As a newly appointed Intensive Care Specialist, you are put in charge of Safety and Quality in your ICU. The infection control department informs you that your ICU has a higher than acceptable rate of central line associated blood stream infections (CLABSI).

Define CLABSI rate.    (10% marks)

Outline your approach to this problem in terms of initial investigation and ongoing management and monitoring.     (90% marks)

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College answer

a) CLABSI rate = confirmed blood stream infections / central line days x 1000

i.e. Number of confirmed blood stream infections per 1000 central line days
CLABSI count and central line days defined by Australian Commission on Safety and Quality in Health Care

b) The ANZICS CORE CLABSI Registry provides a national reporting and benchmarking system

Investigation 

  • Review data/audit to ensure counts are correct and that data quality issues are not responsible for a false estimation
  • Review the cases of confirmed blood stream infection and ensure no false positives or negatives
  • Review method of counting line days as missed days will result in artificially high rate
  • Involve relevant stakeholders – nurses, infection control, ICU medical staff – and form working party
  • Compare with historical CLABSI data for the unit – is this a spike or has it always been a problem
  • Benchmark rate against published targets or benchmarked targets referenced against peer hospitals. Generally reported as number of infections per 1000 line days with expectation of rate <1/1000
  • Ideally benchmark based on contemporary registry based data (ANZICS CORE CLABSI Registry) with risk adjustment although no risk adjustment exists within current reporting

Management

If increased rate confirmed investigate potential causes of high rate.

Implementation of specific strategies based on best available evidence and ideally as part of an established wider program.

Specifically:

  • Staff training and use of correct aseptic technique (ANZICS Central Line Insertion and Maintenance Guideline)
  • Insertion site selection
  • Use of insertion bundle or checklist
  • Consideration of limiting insertion to fewer more experienced operators (insertion team) with accreditation process
  • Documentation of daily review of line
  • Removal of all lines at earliest feasible time
  • Specific evidence for
    • Use of antimicrobial impregnated lines and biopatches
    • Use of Chlorhexidine plus alcohol as disinfectant
  • Consider alternatives to conventional CVC when possible e.g. PICC lines and tunneled lines

Ongoing monitoring

Audits of process such as observation of aseptic technique. Ongoing monitoring of rates over time with review based on appropriate statistical process control to distinguish special cause from common cause variation. That is essentially to ensure that any change is statistically significant. For example:

  • Funnel plots
  • EWMA charts – exponentially moving weighted average
  • CUSUM charts – cumulative sum control

Implementation and monitoring may require additional resources to be provided by administration (equipment, staff etc.)

Submission of data to ANZICS CORE CLABSI Registry

Regular reporting back to staff and hospital S&Q / infection control committee

Additional Examiners’ Comments:

This was poorly answered overall; only a minority of candidates could correctly define CLABSI rate. Most candidates produced standard proforma answers that ignored specifics and could have been referring to any QI issue.

Discussion

This question could just as easily have fit into the "infectious diseases" section, but the focus is on departmental policymaking rather than anything directly clinical. It was therefore shoved into the administrative group of SAQs. Judging by the pass rate of 52.5%, a standard proforma answer could still score highly enough to scrape under the barrier. 

Oh's Manual has a section on "line sepsis" (page 730 of the 7th edition) nested within Rishi and Dhillon's "Nosocomial Infections" chapter. Though brief, the section contains several important definitions worth knowing. Among these is this definition of CLABSI as "Isolation of the same organism from the catheter segment as from a peripheral blood culture in a patient with signs of infection and in the absence of another source." Unfortunately, no CLABSI rate definition is given.  This is another example of the Manual not being enough even for a 10% answer.

The CLABSI rate definition quoted by the college (which "only a minority of candidates could correctly define") comes from the ACSQHC, specifically from this 2015 document

The rest of the answer would have to take the shape of a routine "implement a policy" SAQ. Much of the actual policy can be extracted from the ANZICS statement on prevention of central line associated infections. The rest is a pile of corporatese garbage.

