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Central Line-Associated Bloodstream Infections (CLABSI) in
Central Line-Associated Bloodstream Infections (CLABSI) in
Tools for Implementation NHSN CLIP Option: Insertion Practices
Tools for Implementation NHSN CLIP Option: Insertion Practices
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Central Line-Associated Bloodstream Infections (CLABSI) in Non-Intensive Care Unit (non-ICU) Settings Toolkit

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1Central Line-Associated Bloodstream 20Prevention Strategies: Core Hand
Infections (CLABSI) in Non-Intensive Care Hygiene. Hand hygiene should be a
Unit (non-ICU) Settings Toolkit Activity cornerstone of CLABSI prevention efforts
C: ELC Prevention Collaboratives. Alex For both insertion and maintenance As part
Kallen, MD, MPH and Priti Patel, MD, MPH of a hand hygiene intervention, consider:
Division of Healthcare Quality Promotion Ensuring easy access to soap and water and
Centers for Disease Control and alcohol-based hand gels Education for HCP
Prevention. Draft - 1/22111/09 --- and patients Observation of practices -
Disclaimer: The findings and conclusions particularly around high-risk procedures
in this presentation are those of the (before and after contact with CL)
authors and do not necessarily represent Feedback – “Just in time” feedback if
the official position of the Centers for failure to perform hand hygiene observed.
Disease Control and Prevention. 21Prevention Strategies: Core
2Outline. Background Impact HHS Chlorhexidine Skin Cleansing.
Prevention Targets Pathogenesis Chlorhexidine is the preferred agent for
Epidemiology Prevention Strategies Core skin cleansing for both CL insertion and
Supplemental Measurement Process Outcome maintenance Tincture of iodine, an
Tools for iodophor, or 70% alcohol are alternatives
Implementation/Resources/References. Recommended application methods and
3Background: Impact. Bloodstream contact time should be followed for
infections (BSIs) are a major cause of maximal effect Prior to use should ensure
healthcare-associated morbidity and agent is compatible with catheter Alcohol
mortality Up to 35% attributable mortality may interact with some polyurethane
BSI leads to excess hospital length of catheters Some iodine-based compounds may
stay of 24 days Central Line (CL) use a interact with silicone catheters.
major risk factor for BSI More than 22Prevention Strategies: Core CL Site
250,000 central line-associated BSIs Choice. For adult patients receiving
(CLABSIs) in US yearly Rates of CLABSI non-tunneled CL, femoral site should be
appear to vary by type of catheter. Pittet avoided due to an increased risk of
et al. JAMA 1994; 271 1598-1601. Klevens infection and deep venous thrombosis Note:
et al. Public Health Reports In patients with renal failure, subclavian
2007;122:160-6. site should be avoided to minimize
4Background: HHS Prevention Targets. stenosis which may limit future vascular
Prevention of CLABSIs in Intensive Care access options.
Units (ICUs) and “other locations” have 2 23Prevention Strategies: Core Hub/access
associated goals in HHS HAI Prevention port cleansing. BSI “outbreaks” have been
Plan: -Reduce CLABSIs by 50% -100% associated with failure to adequately
adherence with CL insertion practices in decontaminate catheter hubs or failure to
non-emergent situations. change them at appropriate intervals
5Background: Impact Outside the ICU. Cleanse hubs prior to use with an
Most work aimed at reducing CLABSIs in the appropriate antiseptic (e.g., 70% alcohol)
hospital has been done in ICUs Many CLs Manufacturer recommendations regarding
are found outside ICUs In one study 55% of cleansing and changing connectors should
ICU patients had CL; 24% of non-ICU be followed.
patients had CL However, as more patients 24Prevention Strategies: Core CL
are located outside of the ICU, 70% of Maintenance and Insertion: Education.
hospitalized patients with CLs were Personnel responsible for insertion and
outside the ICU. Climo et al. ICHE 2003; maintenance of catheters should be trained
24:942-5. and demonstrate competence Recurrent
6Background: Impact CLABSI Rates. educational sessions for staff who care
CLABSI rates outside ICUs may be similar and/or insert CLs.
to rates of these infections in ICUs 25Prevention Strategies: Supplemental.
