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)
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
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
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.
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.
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
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
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:
Management of CLABSI risk
The Australian Commission on Safety and Quality in Health Care report on CLABSI, mentioned in Question 6 from the second paper of 2019
Marschall, Jonas, et al. "Strategies to prevent central line–associated bloodstream infections in acute care hospitals: 2014 update." Strategies 35.7 (2014): 753-771.
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.