Expanding Prevention Hospital Wide
Ghinwa Dumyati, MD, FSHEA
Associate Professor of Medicine
University of Rochester Medical Center

• Review the burden of central line associated bloodstream infections (CLABSI) outside the ICU
• Describe the components of a central line maintenance bundle
• Review the methods for implementing and sustaining CLABSI prevention hospital wide
• Questions

• CLABSI rates outside the ICU are similar or higher than the ICU
 Range: 0.9-5.2 per 1,000 line days
• Excess variable cost ~ $ 33,000
• Crude in-hospital mortality: up to 28%
 after controlling for confounders: CLABSI is associated with
2.27-fold (95% CI 1.15–4.46) increased risk of mortality
Climo M, et al. ICHE 2003; 24:942-945 Marshalls J, et al ICHE 2007;28: 905-909
Son CH, et al. ICHE 2012:33; 869-874 Stevens V, et al. CMI 2013;20: O319-O324

• Device utilization ratio varies
In ICU: 0.52-0.77
Non-ICU: Medical-surgical: 0.08-0.27
Specialties: 0.25-0.53
Step down: 0.26-0.73
• Length of catheterization prior to infection
 Median 10-17 days
• Type of central lines differ
Dumyati G, et al. AJIC 2014; 42:723-30
Rhee Y, et al ICHE 2015; 36:424–430
Tedja R, et al. ICHE 2014; 35: 164-168
Son CH, et al. ICHE 2012:33; 869-874

Data from the Rochester CLABSI Prevention Collaborative

Insertion Maintenance Removal
Avoid unnecessary use of central venous catheters

Risk Factors for CLABSI
Patient factors:
• Severity of underlying illness
• Prolonged duration of hospitalization prior to central line insertion
• Prolonged hospitalization
• Immuno-suppression
• Prematurity
• Total parenteral nutrition
Catheter Factors (modifiable):
• Prolonged duration of catheterization
• Heavy bacterial colonization at insertion site
• Heavy bacterial colonization at the catheter hub
• Insertion in jugular area, femoral area (in adults)
• Excessive manipulation of catheter
• Presence of multiple catheters
Marschall J, et al. ICHE 2014;35:753-771
Concannon C, et al. ICHE 2014;35:1140-1146

CLABSI Prevention Focuses on Prevention of Bacterial
Colonization of Insertion Site and Catheter Hub
Contaminated catheter hub
Contamination at the insertion site

Insertion Best Practices Maintenance Best Practices
1.
2.
3.
4.
5.
Hand hygiene 1.
Maximum barrier precautions 2.
Chlorhexidine prep
3.
Optimal site selection avoid femoral site in obese patients
4.
Ultrasound guided insertion
Hand Hygiene
Aseptic access of needleless device
Proper dressing change technique
Regular IV tubing change
Regular assessment of CVC necessity with prompt removal when no longer needed

Hand Hygiene
• Wash hands with soap and water or alcohol based hand rub before accessing line or changing dressing
Needleless access device
Dressing change
Administration
Sets
CVC need assessment
• Clean before accessing with chlorhexidine, iodine, or 70% alcohol using twisting motion for 10-15 sec*
• Change aseptically no more frequently than every 72 hrs and with tubing change
• Assess dressing integrity, change if loose or soiled
• Change transparent dressing every 7 days
• Gauze dressing every 2 days
• Clean site with >0.5 % chlorhexidine/alcohol for 30 sec
• Change no more frequently than every 96 hours but at least every 7 days
• Change every 24 hours for TPN containing lipids and blood and after each chemotherapy infusion
• Assess central line necessity daily
• Promptly remove CVC when no longer necessary
* CLABSI Guidelines “for no less than 5 seconds” Rochester CLABSI Prevention Collaborative

• The joint Commission. Preventing Central Line-Associated
Bloodstream Infection: Useful tools. An International
Perspective, Nov 20,2013. Accessed June 17, 2015. http://www.joint comission.org/CLABSI toolkit
• Wheeler DS, et al. A Hospital-wide Quality-Improvement
Collaborative to Reduce Catheter-Associated Bloodstream
Infections. PEDIATRICS 2011; 128:e995-e997
• Bundy DG, et al. Preventing CLABSI among pediatric hematology/oncology inpatients: National collaborative results. PEDIATRICS 2014; 134: e1678-1685

