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