FOCUS ON INFECTION PREVENTION Central-Line-Associated Bloodstream Infection: Comprehensive, Data-Driven Prevention INTRODUCTION James Davis, BSN, RN, CCRN, CIC Central venous catheters (CVC) provide necessary access to the bloodstream; how- Senior Infection Prevention Analyst ever, their use places patients at risk for central-line-associated bloodstream infection Pennsylvania Patient Safety Authority (CLABSI).1 The two phases, insertion and maintenance, of CVC life and associated CLABSI prevention strategies may challenge infection preventionists when assigning resources to the CVC phase that is causing suboptimal CLABSI rates. A survey of Society of Healthcare Epidemiology of America (SHEA) members found that hospital ABSTRACT epidemiology and infection control departments experienced an increase in responsi- bilities and scope, while in many instances resources were below levels recommended Central venous catheters provide nec- by expert panels in the peer-reviewed literature.2 Designing systems for preventing essary vascular access; however, their CLABSI and auditing compliance with best practices can be daunting without appro- use places patients at risk for infection. priate resources. Data interpretation can help in the design of effective CLABSI Central-line-associated bloodstream prevention programs and prove to be an ally when resources are not available, are not infection occurs when there are lapses in allocated appropriately, or are underutilized. Pennsylvania Patient Safety Authority ana- care in insertion and maintenance. It is lysts have captured data that may help determine whether an institution should focus essential that a comprehensive infection resources on a specific phase of CVC life to prevent CLABSI. prevention program be data driven. Dur- ing calendar year 2010, of Pennsylvania BACKGROUND acute care facilities that had submitted central venous catheter insertion dates to There are two types of CVC: short-term and long-term. Short-term catheters are com- the National Healthcare Safety Network, monly used in acute care or emergent settings and dwell for 10 days or less. Long-term 71.7% reported that central-line-asso- catheters typically remain in place for more than 10 days.3 Long-term catheters usually ciated bloodstream infections occurred contain implanted cuffs and include devices like ports, making them more complex more than five days after insertion. than short-term catheters. Peripherally inserted central catheters (PICCs) have tradition- Biofilm formation in the internal lumen ally been considered long-term devices but are becoming more prevalent in acute care and subsequent late onset of bactere- settings. Data collected from outpatient and inpatient studies suggests that the risk for mia (after five days) may signify failure infection associated with PICC use is similar to that for cuffed or tunneled catheter use.3 in central line maintenance practices. The common risk factor for infection among CVC types is catheter dwell time; the Pennsylvania’s data suggests that health- longer the dwell time and the greater the use, the higher the risk for infection. Mermel care facilities need to focus greater and Maki analyzed the pooled data from four prospective studies that noted the out- attention on catheter maintenance, in comes of 988 Swan-Ganz catheters and concluded that Swan-Ganz catheters, because addition to complying with best practices of infection risk, should be short-term lines, used for no longer than four days except during insertion. (Pa Patient Saf Advis in extenuating circumstances.4 2011 Sep;8[3]:100-4.) Microbes can be introduced into the patient from the patient’s skin, the environment, or healthcare workers’ hands during initial CVC insertion or at any point during use of the CVC. Introduction of organisms into or onto the CVC can precipitate biofilm formation. Microbial biofilm develops when microorganisms irreversibly adhere to and form a structural matrix on a surface.5 CVC surfaces are at risk for biofilm formation wherever they are in a resource-sustainable environment. CVC surfaces come in con- tact with such an environment when the patient’s blood contacts the exterior surface (extraluminal) or the interior channel (intraluminal) of the catheter that is used to administer fluids, medications, blood, or other intravascular therapies. Bloodstream infections related to long-term CVC use are almost always a result of intraluminal biofilm development.6,7 Examining how, when, and where biofilm forms can provide Scan this code insight into CLABSI prevention strategies at both phases of CVC life. with your mobile device’s QR Reader CLABSI PREVENTION: INSERTION AND MAINTENANCE to access the Authority's CLABSI CLABSI may occur as a result of lapses in care in insertion or maintenance; therefore prevention toolkit. infection prevention strategies focus on these areas. Lapses in care surrounding inser- tion happen over a short period, from seconds to hours, setting up an environment Page 100 Pennsylvania Patient Safety Advisory Vol. 8, No. 3—September 2011 ©2011 Pennsylvania Patient Safety Authority for inoculation with bacteria and the Maintenance inadequate monitoring, all of which con- potential for conditions that aid extralu- Insertion is a quick procedure performed tributed to development of CLABSI. 