This blog is part of an ongoing series focused on introducing the current quality initiatives. This month we are featuring the work being done to improve Central-Line Associated Blood Stream Infections (CLABSIs). Thank you to the Quality Improvement Program (QuIP) team for sharing your important work with us and thank you to our readers for taking the time to learn more about the vital work that goes on to improve care for our patients here within UI Health Care. To learn more about the other initiatives please check out the introduction and previous topics.
—Theresa Brennan, MD
Why do some patients need central lines?
Reliable vascular access is necessary for the safe and effective care of hospitalized patients. Central lines are often necessary for many patients requiring acute or long-term venous access treatments. Central lines have many benefits and are indicated for longer dwell times when compared to peripheral vascular access. When determining appropriate venous access, expert teams use evidence-based practice guidelines to aid in decision making for vascular access devices. Key clinical indications must be considered, which include length of treatment, indication for vascular access, need for vessel preservation, and the nature of the infusate. Although central lines provide many patient benefits, there are also associated risks. Due to these risks, central lines should be removed as soon as the benefits no longer outweigh the risks.
What causes a Central-Line Associated Bloodstream Infection (CLABSI)?
CLABSI is a bloodstream infection where germs enter the blood through a central line. It occurs when the patient’s line becomes contaminated. This can happen at the time the line is being placed and the skin is not adequately cleaned. It can happen when dirty health care worker’s hands (or gloves) contact the line. Or it can occur when medications are being introduced through contaminated lumens.
CLABSI is the most expensive hospital-acquired infection and adds approximately $46,000 per event. Furthermore, it impacts length of stay by 10.4 days, and mortality can be high, with approximately 1 in 4 patients (23.8%) dying as compared to similar patients without a CLABSI. CLABSIs occur less frequently than they used to but nationwide, they still impact 41,000 patients annually.
How do we prevent CLABSIs?
At the most basic level, CLABSIs are prevented by ensuring correct and sterile insertion of a central line, proper care of the line, and prompt removal when no longer needed. Accessing and maintaining the line requires health care workers to interact with the device, dressings, and patient’s skin around the line, and each interaction comes with some risk of infection. Reducing the amount of time that a patient has a central line decreases the risk of contamination. All members of the care team have a role in maintaining sterility of the device and site and in reducing the amount of time a patient has a line inserted.
Foundational practices by care team members actively caring for a patient’s central line make a significant difference in keeping the device and site clean. Implementing effective hand hygiene and following best practices for insertion, removal, dressing changes, and blood culture collection are important in preventing contamination. Further, bathing with chlorhexidine gluconate soap keeps the bacterial load on a patient’s skin to a minimum.
Members of the patient’s care team who do not directly interact with their central lines also have a role in preventing CLABSIs. For example, when a patient is admitted with a previously placed central line, documenting the insertion date enables accurate calculation of line days. Epic reporting can then display this timeframe, prompting the care team to review whether that line is still needed. Additionally, when a patient’s environment is contaminated, it is more likely that the contamination will spread to their central line. This is most notable in pediatric patients who are smaller and more active. Further, if a patient is experiencing signs of a CLABSI, timely, properly obtained cultures will allow clinical and epidemiology experts to identify the bacteria and better understand the circumstances to improve in the future.
CLABSI reduction initiative
In December 2020, an interprofessional CLABSI committee was formed to reduce CLABSIs across adult and pediatric units within UI Health Care. Currently co-chaired by Karen Brust, MD, hospital epidemiologist, and John Swenning, BSN, RN, MBA, CENP, director of ISS Nursing, this initiative team monitors CLABSI trends in our institution, investigates changes needed to align with best practices, and implements proven CLABSI reduction strategies.
Upon review of UI Hospitals & Clinics CLABSI trends, a significant number of CLABSIs were found to be associated with peripherally inserted central catheters (PICCs). After researching evidence-based recommendations, the team pilot and implement chlorhexidine-coated PICCs for all eligible adult patients. Chlorhexidine is an antimicrobial that provides another layer of protection in preventing line contamination. During the trial period, more than 550 coated PICCs were placed in eligible adult patients. This trial included extensive data tracking, educational content development, and policy expansion. Combined with basic infection prevention bundle elements, the introduction of chlorhexidine-coated PICCs has significantly decreased PICC CLABSIs. In patients who are not immunocompromised, only one patient in the trial developed a CLABSI from September 2021 to February 2022. Comparatively, the institution averaged three adult CLABSIs per month prior to this trial. With organizational recognition of trial success, the team has begun a similar process to implement chlorhexidine-coated central venous catheters (CVCs).
Another identified opportunity to reduce CLABSIs, was to improve compliance with scheduled central line care and maintenance bundle elements. This includes routine dressing changes, tubing changes, and needleless access device changes. A small workgroup was tasked to build a dashboard that gives frontline staff and unit leadership real-time information about patients with central lines that require those bundle elements to be completed. With quick access to this information, they are in the best position to call out missed bundle elements and concerns during rounding. “Nurse-first” rounding is being used in many areas, and this workbench report will be an asset to all participants.
The central line dashboard will be rolled out in the coming weeks starting with units that have the highest utilization of central lines and then continuing to remaining areas. Look for more information regarding house-wide implementation by the end of this fiscal year.
Everyone can help prevent CLABSIs by focusing on proper insertion, appropriate care and maintenance of central lines, and early removal.
-Kathryn Trautman, MSN, RN, CMSRN, Nursing Practice Leader, Adult Vascular Access
-Mary Beth Hovda Davis, MSN, RN, VA-BC, Nursing Practice Leader, Pediatric Vascular Access
-Karen Brust, MD, Hospital Epidemiologist
-Jill Furgason, MPH, PMP, CPHQ, Sr. Project Manager
-Dominica Rehbein, MHA, MPH, PMP, Sr. Project Manager