To be used if “basic” prevention unsuccessful in reducing
CLABSI rate
1. Antiseptic or antimicrobial-impregnated catheters
2. Use chlorhexidine-impregnated sponge
3. Use an antiseptic-containing hub/connector protector to cover needleless access device
4. Use antibiotic locks
5. Chlorhexidine Bathing

0,6
0,4
0,2
0
1,4
1,2
1
0,8
60% reduction p = 0.02
non CHG sponge
CHG sponge
Timsit JF, et al Am J Respir Crit Care Med. 2012; 186(12):1272-1278
Meta-analysis: Safdar N, et al. Crit Care Med. 2014;42:1703–1713

Wright MO et al. American Journal of Infection Control 41 (2013) 33-8

• Most study support bathing in ICU
– Meta-analysis of 12 ICU studies:
• Pooled odds ratio: 0.44 (95%CI 0.33-0.59; p<0.0001)
– 2 large multicenter studies showed reduction of bloodstream infections
• 1 single center study showed no benefit
O’horo JC, et al. ICHE 2012;33:257-267
Climo MW, et al. N. Engl J Med 2013;368:533-42
Huang SS, et al. NEJM 2013;368:2255-2265
Noto MJ, et al. JAMA 2015; 313:369-78

6
5
4
3
2
1
0
P=0.006
Primary BSI per 1000 pt-days
P=0.004
53%
CLABSI per 1000 catheter days control period
Intervention period
Climo MW, et al. N. Engl J Med 2013; 368:533-42

5
4
3
2
1
0
Targeted versus Universal Decolonization with CHG and Mupirocin to Prevent ICU
Infection
7
6
1% reduction 22% reduction
44% reduction
P<0.001
Baseline
Intervention
Control Targeted decolonization
Universal decolonization
Huang SS, et al. NEJM 2013; 368:2255

• Compliance with bathing:
– 90% in ICU
– 58% in non-ICU
• Effect on CLABSI rates could not be demonstrated possibly due to
– Low baseline rates
– Enforcement of the CL insertion and maintenance bundles
Rupp ME, et al. Infect Control and Hosp Epidemio 2102;33(11):1094-1100

• Active Bathing to Eliminate Infection (ABATE
Infection)
– Cluster randomized trial to reduce multidrug resistance organisms and healthcare associated infections in non-ICU
– Decolonization with CHG bathing and nasal mupirocin for MRSA +
– Results pending https://clinicaltrials.gov/ct2/show/NCT02063867

IMPLEMENTATION CLABSI PREVENTION
HOSPITAL WIDE

Implementation Framework
Engage
Evaluate
Educate
Execute http://www.ahrq.gov/professionals/education/curriculum-tools/clabsitools/index.html

Implementing CLABSI Prevention Hospital Wide
Where to Start?
Engage
• Obtain senior and nursing leadership support and buy-in
– Approve time for oversight of the intervention
– Approve cost for additional products
– Provide accountability
– Demonstrate that CLABSI prevention is a priority

Engage
• Identify one or two non-ICU wards with
– High central venous catheter use
– High CLABSI rate
• Identify and engage local champions on the ward
– Front line nursing staff that can partner with infection preventionist and/or IV access team
– The champion will educate others, perform observations, assess all nursing staff competency
• Establish a CLABSI prevention multidisciplinary team (or expand the ICU team)

Implementing CLABSI Prevention Hospital Wide
Educate
Assessment:
• Current policies for catheter insertion and maintenance hospital wide
 Consolidate if multiple policies exist
• The knowledge of front line staff of the CLABSI prevention policies
• Compliance with the current policies
 Point prevalence of CVC dressing observations
 Documentation of CVC insertion and maintenance procedures/checklist

Survey of 200 Nurses
Scrub access port for 10-15 sec
Clean insertion site with >5% Chlorhexidine
Change transparent dressing every 5-7 days
Change access port every 96 hrs
0 10 20 30 40 50 60 70 80 90
Rochester CLABSI Prevention Collaborative