13 minal biofilm formation.5 Opportunities by a small group of providers that must “There are many procedures, many steps, for failure in the maintenance phase adhere to a proven set of best practices. and many personnel that are involved in are numerous and have days to months Maintenance of the line occurs over many the placement, care and maintenance of to precipitate intraluminal-sourced hours to months and involves a host of central venous catheters,”14 said Neil CLABSI.6,7 For example, in the pediatric individuals (e.g., nurses, physicians, care- Fishman, MD, past president of SHEA. population, McKee alludes to mainte- givers, patients, and families), all of whom How healthcare providers interact with nance failures by stating that improving have a hand in causing or preventing the the CVC has direct impact on care failures practices for central line insertion leads development of CLABSI. Practices that experienced by the patient. For example if to a reduction in CLABSI, but not its limit the introduction of organisms into a caregiver does not thoroughly disinfect elimination.8 If proper insertion is the the CVC have been a focus of CLABSI the hub and needleless connector of a foundation of a strong CLABSI preven- prevention, specifically when the catheter CVC with an antiseptic, organisms could tion program, then solid maintenance is accessed by the healthcare professional. be injected into the CVC and precipitate practices are essential to protect patients Failure to disinfect hubs and caps, for the formation of biofilm.15 Ryder notes from infection. example, can lead to the development that the internal lumen can be the pri- of intraluminal biofilm, which may mary source of bacteremia in short-term Insertion lead to infection. Microbial biofilms on catheters as early as day 5 postinsertion.6 The intensive care unit (ICU) project the intraluminal surface originate from Causal or preventative opportunities begin of the Michigan Health and Hospital microorganisms transported through the minute the decision is made to place a Association (MHA) Keystone Center for contaminated injection ports, needle- central line in a patient. Patient Safety and Quality, funded by less connectors, stopcocks, and catheter the Agency for Healthcare Research and hubs.11 The CVC hub, needleless cap, METHODS Quality (AHRQ), was able to achieve and intraluminal surfaces of CVCs are a potential source of CLABSI.7 Safdar and Using fields readily available in the NHSN impressive results with relatively simple Maki report that after changing CVC data analytics function tab, Authority interventions. The interventions included insertion protocols in an ICU to chlorhex- analysts queried the Centers for Disease the use of an insertion checklist, hand idine (CHG) skin antisepsis and a CHG Control and Prevention (CDC) National hygiene, chlorhexidine for skin prepara- dressing, CLABSI shifted from extralu- Healthcare Safety Network (NHSN) tion, appropriate site selection, maximal minal sources to intraluminal sources.12 database to determine the date of barriers, daily review of line necessity, Extraluminal contamination can be infection event from the documented date and a maintenance protocol. During the minimized if staff performs adequate skin of insertion for CVCs in Pennsylvania’s project, participants were able to maintain antisepsis and applies an occlusive dress- acute care facilities from January through very low infection rates for extended peri- ing including a CHG delivery method December 2010, as of March 22, 2011. ods.9 Many CLABSI prevention programs (sponge or other product). Date of CVC insertion and date of have been modeled after this study, using infection event were the two fields chosen the insertion protocol, insertion check- Maintenance of the CVC is essential for to isolate data related to the determination list, and daily goal sheets. These selected building a program that is resistant to the of early- versus late-onset CLABSI. It interventions are relatively inexpensive late development of CLABSI. Opportuni- is important to note that the date of and simple to implement, but they focus ties for intraluminal contamination are insertion field in the NHSN reporting on CVC insertion. Many regulatory bod- more frequent after the line is in use. system is not a mandatory field. Analysts ies now require compliance with these During a root-cause analysis conducted to excluded events when