abstract # 59300 poster board # 417 impact of a
TRANSCRIPT
Shruti K. Gohil, MD, MPH1,2, Jennifer Yim, RN, BSN, CIC1, Kathleen Quan, RN, MSN, CIC1, Maurice Espinoza, RN, MSN, CNS,CCRN5, Deborah J. Thompson RN, CIC1, Allen P. Kong, MD3, Tom Tjoa, MS, MPH2,
Bardia Bahadori2, Chris Paiji, BA4, Syma Rashid2, Suzie S. Hong2, Linda Dickey, RN, MPH, CIC1, Mohamad N. Alsharif, MD2, Alpesh N. Amin, MD, MBA, MACP, SFHM, FACC4,5, Justin Chang, BS2, Usme Khusbu, MA1, and Susan S. Huang, MD, MPH1,2
1Epidemiology & Infection Prevention Program, UC Irvine Medical Center 2Division of Infectious Diseases, UC Irvine School of Medicine, 3Department of Surgery, UC Irvine School of Medicine, 4University of California Irvine School of Medicine,5UC Irvine Medical Center
BACKGROUND
STUDY POPULATION
SUMMARY & IMPLICATIONS
STUDY DESIGN & ANALYSIS
Progression of locally inflamed/infected insertion sites accounts
for nearly 40% of central line-associated bloodstream infections
(CLABSIs).
We developed and implemented a central line insertion site
assessment (CLISA) score to standardize assessment of
insertion sites for early identification of localized infection and
prompt timely removal of high-risk lines.
Principal Aims
Evaluate prevalence and incidence of pre- and post-CLISA Score
implementation on:
1) Central line insertion site inflammation and infection
2) Incidence of CLABSIs
Adult inpatients with central lines hospitalized in an intensive
care unit or oncology ward at a large academic center
Excluded hemodialysis and port-a-catheters
Study period: April, 2014 - March, 2016
Pre- and post-intervention quality improvement study
Periodic photosurveys of line insertion sites of all eligible patients
were conducted at baseline (4/1/14-3/31/15) and post-
intervention (4/1/15-3/31/16) after hospital-wide implementation
of the following:
1) Electronic nursing documentation of CLISA cascaded into
physician electronic progress notes
2) Physician attestation and determination of line removal for
CLISA 2 or 3 required for finalization of progress notes.
• Cox proportional hazards model compared frequency of localized
insertion site infection pre- and post-intervention. Chi-square
tests compared hospital CLABSI rates (2014 NHSN criteria)
The CLISA score enabled an automated primary
prevention strategy to standardize insertion site
assessment across providers
The CLISA score allowed earlier recognition of
insertion site inflammation and infection with
proactive removal before localized infections led
to CLABSI
The CLISA score was well-received and widely
adopted across training levels and disciplines
Impact of a Standardized Central Line Insertion Site Assessment (CLISA) Score
on Localized Inflammation and Bloodstream Infection
Key Findings Results
Insertion site infection decreased by more than half,
from 40 (10%) at baseline to 14 (4%) after CLISA
score implementation (p=.01), after adjustment for
line type and site
CLABSI rates decreased by 29% post-intervention,
but did not reach statistical significance
Among central lines that progressed to localized
infection, mean dwell time was 10 days
Physician progress notes documenting insertion site
appearance of inflamed lines increased from 0%
during baseline to 100% due to automated process
Nursing acceptance of the CLISA score was high
(92% compliance), due to both desired standardized
language and communication with MDs via linkages
between RN and MD progress note documentation.
After house-wide implementation of CLISA Scoring,
all 5 ICUs and Oncology units reported:
Easy adoptability
Improved RN-RN and RN-MD communication
Increased attention to and recognition of early
signs of infection
Limitations: (1) cohort limited to single academic
center, (2) generalizability may be limited by tertiary
care setting, (3) CLABSI events in 2015 required re-
evaluation with 2014 criteria due to definitional
changes.
Abstract # 59300
Poster Board # 417
Descriptor Baseline Post-Intervention
Number of Central Lines , N 402 322
Number of Assessments with Visible
Insertion Sites, N 696 963
Number of Assessments/Line, mean
(SD) 2 (1.8) 3.5 (4.1)
Mean dwell time, days (SD) 14 (10.6) 14 (19.5)
Mean age, years (SD) 56 (16.5) 55 (17.7)
Line site, N (%)
Brachial 271 (67) 180 (56)
Subclavian 34 (8) 51 (16)
Internal Jugular 79 (20) 78 (24)
Femoral 18 (4) 13 (4)
Unit, N (%)
Medical ICU 61(15) 45 (14)
Cardiac Care Unit 38 (9) 26 (8)
Surgical ICU 99 (25) 98 (30)
Neurosurgical ICU 71(18) 66 (21)
Burn ICU 31 (8) 15 (5)
Oncology (non-ICU) 102 (25) 72 (22)
Central Line Insertion Site Assessment (CLISA) Score
*Baseline and Intervention CLABSI rates normalized to 2014 NHSN Criteria
**Chi-square test comparing baseline and post-intervention CLABSI rates
Central Line Characteristics
Device-Days CLABSI*
CLABSI
Rates
per 1000
line-days
p-value**
Baseline 36,458 19 0.52 0.42
Post-Intervention 35,398 13 0.37
Prevalence of Inflammation/ CLISA
Score Assessments
Baseline
N (%)
Post-Intervention
N (%)
CLISA 0 273 (68) 150 (47)
CLISA 1 72 (18) 153 (48)
CLISA 2 49 (12) 41 (13)
CLISA 3 40 (10) 14 (4)
Days to Inflammation Baseline Mean
(SD)
Post-Intervention Mean
(SD)
CLISA 1 7 (6) 6 (6)
CLISA 2 9 (8) 10 (10)
CLISA 3 10 (7) 10 (11)
Local Infection (CLISA 3) Baseline vs Post-Intervention
Variable OR CI p-value*
Line Site
Brachial -- -- --
Internal Jugular 0.3 0.1-0.1 0.1
Subclavian 0.6 0.2-2.1 0.9
Femoral 0.8 0.2-4.0 0.7
Unit
NSICU -- -- --
SICU 1.9 0.6-6.6 0.3
MICU/CCU 2.3 0.7-7.4 0.15
BICU 4.7 1.3-16.9 0.02
Oncology 3.2 1.1-9.3 0.03
Intervention Period 0.4 0.2-0.8 0.01
CLABSI Rates Baseline & Post-Intervention
*Cox proportional hazards model, adjusted for age.
CLISA Score Embedded Into
Physician Progress Note for Daily Attestation
• Nursing documentation of CLISA score is embedded into physician progress notes
• If CLISA score > 2, physician must remove line or document reason for retaining
• Insertion site infection decreased significantly from 40 (10%) at baseline to
14 (4%) after intervention after CLISA score implementation