Getting to Zero
Strategies to Reduce Central Line Associated
Bloodstream Infections (CLABs)
Brian S. Koll, MD, FACP
Medical Director, Infection Prevention
Chief, Epidemiology
Beth Israel Medical Center, New York, NY
Beth Israel Medical Center
2004
• Petrie Division
• Kings Highway Division
• 94 ICU beds
– 3,000 discharges
• 824 non-ICU beds
– 43,000 discharges
• > 3,000 central lines placed
annually
BIMC
USA
40%
48%
CLABs Rate per
1,000 line days
4.5
5.3
CLABs Rate per
100 patients
2%
4%
Increase LOS
5d
14 d
Patients in ICU with
Central Line
Costs Incurred
Care of Patients with CLABs
Discharges
Per Year
CLAB
Patients
Incremental
Cost Per
CLAB Patient
94 ICU Beds
3,000
24
$40,000
$960,000
824 Non-ICU
Beds
43,000
22
$25,000
$550,000
Total Incremental CLAB Costs
Used BI BSI information and
discharge information from 2004
Annual
Incremental
Costs
$1,510,000
Leadership
• Administrative
• Clinical
• Physician and Nursing
Champions
American Journal of Infection Control
2008;36:232-40
•
•
•
•
•
Everyone
has
the
ability,
permission and responsibility to
“stop the line” to prevent risk to
patients (and staff)
All are empowered to identify and
change (or eliminate)
risky
processes, no matter when, where
or who is involved and always
without fear of retaliation
There
is
participatory
management at every level of the
organization with both top-down
and bottom-up communication
Integrity and trust are woven into
the fabric of the organizational
culture
Everyone is engaged in the
prevention system, and there is
reciprocal responsibility
Inter-disciplinary Team Members
Physicians
• Chief Executive Officer
• Chief Medical Officer
• Administrative Intern
• Associate Chairman, Department of
Medicine
• Director
– ICU, MICU, SICU
– Emergency Room
– Medical Residency Programs
•
•
•
•
Intensivist
Critical Care Fellow
Residents and Interns
Medical Student
Infection Control
• Hospital Epidemiologist
• Manager
• Practitioner
Patient Care Services
• Vice President
• Director
• Nurse Manager
– ICU, MICU, SICU
•
•
•
Nurse Education Manager
New Nurses
Nursing Student
Other
• Director
–
–
–
–
•
•
•
•
Materials Management
Housekeeping
Respiratory Therapy
Quality Improvement
Pharmacist
Pharmacy Intern
Radiology
Transport Services
Multi-disciplinary CLABs Team
Principles
• It is not good enough that our infection rates are
below national benchmarks.
• CLABs are preventable, they are not an
inevitable
consequence of
sophisticated,
complex care that we provide to our severely ill
patients.
• CLABs can be eliminated by determination as
opposed to additional resources.
Strategies to Reduce Central Line Associated
Bloodstream Infections (CLABs)
BETH ISRAEL MEDICAL CENTER
VASCULAR ACCESS PROCEDURE NOTE
Date: _________________
Time Out at _______ AM/PM
Verified Correct (all must be verified):
 Position
 Supplies
 Patient
 Procedure
 Equipment
_________________________ RN/MD
 Site/Side
________________________RN/MD
Central vein:
R L
Pulmonary artery:
R L
Transvenous pacemaker
R L
 subclavian  internal jugular
 femoral (if femoral, reason for choice)
________________________________________________________________
Arterial:
R
L
 radial
 femoral other_______________
Indication(s):
_________________________________________________________
Consent in chart 
Operator(s): _______________________________________
Central Line Check List :
1- all equipments at bedside
2- Wash hands
3- Chlor- prep
4- Gown
5- Gloves
6- Cap
7- Drape
8-Time-out
9- Mask
10- procedure with sterile technique
11- Bio-Patch
12- Dressing with date
13- Dispose sharps
14- wash hands
Anesthesia: _________________________________________________________
Technique: _________________________________________________________
Comments: ________________________________________________________
Complications: ______________________________________________________
__________________________________________________________________
Signature/Title
Time:_______
8
Beth Israel Medical Center
CLABs Prevention ICUs
Bundle Compliance
5
4
Rate
100
90
80
70
60
Rate (%) 50
40
30
20
10
0
CLABs Rates
3
2
1
0
Aug
Oct
Dec
Feb
Time
Apr
Jun
Aug
2004
2005
Rate per 1,000 Line Days
2006
2007
Rate per 100 Patients
Beth Israel Medical Center
CLABs Prevention
Unit
CCU
Longest Duration
of Days Without
CLAB
HAI Rates
8
644
7
ICU
601
6
5
547
SICU
483
3
PICU
396
1
Rate
ED
4
2
0
non-ICU
345
Pre-Bundle
Post-Bundle
CLAB
MICU
344
CSICU
300
VAP
MRSA
CDI
CLABs Collaborative Infection Results
5
4.85
4.5
CLABs Rate per 1,000 Line Days
4.34
4
3.5
3.26
3
2.5
2.77
2.61
2.62
2.59
2.52
2.43
2.26
2
2.00 1.98
1.68
1.5
2.65
2.74
2.53
2.27
1.72
1.95
1.46
2.18
2.22
2.11
1.67
1.87
2.51
2.58
2.28
2.06
1.59 1.80
1.35
1.55
1.44
1
0.5
0
Reporting Period
11
CLABs Prevention ICUs
6
Mean Rate
5
Central Line-Associated Blood Stream Infection
(CLABSI) Rates by Type of Adult or Pediatric
Intensive Care Unit
4
3
2
1
*
L
*L
GNYHA/UHF
0
ICU Type
*L = GNYHA /UHF rate significantly lower than rate in other hospitals
Mean rate=1000 * Number of CLABSI / Number of Central Line Days
2007 NYS data, reported as of April 1, 2008
12