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).

a)    Define CLABSI rate.    (10% marks)

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

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College answer

CLABSI = 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

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. Review practices of centres with favourable CLABSI rates and compare with local practice.

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/Local Health jurisdiction 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 tunnelled lines.

Ongoing monitoring
Audits of process such as observation of aseptic technique
Ongoing monitoring of rates over time
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

Important Points:
Lists at least one reason for possible inaccuracy of data
Management and monitoring include elements of audit cycle (identification of issue, working party, implementation of change, audit and follow-up data collection, feedback, re-training, ongoing audit etc) Includes importance of technique in CVC insertion and maintenance and use of insertion bundle

Discussion

This question is identical to Question 10 from the first paper of 2017, except this time the pass rate was about 10% higher. Also, the college answer to this question is not entirely identical: some elements were chopped, and others rearranged, by unknown forces and to unknown purpose. These Lovecraftian mysteries aside, the answer below is essentially unchanged from what was used in 2017:

Definitions:

  • Cental line colonisation:
    • The growth of >15 colony-forming units (semiquantitative) or 100 (quantitative) from a proximal or distal catheter segment, in the absence of accompanying clinical symptoms and signs.
  • Central line associated blood stream infection (CLABSI):
    • A laboratory-confirmed bloodstream infection in a patient where the central line was in place for over 48 hours on the date of the event, where the organism cultured from blood is not related to an infection at another site.
  • CLABSI rate
    • CLABSI rate = (Number of CLABSI / number of central line days ) ×1000
    • i.e. CLABSI rate is number of CLABSIs per 1000 central line days

Management approach:

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 stimulate the examiners' central ganglia.
  • 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