Implementing CLABSI Prevention Hospital Wide
Educate
• Use multiple approaches for education:
– Lectures
– On-line course
– One on one education
– Assessment of staff competency
• Repeat education regularly and with any new products or change in policies

On Line Education: example of dressing change
1 of 6 2 of 6 3 of 6
4 of 6 5 of 6
6 of 6
Educational module https://www.urmc.rochester.edu/community-health/research/communicable-diseasesurveillance/healthcare-associated-infections/clabsi/central-line-education.aspx

Implementing CLABSI Prevention Hospital Wide
Execute
• Identify your target goals:
– CLABSI rate or SIR (unit level and hospital wide)
– Percent compliance with insertion and maintenance bundles
Be aggressive with your target goals
• Make your hospital wide CLABSI rate information a part of the organization score card
• Share at executive and board meetings

Implementing CLABSI Prevention Hospital Wide
Execute
• Assess location and services inserting CVC in non ICU patients
 Ensure that all staff inserting CVC are educated
 Insertion checklist implemented outside the ICU setting, e.g. radiology, ED
• Assess the availability of supplies
 Insertion cart
 Supplies for dressing change (bundle into one package)
 Chlorhexidine sponge, securement device, alcohol caps (if used)

Key drivers for the CCHMC CA-BSI QIC. Shown is the learning structure of our qualityimprovement project, including the aim statement, key drivers, and the change strategies to be tested or implemented during the project.
Derek S. Wheeler et al. Pediatrics 2011;128:e995-e1007
©2011 by American Academy of Pediatrics

Implementing CLABSI Prevention Hospital Wide
• Evaluate Process
– Compliance with the insertion bundle
– Compliance with the maintenance bundle
• Evaluate outcome
– CLABSI rate
– Number of patients affected each month
– Days since last infection

Evaluate
Audits
1. Observation of nurses practice
(n=200)
– Needleless access device scrubbing
– CVC dressing change
2. Status of dressing and administration sets (n=800)
– CVC dressing integrity
– Documentation of CVC dressing assessment, tubing and needleless access device date change
Results of audits
>90% compliance with all the recommended line maintenance guidelines
82% compliance with scrubbing the needless access device
Rochester CLABSI Prevention Collaborative

10.0
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
CLA BSI on monitored floors outside ICU, April-June
Your unit
Hospital Unit
37

• Establish a Team to Brainstorm about each
CLABSI case:
– Nurses
– Infection Preventionist
– Intravenous access team
– Unit nurse manager
– Physicians
• Review:
• WHY did it happen?
• WHAT can be done to prevent harm to the next patient?
39

The Tale of Two Units
Unit #1
6
4
2
0
10
8
Q1 Q2 Q3 Q4 Q5 Q6 Q7
Unit #2
10
8
6
4
2
0
Q1 Q2 Q3 Q4 Q5 Q6 Q7
Nurse Champion Efforts:
1. One on one education
2. Observations of compliance with maintenance bundle
3. Incentives for no CLABSI events

10
8
6
4
2
Unit #1
0
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12
10
8
6
4
2
Unit #2
0
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12
Multidisciplinary team
New nurse manager
Open discussion of all adverse events
Audits, nurse bedside rounding
Success celebrated

1. Aggressive goal setting and support: getting to zero CLABSI
2. Strategic alignment/communication and information sharing: CLABSI rate shared at executive/board level meetings
3. Systematic education: Structured and part of a patient safety education
4. Inter-professional collaboration: physicians and nursing collaboration
5. Meaningful use data: Share data regularly with everyone, strive toward automation
6. Recognition for success: incentive compensation linked to the CLABSI prevention goals

Dumyati G, et al. AJIC 2014; 42:723

• Improvement in safety culture
• Ensure that all changes are included in policies and daily work flow
• Continue to repeat education due to staff turn over
• Continue feedback of CLABSI data
• Continued involvement of senior leadership
– Review of infection data and
– provide teams with the resources needed
• Alignment of the prevention project with the organizational goals
• Continue to support local champions and celebrate success
Pronovost PJ, et al.; BMJ, 2010; 340:c309