insertion-to-event practices, heavily weighting the insertion identify sources of CLABSI in Canadian times were less than one day. Analysts phase of CVC care. Since January 2010, pediatric ICUs, investigators found several also excluded events with blank fields, the Joint Commission has required hos- causal factors, including positive pressure missing data, or dates in reverse order. pitals to use a standardized supply kit or needleless caps on PICC s and an exces- The final sample size included 653 events. cart, a catheter checklist, and a standard sive number of ports on infusion systems. Authority analysts have chosen a cut point protocol for insertion.10 These inser- In addition, they noticed inconsistent after day 5 that would most likely indicate tion requirements are the foundation of practice, line necessity based on limited intraluminal biofilm formation caused by CLABSI prevention but do not constitute alternatives for intravenous access, and maintenance failures.6 a complete prevention program. Vol. 8, No. 3—September 2011 Pennsylvania Patient Safety Advisory Page 101 ©2011 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION Figure 1. Time Distribution of CLABSI: Pennsylvania NHSN Facilities 2010 60 54 50 Only infections within two months of insertion are 43 42 displayed, representing 98% of the population NUMBER OF INFECTIONS 40 39 40 38 33 Mode Median Mean Count 35 30 28 22 20 24 24 17 17 12 14 12 11 10 8 10 11 11 11 56 6 4 5 7 7 2 3 3 4 3 3 2 2 2 MS11366 2 3 1 1 0 1 1 2 1 0 1 1 1 1 0 1 0 0 0 1 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 DAYS FROM INSERTION TO INFECTION RESULTS versus extraluminal biofilm formation, note the importance of an infrastructure According to Authority analysis of 2010 can help allocate resources that focus on used to monitor CLABSI rates and the use event reports, the majority of CLABSIs corrective actions. Data-driven decisions, of a staff of hospital-based infection pre- occurring in Pennsylvania acute care data-based interventions, and corrective ventionists for this study. They note that facilities have been late in onset: of actions can be directed at the specific time similar infrastructure does not exist for the 653 central-line-related infection at which CLABSI develops. Utilizing time- most other issues related to patient safety.9 events reported to NHSN in 2010 by to-infection data will have a significant Despite the possibility of infrastructure Pennsylvania facilities, 468 (71.7%) effect on a facility’s CLABSI prevention differences, each facility in Pennsylvania occurred after day five (see Figure 1). program, especially if resources are scarce. can use its own data and determine which Pennsylvania facilities may need to direct If there are more breaches in compliance way it believes the scale is tipped. If the their resources toward maintaining CVCs. with insertion practices, the incidence of majority of infections occur before or on infection will increase early in the life of day 5, insertion bundle compliance may Figure 2 represents 104 Pennsylvania the CVC. If infections are occurring later be worth auditing more closely; conversely, facilities that reported data for both in the life of the CVC, breeches in the if the majority of infections occur after five CLABSI and time of CVC insertion in care and maintenance of CVCs may be days postinsertion, perhaps care and main- 2010. Individual facilities were listed implicated. tenance practices should be monitored. based on total number of infections, then When a facility knows where to allocate numbered and deidentified. This distribu- The MHA project allocated significant resources and funds to a CLABSI preven- resources, infection prevention measures tion of infection implicates maintenance can be implemented to effectively reduce as the phase in which CLABSI most likely tion infrastructure (AHRQ financially supported the majority of the project). In infection rates. is developed. addition to the recommended evidence- The following links from CDC provide DISCUSSION based procedures for CVC insertion and information on isolating facility-specific daily goal sheets, the MHA study imple- data from NHSN for analysis: Data points for catheter dwell time to mented a comprehensive program that infection event, combined with published — Quick Tips: Run and Modify Output addressed a culture of safety in the units http://www.cdc.gov/nhsn/PDFs/ time lines on pathogenesis of intraluminal where data was collected. Pronovost et al. AnalysisBasics.pdf Page 102 Pennsylvania Patient Safety Advisory Vol. 8, No. 3—September 2011 ©2011 Pennsylvania Patient Safety Authority Figure 2. Time to CLABSI as Reported by Pennsylvania NHSN Facilities in 2010: Insertion versus Maintenance 40 Majority of infections during maintenance phase (after 5 days) DURING MAINTENANCE PHASE 30 Majority of infections during insertion phase (5 days or less) NUMBER OF INFECTIONS Nonmajority number of infections 20 10 DURING INSERTION PHASE 0 NUMBER OF INFECTIONS 10 MS11367 20 FACILITIES (in order of most infections to least) — NHSN Analysis: Advanced prevention toolkit, available at http:// invested a great deal of effort uploading Features & Terminology patientsafetyauthority.org/ infection-related event data. All infec- http://www.cdc.gov/nhsn/ EducationalTools/PatientSafetyTools/ tion types can benefit from like analysis wc_Analysis_Advan_Features.html clabsi/Pages/home.aspx. and interpretation. Event reporting is — NHSN Analysis: Advanced mandatory, and reported data is a pow- Features & Terminology: Training CONCLUSION erful assessment tool that needs to be Session for NHSN Hospitals, continually used by facility-level infection The CLABSI data presented here by December 19, 2006 preventionists and all disciplines for Authority analysts is a glimpse into the http://www.cdc.gov/nhsn/ the safety of Pennsylvania patients. The meaningful use of event data collected by PDFs/slides/NHSN_ effectiveness of intervention and applied dedicated Pennsylvania infection preven- trainingDec19PAandMAAnalysis.pdf resources is compelling. Pennsylvania’s tionists and others. Given the available To help Pennsylvania facilities assess their data suggests that healthcare facilities sample size, the Authority believes that overall CLABSI prevention programs, need to focus greater attention on cathe- facilities are putting time-to-infection the Authority maintains a CLABSI ter maintenance, in addition to complying data to use. Infection preventionists have with best practices during insertion. Vol. 8, No. 3—September 2011 Pennsylvania Patient Safety Advisory Page 103 ©2011 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION NOTES 1. O’Grany NP, Alexander M, Burns LA, 6. Ryder M, Gunther RA, Breznock EM, 11. Ryder M. Improve CRBSI prevention: et al. Guidelines for the prevention of et al. The effect of chlorhexidine anti- target intraluminal risks [website]. [cited intravascular catheter-related infections, microbial coating on the reduction of 2011 Jul 21]. Available from Internet: 2011 [online]. 2011 Jun [cited 2011 Jun 6]. intraluminal biofilm formation in a clini- http://www.executivehm.com/article/ Available from Internet: http://www. cally simulated ovine model (pilot study). Improve-CRBSI-Prevention-Target- cdc.gov/hicpac/pdf/guidelines/ Abstract at: SHEA 2011 Annual Scientific Intraluminal-Risks. bsi-guidelines-2011.pdf. Meeting; 2011 April. 12. Safdar N, Maki DG. The pathogenesis 2. Wright SB, Ostrowsky B, Fishman N, 7. Ryder MA. Catheter-related infections: of catheter-related bloodstream infec- et al. Expanding roles of healthcare it’s all about biofilm [online]. Top Adv tion with noncuffed short-term central epidemiology and infection control in Nurs 2005 Aug 18 [cited 2011 Mar 23]. venous catheters. Intensive Care Med 2004 spite of limited resources and compensa- Available from Internet: http://www. Jan;30(1)62-7. tion. Infect Control Hosp Epidemiol 2010 medscape.com/viewarticle/508109. 13. Northway T, Mawdsley C. The Canadian Feb;31(2):127-32. 8. McKee C, Berkowitz I, Cosgrove SE, et al. ICU collaborative: sustaining the gains: a 3. Crnich CJ, Maki DG. The promise of Reduction of catheter-associated blood- lesson in humility. Dynamics 2009 Fall; novel technology for the prevention of stream infections in pediatric patients: 20(3):23-7. intravascular device-related bloodstream experimentation and reality. Pediatr Crit 14. Harutyunyan R. Drawing road map for infection. II. Long-term devices. Clin Infect Care Med 2008 Jan;9(1):40-6. CLABSI elimination [online]. Emax- Dis 2002 May 15;34(10):1362-8. 9. Pronovost P, Needham D, Berenholtz S, Health 2009 Mar 21 [cited 2011 Mar 31]. 4. Mermal LA, Maki DG. Infectious compli- et al. An intervention to decrease Available from Internet: http://www. cations of Swan-Ganz pulmonary artery catheter-related bloodstream infections emaxhealth.com/2/39/30023/drawing- catheters. Pathogenesis, epidemiology, in the ICU. N Engl J Med 2006 Dec road-map-clabsi-elimination.html. prevention, and management. Am J Respir 28;355(26):2725-32 15. Ryder M, Schaudinn C, Gorur A. Crit Care Med 1994 Apr;149(4 Pt 1): 10. Joint Commission. National Patient Microscopic evaluation of microbial 1020-36. Safety Goals [2008 Goal 7:07.04.01 colonization on needleless connectors. 5. Donlan RM. Biofilms and device-asso- online]. [cited 2011 Mar 30]. Abstract at: APIC 2008 Annual ciated infections. Emerg Infect Dis 2001 Available from Internet: http:// Meeting; 2008. Mar-Apr;7(2): 277-81. jointcommission-lms.org/ 1900_00_HAI_NPSG_7/player.html. Page 104 Pennsylvania Patient Safety Advisory Vol. 8, No. 3—September 2011 ©2011 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 8, No. 3—September 2011. 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