clearance to Eliminate Methicillin-Resistant Staphylococcus aureus), which found that universal decolonization was the most effective intervention. Universal decolonization led to a 37 percent reduction in MRSA clinical cultures and a 44 percent reduction in all-cause bloodstream infectionsHuang, S.,et al., NEJM, 2013

Universal Decolonization Protocol• Detailed Protocol:• For each adult ICU patient, each day:

• Stop admission ICU screening (if not required by law).

• Determine if any CHG exclusion criteria exist.• CHG allergy.

• Determine if any mupirocin exclusion criteria exist.

• Mupirocin allergy.• Nasal packing or physical inability to use

mupirocin.• Bathe patient with CHG daily, starting on day 1

of ICU admission, for entire ICU stay.• Administer mupirocin to patient twice a day,

starting on day 1 of ICU admission, for 5 days or until ICU discharge (if prior to 5 days).

• If patient is readmitted, restart the protocol for both CHG and mupirocin.

• Stop protocol upon discharge or transfer from the ICU.

Source: Appendix E. Training and Educational Materials . 2013. Agency for Healthcare Research and Quality, Rockville, MD.

CDC Vital Signs, March 2019

Source: https://www.cdc.gov/vitalsigns/staph/index.html

https://www.cdc.gov/vitalsigns/staph/index.html

Umbilical Catheters

• Perform skin antisepsis prior to insertion:• Use povidone-iodine, >0.5% chlorhexidine in alcohol solution, or aqueous

chlorhexidine solution.• Use both aqueous and alcohol-based chlorhexidine with caution in preterm

neonates, low-birthweight neonates, and within the first 14 days of life, due to risks of chemical burns to the skin.

• Systemic absorption has been reported due to skin immaturity; however, systemic effects are not documented. Studies have not established the safest and most effective chlorhexidine solution in neonates. Use all chlorhexidine antiseptic agents with caution in infants under 2 months of age.

• Avoid the use of tincture of iodine due to the potential deleterious effect on the neonatal thyroid gland

• Remove umbilical catheters promptly when no longer needed or if a complication occurs.

Gorsky, L. et al. INS Standards of Care, 2016

CLABSI High Performer

Hunterdon Medical Center

Identifying The Root Cause• Frequent Infection Prevention rounds on all

nursing units to visualize and evaluate central lines

• Interviewed nursing staff to identify issues leading to maintenance noncompliance

Data Collection/Sharing• Created rounding tool that focused on key issues

– Every patient with a central line is rounded on 3 times a week to evaluate site

– IP Department initially used the tool to collect/analyze data, but now each nursing unit completes for their area

– Any issues of noncompliance are corrected at the time of the observation

• Data on process measures shared monthly with all units• Data on outcome measures shared monthly with

frontline healthcare workers through Leadership/Quality Board

Education/Collaboration• Mandatory nursing education

– All nurses (including contracted dialysis staff)• Computer based education and in person education during

annual competencies

• Mandatory MD education– All inserting MDs from nursing units and radiology

• All key stakeholders were able to see the data, understand the importance of the issue, and become committed in order to achieve ‘zero’

Group Discussion• Do you have a well functioning team (or work group) focusing on CLABSI prevention? • Do you have a team leader with dedicated time to coordinate your CLABSI prevention

activities? • Do you have an effective nurse and physician champion for your CLABSI prevention activities? • Does your facility use a standardized central vascular catheters (CVC) insertion tray that

includes chlorhexidine gluconate for skin antisepsis?

• Do nurses stop a CVC insertion if aseptic insertion technique is not being followed? • Do bedside nurses take initiative and contact physicians to ensure that CVCs are removed when

the device is no longer needed?

• Do bedside nurses assess dressing integrity and replace loose, wet, soiled dressings on vascular catheters on a daily basis?

• Is senior leadership supportive of CLABSI prevention activities? • At your facility, do patients and/or families request CVCs such as peripherally inserted central

catheters (PICCs)?

• At your facility are CVCs, such as PICCs, being inserted without an appropriate indication?

Source: CLABSI GPShttp://www.hret.org/quality/projects/resources/STRIVE_CLABSI-GPS-Tool_Final.pdf

New Jersey Hospital Improvement Innovation Network (NJHIIN)��CLABSI Prevention�Central line-associated Bloodstream infections (CLABSI)New Jersey CLABSI RatesCentral Line Associated Bloodstream Infections (CLABSI) FactsCentral Line-Associated Bloodstream InfectionSlide Number 6CLABSI: Measures to TargetCLABSI: TAP ReportMonitor Trends: Provide FeedbackSlide Number 10CLABSI: AssessmentCLABSI TAP Facility Assessment ToolNew Jersey CLABSI Assessment Feedback ResultsSlide Number 14CLABSI PreventionGeneral Infrastructure, Capacity & ProcessesCLABSI Prevention: BasicICU RoundingICU Rounds with Daily GoalsAppropriate Use of CVCsProper Insertion PracticesCentral Line Insertion PracticesProper Maintenance PracticesCLABSI- CHG Training ToolsCentral Prevention: Device MaintenanceUniversal DecolonizationUniversal Decolonization ProtocolCDC Vital Signs, March 2019Umbilical CathetersCLABSI High PerformerIdentifying The Root CauseData Collection/SharingEducation/CollaborationGroup Discussion