Although data are sparse, in one study Supplemental strategies include:
CLABSI rates were: 5.7 per 1,000 Chlorhexidine bathing*
catheter-days in 4 inpatient wards 5.2 per Antimicrobial-impregnated catheters
1,000 catheter-days for medical ICU. Chlorhexidine-impregnated dressings*. *
Marschall et al. Infect Control Hospital Not part of 2002 HICPAC Guidelines for the
Epidemiol 2007;28:905-9. Prevention of Intravascular
7From 2006 – 2008 NHSN report, pooled Catheter-Related Infections.
mean CLABSI rates were: Medical-Surgical 26Prevention Strategies: Supplemental
ICUs = 1.5 to 2.1 per 1,000 catheter-days Chlorhexidine Bathing*. In an ICU at a
Medical-Surgical wards = 1.2 per 1,000 single center, daily bathing with 2%
catheter-days. Background: Impact National chlorhexidine-impregnated cloths decreased
Healthcare Safety Network (NHSN) CLABSI the rate of BSIs compared to soap and
Rates. Edwards JR, et al. Am J Infect water No data outside the ICU. Bleasdale,
Control 2009;37:783-805. et al. Arch Intern Med 2007;167:2073-9. *
http://www.cdc.gov/nhsn/PDFs/dataStat/2009 Not part of 2002 HICPAC Guidelines for the
HSNReport.PDF. Prevention of Intravascular
8Background: Impact CLABSI in Catheter-Related Infections.
Outpatient Settings. A number of patient 27Prevention Strategies: Supplemental
groups may have long-term CLs as Antimicrobial-Impregnated Catheters. 2
outpatients Hemodialysis Malignancy types with most supporting evidence:
Gastrointestinal tract disorders Pulmonary Minocycline-Rifampin Chlorhexidine–Silver
hypertension Rates of CLABSI may be as Sulfadiazine Platinum-Silver catheter
high as those seen in ICUs In hemodialysis available but less evidence to support use
- 1 to 4 per 1,000 catheter-days. These may be appropriate for patients
9Background: Pathogenesis CLABSI. More whose catheter is expected to be used for
Common Mechanisms 1. Pathogen migration more than 5 days and when Core strategies
along external surface - more common early have not decreased rates of CLABSI to
(< 7days) 2. Hub contamination with established goals.
intraluminal colonization -more common 28Prevention Strategies: Supplemental
>10 days Less Common Mechanisms 1. Chlorhexidine Dressings*.
Hematogenous seeding from another source Chlorhexidine-impregnated sponge dressings
2. Contaminated infusates. HICPAC. have been shown to decrease rates of
Guideline for Prevention of Intravascular CLABSIs in some studies and not in others.
Device-Related Infections. 1996. These dressings may be an option when Core
Healthcare Personnel Hand Contamination. interventions have not decreased rates of
Hub Contamination. Contamination of CLABSI to established goals. * Not part of
insertion site. Contaminated Infusate. 2002 HICPAC Guidelines for the Prevention
Extraluminal Contamination. Hematogenous of Intravascular Catheter-Related
spread. Infections.
10MRSA CLABSI. MSSA CLABSI. Background: 29Summary of Prevention Strategies*.
Epidemiology ALL ICU TYPES: Rates of Core Measures. Supplemental Measures.
Methicillin-Resistant and Implementing chlorhexidine bathing* Using
Methicillin-Susceptible Staphylococcus antimicrobial-impregnated catheters
aureus CLABSIs—United States, 1997-2007. Applying chlorhexidine site dressings*.
Are CLABSI Rates falling? Data from NHSN Removing unnecessary CL Following proper
for ICUs suggest rates of MRSA and MSSA insertion practices Facilitating proper
central line-associated BSIs are falling insertion practices* Complying with hand
in the U.S. -49.6%**. -70.1%*. *P=0.02 hygiene recommendations Performing
**P<0.0001. Burton et al. JAMA 2009; adequate skin cleaning Choosing proper CL
301:727-36. insertion sites Performing adequate
11Background: Epidemiology Modifiable hub/access port cleaning Providing
Risk Factors. Characteristic. Risk Factor education on CL maintenance and insertion.
Hierarchy. Insertion circumstances. * Not part of 2002 HICPAC Guidelines for
Emergency > elective. Skill of the Prevention of Intravascular
inserter. General > specialized. Catheter-Related Infections.
