Authors: Daniel Lee & Laura Pozzobon
Laura Pozzobon is a Registered Nurse currently working as a Quality Improvement & Patient Safety Specialist in Toronto, Ontario. Laura has expertise in improvement science and patient safety incident analysis. She earned her MSc in Healthcare Quality and is currently a PhD (Health Quality) student at Queen’s University.
You are a resident rotating through the ICU. One of your patients is a 75-year-old female who was admitted for urosepsis (sepsis originating from the urinary tract). She required vasopressor support and had an internal jugular vein central venous catheter placed in the ED. Since admission the patient has been improving with broad-spectrum antibiotics. However, on the 7th day post-admission, you’re alerted that the patient is deteriorating, with tachycardia and worsening fever. You rush to assess the patient and notice inflammation surrounding the catheter entry site. You posit that this could be a CLABSI - a Central Line Associated Bloodstream Infection. After you order blood cultures, you wonder, “what could have been done to prevent this?
Welcome to Part 2 of the HiQuiPs Patient Safety Primer! In partnership with experts in Quality, Patient Safety and Clinical Adoption from the University Health Network (UHN), a healthcare organization in Toronto, we aim to bring you succinct, high-yield posts exploring issues that continue to be associated with significant morbidity and mortality for patients: adverse drug events, surgical site infections, falls and more. You can read Part 1 of our primer here.
What is a Central Line Associated Bloodstream Infection?
A CLABSI is a laboratory-confirmed bloodstream infection not attributable to another site.(1)
Why does it matter?
CLABSIs lead to increased patient mortality, prolonged hospital stays, and increased health care costs. Much of the data on the health burden of CLABSIs comes from the United States, where 48% of patients in the intensive care unit (ICU) have indwelling central catheters leading to 15 million catheter-days per year.(2) There are an estimated 40,000 CLABSIs in the United States per year, which significantly increases the likelihood of all-cause mortality in an already fragile population (relative risk of death = 1.57).(3)
While we do not have equivalent figures in Canada, data collected from the Canadian Nosocomial Infection Surveillance Program from 2009–2018 reported the rate of CLABSIs as 1.1 per 1,000 line-days in adult ICUs, 1.9 per 1,000 line-days in pediatric ICUs, and 2.7 per 1,000 line-days in neonatal ICUs; these rates have been consistent over 10 years.(4) With over 3,000 ICU beds in Canada, it is easy to see that CLABSI represents both a large health and cost burden to our healthcare system.
What are current best practices?
One of the most important interventions to reduce the incidence of CLABSIs is a five-point strategy developed by the Center for Disease Control (CDC), as delineated below.(5) The implementation of this strategy has been shown to result in a sustained reduction of 66% in a large multi-site study and has quickly become the standard of care across the world.(5) The five principles are:
Handwashing with soap and water;
Sterile insertion with full barrier precautions (cap, mask, sterile gown, sterile gloves, full sterile tape);
Use of 2% chlorhexidine solution with proper air drying before insertion;
Avoiding femoral site for catheterization when possible;
Prompt removal of unnecessary catheters.
In addition, there are several other evidence-based recommendations with regards to the insertion and maintenance of central venous catheters to reduce the incidence of CLABSIs:
Selecting the insertion right site for the patient (e.g. femoral and subclavian);
Using ultrasound to reduce the number of insertion attempts;
Using a catheter with the minimum number of ports required to manage the patient;
Using antiseptic/antibiotic catheters in higher-risk settings;
Using chlorhexidine gluconate-impregnated dressings.(6–11)
An Organizational Approach to Reducing CLABSIs
In 2017, UHN began an organization-wide approach to reducing CLABSIs. In three years, TeamUHN was able to reduce the overall CLABSI rate for four ICU units by 22% over three years.(11) There have been many learnings along the way, some of which are outlined below:
Establishing Accountability: A framework for governance and accountability for CLABSI reduction was established. The identification of clinical and administrative leaders to co-lead the initiative was key to the success of this initiative.
Reducing variability and building reliability: Two evidence-based “bundles” (see figure 1) for the prevention of CLABSIs were developed collaboratively: (1) central line insertion and (2) central line maintenance. A central line Dressing Change Kit and an associated dressing change procedure were also developed and implemented to reduce dressing change practice variation.