Initial investigation:

  • Create a multidisciplinary committee, involving the Infection Control department. The savvy candidate will use such key words as "relevant stakeholders" and "working party" to tickle the examiners in just the right places.
  • Define the problem and track it retrospectively, so it might be associated with specific events (eg. annual recruitment of new staff, etc)
  • Review the data collection methods for errors
  • Explore existing CLABSI control measures and barriers to their implementation
  • Explore the evidence for CLABSI control measures
  • Combine the best evidence into an updated policy document

Management of CLABSI risk

  • Explore the evidence for CLABSI control measures
  • Combine the best evidence into an updated policy document, detailing practices associated with a decreased risk of CVC infection:
    • Use of subclavian lines.
    • Minimum number of lumens.
    • Use of dedicated lumens for lipid infusions.
    • Immunosuppressed patients or those with burns should have antibiotic-coated lines.
    • For insertion, use aseptic technique and maximal barrier precautions.
    • 0.5% chlorhexidine in 70% alcohol is the preferred cleaning agent.
    • Handle ends of administration sets with gauze soaked in chlorhexidine.
    • Review the line daily.
    • Remove the line as soon as possible.
    • Change lines early - ideally, every 7 days.
    • Sterile, transparent semipermeable dressings
    • Change dressings regularly (every 7 days for standard dressings)
    • Avoid/minimise CVCs if possible
    • Accredit staff in the use of safe technique (if word gets around that your ICU limits CVC insertion experience to some sort of elite "insertion team", your recruitment of junior staff will suffer)
  • Implement these practices: circulate the document widely, and hold meetings to discuss it with key staff
  • Appoint champions who ensure adherence to these practices
  • Assign specific timeframes over which the practice is to be audited

Monitoring

  • Repeated data analysis and collection should be carried out after the guidelines are disseminated and implemented.
  • Guideline dissemination efficacy, uptake and adherence by practitioners, consumer satisfaction and health outcomes are possible data to be collected for audit.
  • Auditors are nominated from departments to implement this policy monitoring processes
  • The auditing team creates short-term and long-term frameworks for evaluation and identifies who will conduct the studies.
  • Regular meetings are scheduled by the auditors to monitor compliance and to feed back on the implementation process

Revision

  • A multidisciplinary group not unlike the one which developed the guidelines should meet regularly to determine whether new evidence needs to be incorporated.
  • The group should review research strategies of the original group, and improve on the process where possible
  • Outcomes and recommendations arising from audit activity should be incorporated into the revision process

References

Marschall, Jonas, et al. "Strategies to prevent central line–associated bloodstream infections in acute care hospitals: 2014 update." Strategies 35.7 (2014): 753-771.

ANZICS statement on prevention of central line associated infections

ANZICS statement on insertion and maintenance of CVCs

LIFL have made as short a summary as one can manage without omitting vital facets of the overall strategy.

Maki, Dennis G., Daniel M. Kluger, and Christopher J. Crnich. "The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies." Mayo Clinic Proceedings. Vol. 81. No. 9. Elsevier, 2006.

Australian Commission on Safety and Quality in Health Care; Wilkinson, et al "Implementation Guide for Surveillance of Central Line Associated Bloodstream Infection", 2015

Moulding, Nicole Therese, C. A. Silagy, and D. P. Weller. "A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines." Quality in Health Care 8.3 (1999): 177-183.

Schünemann, Holger J., Atle Fretheim, and Andrew D. Oxman. "Improving the use of research evidence in guideline development: 1. Guidelines for guidelines." Health Research Policy and Systems 4.1 (2006): 1.

Silagy, C., et al. "A guide to the development, implementation and evaluation of clinical practice guidelines." National Health and Medical Research Council, Canberra, Commonwealth of Australia (1998): 1-79.