Insertion site. Femoral > subclavian. 30Measurement. With CLABSI measurement
Skin antisepsis. 70% alcohol, 10% it is important to Have a definition that
povidone-iodine > 2% chlorhexidine. is consistent between sites Collecting
Catheter lumens. Multilumen > single blood cultures in a similar fashion For
lumen. Duration of catheter use. Longer recommended indications Via a peripheral
duration of use greater risk. Barrier venipuncture vs. via a CL.
precautions. Submaximal > maximal. 31Measurement: Process Measures. Process
12Background: Prevention Strategies measures can help determine if
Interventions. Pittsburgh Regional Health interventions are being fully implemented
Initiative – Decrease in CLABSIs in 66 Ensuring interventions are being performed
ICUs (68% decrease) Interventions is itself a “core” intervention
Promotion of best practices Maximal Potentially important process measures to
barrier precautions Use of chlorhexidine consider are: Hand hygiene adherence
for skin cleansing prior to insertion Proportion of patients with CLs, and/or
Avoidance of femoral site for CL Use of duration of CL use Proportion of CL
recommended insertion-site dressing insertions in which maximal barrier
practices Removal of CL when no longer precautions were used Consider using NHSN
needed Educational module about BSI Central Line Insertion Practices (CLIP)
prevention Engagement of leadership and option.
clinicians Standard tools for recording 32Measurement: Outcome Calculating
adherence to best practices Standardizing CLABSI Rates. Stratify by: Type of
catheter insertion kits Measurement of ICU/Other Location For special care areas
CLABSI and reporting of rates back to Catheter type (temporary or permanent) For
facilities. CDC. MMWR 2005;54:1013-6. neonatal intensive care units Birthweight
13Background: Prevention Strategies category Catheter type (umbilical or
Interventions. Michigan Keystone Project central).
Decrease in CLABSI in 103 ICUs in Michigan 33Measurement: Outcome Device
(66% reduction) Basic interventions: Hand Utilization (DU) Ratio. # central
hygiene Full barrier precautions during CL line-days. CL DU Ratio. =. # patient-days.
insertion Skin cleansing with DU Ratio measures the proportion of total
chlorhexidine Avoiding femoral site patient-days in which central lines were
Removing unnecessary catheters Use of used.
insertion checklist Promotion of safety 34Measurement: Process CLIP Adherence
culture. Pronovost et al. NEJM Rates. Using NHSN, adherence rates can be
2006;355:2725-32. calculated for: Hand hygiene Barrier
14Background: On the CUSP: Stop BSI precautions used including masks, sterile
project. This national program is a drape, gowns and sterile gloves Skin
collaboration between Health Research and preparation including type of agent and
Educational Trust Johns Hopkins University whether agent was allowed to dry Other
Quality and Safety Research Group Michigan measures collected in the NHSN CLIP option
Health and Hospital Association Keystone that can be summarized include: CL type,
Center for Patient Safety and Quality location, and number of lumens Antiseptic
Builds on successes in Michigan Keystone ointment applied to site.
project CLABSI prevention bundle 35Measurement: Process Calculating CLIP
Collaborative model Promotion of safety Adherence Rates. # hand hygiene performed
culture Hospitals in all 50 states, the for CL insertion. Hand Hygiene Adherence
District of Columbia, and Puerto Rico are Rate. =. # CL insertions records
eligible to participate. completed. Adherence rates can also be
15Prevention Strategies. Supplemental measured for each of the barrier and
Strategies Some scientific evidence prevention practices by using the number
Variable levels of feasibility. Core of CLIP records completed as the
Strategies High levels of scientific denominator.
evidence Demonstrated feasibility. *The 36Tools for Implementation NHSN CLIP
Collaborative should at a minimum include Option: Insertion Practices.
core prevention strategies. Supplemental 37Evaluation Considerations. Assess
prevention strategies also may be used. baseline policies and procedures Areas to
Most core and supplemental strategies are consider Surveillance Prevention
based on HICPAC guidelines. Strategies strategies Measurement Coordinator should
that are not included in HICPAC guidelines track new policies/practices implemented
will be noted by an asterisk (*) after the during collaboration.
strategy. HICPAC guidelines may be found 38References. Bleasdale SC, Trick WE,
at www.cdc.gov/hicpac. Gonzalez IM, et al. Effectiveness of
16Prevention Strategies: Core. Removing chlorhexidine bathing to reduce
unnecessary CL Following proper insertion catheter-associated bloodstream infections
practices Facilitating proper insertion in medical intensive care unit patients.
practices* Complying with hand hygiene Arch Intern Med 2007; 67:2073-9. Burton
recommendations Adequate skin antisepsis DC, Edwards JR, Horan TC, et al.