Collaboration with clinicians: Engagement with front-line clinicians was integral to the scale and spread of the CLABSI prevention work. For example, more than 30 registered nurses were upskilled to provide coaching to peers on best practices.
Improving data collection on CLABSIs: Clear definitions for central lines (identification of line types were considered central lines at UHN) and CLABSIs supported surveillance and consistent data collection across the organization.CLABSI surveillance was also expanded to systematically collect and analyze data on CLABSIs.
A continuous focus on CLABSI prevention at all levels within the organization: UHN’s safety huddle structure used to report and anticipate safety concerns has helped units keep a pulse on CLABSI prevention. Additionally, UHN’s Quality, Safety and Clinical Adoption team implemented a process for rigorous review of all CLABSIs to ensure continued learning from CLABSI events. CLABSI measures were added to the Safety and Quality scorecard to maintain consistent organizational focus as well.
Conclusion
CLABSIs are a serious patient safety issue associated with significant morbidity and mortality, especially amongst the most fragile and sick patients in our healthcare system.
There are well-established methods to prevent CLABSIs that can reduce an organization’s CLABSI rate, as seen with UHN. Having a focused attention on the processes associated with inserting and maintaining a central line at all levels within an organization is critical in reducing infection.
The blood cultures come back positive, and you and your team treat this patient’s infection. After some background research, you learn there are many effective strategies to prevent CLABSIs that are easy to implement! With your new knowledge, you work with the unit’s Patient Safety Lead to spread and disseminate the knowledge to your colleagues.
That's it for the second instalment in our 4-part series on Patient Safety Fundamentals in partnership with the University Health Network. Let us know what you think on Twitter at @Hi_Qui_Ps. If there is anything specific you would like to learn about, e-mail us at hiquips@gmail.com. Stay tuned for Part 3 of our series on Patient Safety Fundamentals. Next post's topic: Reducing Patient Falls!
Senior Editor: Dr. Lucas Chartier
Copyedited by: Daniel Dongjoo Lee
References
Centers for Disease Control and Prevention. Bloodstream infection event (central line-associated bloodstream infection and non-central line-associated bloodstream infection). Device-associated Module BSI. 2017 Jun:1-38.
Mermel LA. Prevention of intravascular catheter–related infections. Annals of internal medicine. 2000 Mar 7;132(5):391-402.
Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, Keohane C, Denham CR, Bates DW. Health care–associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA internal medicine. 2013 Dec 9;173(22):2039-46.
Canadian Nosocomial Infection Surveillance Program. Device-associated infections in Canadian acute-care hospitals from 2009 to 2018. Canada Communicable Disease Report. 2020 Nov 5;46(11/12).
Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J. An intervention to decrease catheter-related bloodstream infections in the ICU. New England journal of medicine. 2006 Dec 28;355(26):2725-32.
Pikwer A, Bååth L, Davidson B, Perstoft I, Åkeson J. The incidence and risk of central venous catheter malpositioning: a prospective cohort study in 1619 patients. Anaesthesia and intensive care. 2008 Jan;36(1):30-7.
Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database of Systematic Reviews. 2015(1).
Templeton A, Schlegel M, Fleisch F, Rettenmund G, Schöbi B, Henz S, Eich G. Multilumen central venous catheters increase risk for catheter-related bloodstream infection: prospective surveillance study. Infection. 2008 Aug; 36(4):322-7.
Rates of infection for single-lumen versus multilumen central venous catheters: a meta-analysis.Dezfulian C, Lavelle J, Nallamothu BK, Kaufman SR, Saint S. Crit Care Med. 2003 Sep; 31(9):2385-90.
Lai NM, Chaiyakunapruk N, Lai NA, O'Riordan E, Pau WS, Saint S. Catheter impregnation, coating or bonding for reducing central venous catheter‐related infections in adults. Cochrane Database of Systematic Reviews. 2016(3).
Ullman AJ, Cooke ML, Mitchell M, Lin F, New K, Long DA, Mihala G, Rickard CM. Dressings and securement devices for central venous catheters (CVC). Cochrane Database of Systematic Reviews. 2015(9).
UHN’s Quality and Safety Journey. https://www.uhn.ca/corporate/News/Documents/Quality_Safety_Journey_2020.pdf