CLABSI

Tony Burrell

Healthcare associated infections

• 2009 – 175,153 estimated HAIs (5% admissions) cost Australian healthcare system 850,000 lost bed days

• Increasing concerns about HAIs with emphasis on:o MROs and Antimicrobial Stewardship (AMS)o Hand Hygiene

• Vascular access devices common cause• CLABSI

o Attributable mortality – 12-25%o Significant increase in ICU LOSo Largely preventable

ANZICS/ACSQHC initiative

• Acknowledges work in various states and individual ICUs• Aims to develop standardised approach nationally• Consistent surveillance definition and national database

using ANZICS CORE• Partnership between ANZICS and ACSQHC

Evidence

CLAB is preventable• Good evidence base going back 15 years

• Raad II, Hohn DC, Gilbreath BJ et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiology. 1994; 15:231-8

• Eggimann P Prevention of intravascular catheter infection. Curr Opin Infect Dis 2007; 20:360-369

• Berenholtz et al 2004. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 32 (10) 2014-2020.

• Quality not research

Major Collaboratives

• CLABSI rate was reduced to:• 1.36/1000 line days over a 4 year period in 69 ICUs in South Western

Pennsylvania CDC MMWR reported in JAMA 2006; 269-270

• 1.44/1000 line days in 46 ICUs in New York State Koll BS, Straub TA, Jalon HS et al Jt Comm J Qual Patient Saf 2008; 34:713-723

• 1.7/1000 line days in 9 VA Hospitals, Midwest, US Bonello RS, Fletcher CE, Becker WK et al. Jt Comm J Qual Patient Saf 2008; 34:639-645

• 1.4/1000 (mean) line days in 103 ICUs in Michigan Pronovost et al NEJM 2006

• 0.6/1000 line days (down from 1.5/1000) in 20 ICUs in Hawaii Lin DM et al Am J Med Qual 2011 epub

• ‘Matching Michigan’

NSW CLAB-ICU

• ‘Top down/bottom up’ project – NSW Intensive Care Coordination & Monitoring Unit and Clinical Excellence Commission

• 38 ICUs• Methodology modelled on the work of Pronovost et al.• The project promoted a standardised insertion technique

including: Hand washing Full barrier precautions during insertion Cleaning skin with chlorhexidine Avoiding femoral site if possible Removing unnecessary catheters

Burrell et al MJA 2011

Method

• Central Line Insertion Guidelines developed• Emphasis on aseptic technique• Insertion checklist• Data management established

– Completed checklist faxed to CEC – Teleform methodology

• Central Line Insertion Pack developed• ICCMU Nursing management guideline

Checklist detail

Checklist Compliance –– 10,890 line insertions July 07 – Dec 08

Competency assessed 48.3%

Hat, mask, eyewear 79.9%

Hands washed 2 mins 91.6%

Sterile gown/gloves 95.9%

Alcoholic chlorhexidine prep allowed to dry 95.8%

Entire patient draped 93.4%

Sterile technique maintained 95.6%

No multiple passes 80.9%

Confirm position radiologically 74.3%

Other method to confirm placement 43.6%

For further analysis data from checklist divided into:

• ‘Clinician bundle’– Undertake competency assessment– Clean hands– Sterile gloves/gown– Hat, mask, protective eyewear

• ‘Patient bundle’ – Prep with 2% chlorhexidine & dry 2 mins– Large sterile drape– Maintain sterile technique– No multiple passes– Confirm catheter position

0

10

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100

Jul-Sep 07 Oct-Dec 07 Jan-Mar 08 Apr-Jun 08 Jul-Sep 08 Oct-Dec 08

Clinician bundle complianceClinician bundle compliance excluding routine non-hat wearersPatient bundle complianceTotal

Results

Culture• Apathy

– ‘We don’t have CLABS’– Infection control reporting independently

• Impact of clinical leadership and support readily apparent and vice versa• ‘I don’t believe the evidence’

– Mistake promoting one high profile study – 4 ICUs refused to wear hats – Why fully drape the patient?– Excuse for not changing

• Data collection/reporting requirements – ‘Where’s the money? – excuse for not engaging in project, other ICUs used checklist but didn’t follow up lines or submit data

HATS!!!

• ‘As in OT’ argument didn’t work• Not a lot in literature but found:

– Hair reservoir for organisms in proportion to length, oiliness & curliness– Clinicians acquire transient flora in hair

– Fletcher et al J Bone & Joint Surg 2007– Owers et al J Hosp Inf 2004– Nicolay Int J Surg 2006

• Studies linking hair to surgical site infection:– Mastro et al New Engl J Med 1990– Dineen, Drusin Lancet 1973– Summers et al J Clin Path 1965

• Studies linking max sterile barrier precautions to CLAB less clear:– Raad et al Inf Control & Hosp Epid 1994– Carrer et al Minerva Anesth 2005

Marghie Murgo, Eda Calabria CEC

Impact of compliance

• Non compliance with the ‘clinician bundle’: – relative risk of CLABSI was RR 1.62 (95% CI 1.1-2.4, p=0.0178)– For central lines RR 1.99 (95% CI 1.2-3.2 , p=0.0037)– For PICC RR 5.08 (95% CI 1.03-25 , p=0.059)– Dialysis catheters – no difference

• If compliant with both ‘clinician bundle’ and ‘patient bundle’ then risk of CLAB was RR 0.6 (95%CI 0.4-0.9, p=0.0103)

Survival analysis

• In non-referral ICUs lowest probability of CLABSI (1 in 100) was at day 3 in first 12 months – this was extended to day 8 in last 6 months

• In referral ICUs the lowest probability of CLABSI was extended from day 7 to day 9

• 75% central lines in place for less than 7 days• ‘Zero-risk’ (<1/1000 line days) is possible

– McLaws, Burrell Crit Care Med 2011 epub Oct

• Many ICUs do not have CLABSIs for months at a time• Other strategies ie BioPatch, coated catheters best reserved for

longterm lines, ICUs where CLABSI is a continuing problem

Improvement multi-factorial

• Increased awareness of need for scrupulously aseptic insertion• Increasing compliance with clinician bundle (if non hat wearers excluded)• Not due to ↓femoral lines or ↓time in situ• Significantly better communication between intensive care & infection

control• Greater understanding of surveillance definition• Increasing ownership by intensive care clinicians following reporting of

individual ICU CLABSI data