Choosing proper CL insertion sites Methicillin-resistant Staphyloccus aureus
Performing adequate hub/access port central line-associated bloodstream
disinfection Providing education on CL infections in US intensive care units,
maintenance and insertion. * Not part of 1997-2007. JAMA 2009;301:727-36. CDC.
2002 HICPAC Guidelines for the Prevention Reduction in central line-associated
of Intravascular Catheter-Related bloodstream infections among patients in
Infections. intensive care units—Pennsylvania, April
17Prevention Strategies: Core Removing 2001-March 2005. MMWR 2005;54:1013-6.
Unnecessary CL. In one study, 9% of CLs 39References. Climo M, Diekema D, Warren
outside of ICU deemed inappropriate DK, et al. Prevalence of the use of
Perform daily assessment of the need for central venous access devices within and
the CL and promptly discontinue CLs that outside of the intensive care unit:
are no longer required Nursing staff results of a survey among hospitals in the
should be encouraged to notify physicians prevention epicenter program of the
of CLs that are unnecessary Use peripheral Centers for Disease Control and
catheters instead These generally have Prevention. ICHE 2003;24:942-5. Edwards,
lower rates of BSIs than CL. Trick et al. JR, Peterson KD, Mu Y, et al. National
Infect Control Hospital Epidemiol Healthcare Safety Network (NHSN) report:
2004;25:266-8. Data summary for 2006 through 2008, issued
18Prevention Strategies: Core Proper December 2009. Am J Infect Control
Insertion Practices. Ensure utilization of 2009;37:783-805.
insertion bundle: Chlorhexidine for skin 40Klevens RM, Edwards JR, Richards CI,
antisepsis Maximal sterile barrier et al. Estimating health care-associated
precautions (e.g., mask, cap [i.e., infections and deaths in U.S. hospitals,
similar to those worn in the O.R.], gown, 2002. Public Health Reports
sterile gloves, and large sterile drape) 2007;122:160-6. Pittet D, Tarara D, Wenzel
Hand hygiene Many CLs in patients on RP. Nosocomial bloodstream infection in
non-ICU hospital wards are placed outside critically ill patients. Excess length of
those wards (Emergency room, ICU, stay extra costs, and attributable
Operating room, or Pre-operative areas) In mortality. JAMA 1994;271:1598-1601.
one study, 49% of CLs were present on 41References. Marschall J, Leone C,
admission to the ward. Rates of BSI in Jones M, et al. Catheter-associated
this study were higher in CLs placed in bloodstream infections in general medical
Emergency Room Define where placement patients outside the intensive care unit :
occurs and review technique in those a surveillance study. ICHE 2007; 28:905-9.
areas. Trick et al. Am J Infect Control Pronovost P, Needham D, Berenholtz S, et
2006;34:636-41. al. An intervention to decrease
19Prevention Strategies: Core catheter-related bloodstream infections in
Facilitating Proper Insertion Practices*. the ICU. NEJM 2006;355:2725-32. Trick WE,
“Bundling” all needed supplies in one area Vernon MO, Welbel SF, et al. Unnecessary
(e.g., a cart or a kit) helps ensure items use of central venous catheters: the need
are available for use Use of a “checklist” to look outside the intensive care unit.
to ensure all insertion practices are Infect Control Hospital Epidemiol 2004;
followed may be beneficial Empowering 25:266-8.
staff to stop a non-emergent CL insertion 42References. Trick WE, Miranda J, Evans
if proper procedures are not followed AT, et al. Prospective cohort study of
Promoting safety culture. * Not part of central venous catheters among internal
2002 HICPAC Guidelines for the Prevention medicine ward patients. Am J Infect
of Intravascular Catheter-Related Control 2006;34:636-41.
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