On the CUSP: STOP BSI
Using the Centers for Disease Control and Prevention’s National
Healthcare Safety Network (NHSN) for CLABSI Surveillance in Adult ICUs
© 2009
Learning Objectives
• To review the NHSN definition of a central line
• To review the NHSN definition of bloodstream
infection (BSI)
• To review the NHSN denominator definition for
calculating CLABSI rates in adult ICUs
© 2009
What is a Central Line?
• An intravascular catheter that terminates at or
close to the heart or in one of the great vessels
which is used for infusion, withdrawal of blood, or
hemodynamic monitoring.
– Great vessel: aorta, pulmonary artery, superior vena
cava, inferior vena cava, brachiocephalic veins,
internal jugular veins, subclavian veins, external iliac
veins, and common femoral veins
– Infusion: introduction of a solution through a blood
vessel via a catheter lumen
• The location of the insertion site and type of
device are NOT relevant
© 2009
What is a Central Line?
The following are examples of
central lines, as long as they
terminate at or close to the heart
or in one of the great vessels
NOTE: This list is not inclusive
The following are examples of
devices that are not central lines
NOTE: This list is not inclusive
Non-tunneled central lines
Tunneled central lines
Introducers
Implanted ports
Hemodialysis catheters
Peripherally inserted
central catheters (PICCs)
• Femoral artery catheter
• Pacemakers
• Implanted cardiac
defibrillators
• Radial, dorsalis pedis,
brachialis, ulnar arterial
lines
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•
•
•
•
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© 2009
Data That Need to Be Collected
• For determining CLABSI rate
– Numerator: number of CLABSIs
– Denominator: number of central line-days
– Expressed as a rate of X CLABSI/1,000 central line days
• #CLABSI/# central line days X 1000
• For determining the Central Line Utilization Ratio
– Numerator: number of central line-days
– Denominator: number of patient-days
© 2009
The Numerator
© 2009
Definition of BSI in Adults
Criterion 1:
• Patient has a recognized pathogen cultured from one or
more blood cultures
AND
• Organism cultured from blood is not related to an infection
at another site.
© 2009
Definition of BSI in Adults
Criterion 2:
• Patient has at least one of the following signs or symptoms:
fever (>38oC), chills, or hypotension
AND
• Signs and symptoms and positive laboratory results not related
to an infection at another site
AND
• Common skin contaminant is cultured from two or more blood
cultures drawn on separate occasions.
– Blood from ≥ 2 blood draws collected within 2 days
© 2009
Microbiology
Examples of Common
Recognized Pathogens
(not inclusive)
•
•
•
•
•
•
•
•
•
•
Examples of Common
Skin Contaminants
(not inclusive)
• Diphtheroids:
Corynebacterium spp.
• Bacillus spp.
S. aureus
Enterococcus spp.
E. coli
Pseudomonas spp.
Klebsiella spp.
Enterobacter spp.
Citrobacter spp.
Serratia marcescens
Acinetobacter spp.
Candida spp.
– Not B. anthracis
• Propionibacterium spp.
• Coagulase-negative
staphylococci
– Including S. epidermidis
• Viridans group
streptococci
• Aerococcus spp.
• Micrococcus spp.
© 2009
When Are Organisms
the Same?
• If isolates are identified to the species level in one
culture, and with only a descriptive name (i.e., to
the genus level) from the other culture
• If isolates are speciated but no antibiograms are
done or done for only one of the isolates
© 2009
When Are Organisms
Not the Same?
• If isolates have different antibiograms for
two or more antimicrobial agents
– For the purpose of NHSN antibiogram reporting, the
category interpretation of intermediate (I) should NOT be
used to distinguish whether two organisms are different
© 2009
Timing of CLABSI
• Central line-associated BSI
– A central line was in place at the time of onset of the event
OR
– A central line was in place within 48 hours before onset of the
event
• There is no minimum period of time that the central line
must be in place in order for the BSI to be considered
central line-associated
© 2009
Location of Attribution
• The patient care area where the event became
evident
– CLABSIs in patients with central lines placed in noninpatient areas (emergency department, operating
room) are attributed to the inpatient unit
– Transfer Rule: If a CLABSI develops within 48 hours of
transfer from one inpatient location to another in the
same facility, the infection is attributed to the
transferring location
© 2009
Entering Numerator Data
• The Primary Bloodstream Infection (BSI) Form
(CDC 57.108) is used to collect and report each
CLABSI that is identified during the month
• Other data requested
–
–
–
–
Specific criteria met for identifying the primary BSI
Whether the patient died
Causative organisms
Organisms’ antimicrobial susceptibilities.
© 2009
The Denominator
© 2009
Collecting Central Line Days
• For ICUs, the number of patients with one or
more central lines of any type is collected daily,
at the same time each day, and then summed
– The total is reported for the month on the Denominators
for Intensive Care Unit (ICU)/Other Locations (Not NICU
or Specialty Care Area (SCA)) (CDC 57.118).
© 2009
Collecting Central Line Days:
Multiple Lines in an ICU Patient
• If a patient has more than one central line
(permanent or temporary) on a given day,
count the day as only one central line day.
© 2009
Action Items
• Verify that the infection control group in your
institution is collecting CLABSI rates based on the
NHSN definitions for what is a central line and
what is a BSI
• Verify that both catheters days and patient days
are being collected correctly in the ICU(s)
© 2009
References
•
National Healthcare Safety Network (NHSN):
Device-Associated (DA) Module
– www.cdc.gov/nhsn/psc_da.html
© 2009