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CLABSI
Tony Burrell
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Healthcare associated infections
• 2009 – 175,153 estimated HAIs (5% admissions) cost Australian healthcare system 850,000 lost bed days
• Increasing concerns about HAIs with emphasis on:o MROs and Antimicrobial Stewardship (AMS)o Hand Hygiene
• Vascular access devices common cause• CLABSI
o Attributable mortality – 12-25%o Significant increase in ICU LOSo Largely preventable
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ANZICS/ACSQHC initiative
• Acknowledges work in various states and individual ICUs• Aims to develop standardised approach nationally• Consistent surveillance definition and national database
using ANZICS CORE• Partnership between ANZICS and ACSQHC
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Evidence
CLAB is preventable• Good evidence base going back 15 years
• Raad II, Hohn DC, Gilbreath BJ et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiology. 1994; 15:231-8
• Eggimann P Prevention of intravascular catheter infection. Curr Opin Infect Dis 2007; 20:360-369
• Berenholtz et al 2004. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 32 (10) 2014-2020.
• Quality not research
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Major Collaboratives
• CLABSI rate was reduced to:• 1.36/1000 line days over a 4 year period in 69 ICUs in South Western
Pennsylvania CDC MMWR reported in JAMA 2006; 269-270
• 1.44/1000 line days in 46 ICUs in New York State Koll BS, Straub TA, Jalon HS et al Jt Comm J Qual Patient Saf 2008; 34:713-723
• 1.7/1000 line days in 9 VA Hospitals, Midwest, US Bonello RS, Fletcher CE, Becker WK et al. Jt Comm J Qual Patient Saf 2008; 34:639-645
• 1.4/1000 (mean) line days in 103 ICUs in Michigan Pronovost et al NEJM 2006
• 0.6/1000 line days (down from 1.5/1000) in 20 ICUs in Hawaii Lin DM et al Am J Med Qual 2011 epub
• ‘Matching Michigan’
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NSW CLAB-ICU
• ‘Top down/bottom up’ project – NSW Intensive Care Coordination & Monitoring Unit and Clinical Excellence Commission
• 38 ICUs• Methodology modelled on the work of Pronovost et al.• The project promoted a standardised insertion technique
including: Hand washing Full barrier precautions during insertion Cleaning skin with chlorhexidine Avoiding femoral site if possible Removing unnecessary catheters
Burrell et al MJA 2011
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Method
• Central Line Insertion Guidelines developed• Emphasis on aseptic technique• Insertion checklist• Data management established
– Completed checklist faxed to CEC – Teleform methodology
• Central Line Insertion Pack developed• ICCMU Nursing management guideline
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Checklist detail
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Checklist Compliance –– 10,890 line insertions July 07 – Dec 08
Competency assessed 48.3%
Hat, mask, eyewear 79.9%
Hands washed 2 mins 91.6%
Sterile gown/gloves 95.9%
Alcoholic chlorhexidine prep allowed to dry 95.8%
Entire patient draped 93.4%
Sterile technique maintained 95.6%
No multiple passes 80.9%
Confirm position radiologically 74.3%
Other method to confirm placement 43.6%
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For further analysis data from checklist divided into:
• ‘Clinician bundle’– Undertake competency assessment– Clean hands– Sterile gloves/gown– Hat, mask, protective eyewear
• ‘Patient bundle’ – Prep with 2% chlorhexidine & dry 2 mins– Large sterile drape– Maintain sterile technique– No multiple passes– Confirm catheter position
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0
10
20
30
40
50
60
70
80
90
100
Jul-Sep 07 Oct-Dec 07 Jan-Mar 08 Apr-Jun 08 Jul-Sep 08 Oct-Dec 08
Clinician bundle complianceClinician bundle compliance excluding routine non-hat wearersPatient bundle complianceTotal
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Results
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Culture• Apathy
– ‘We don’t have CLABS’– Infection control reporting independently
• Impact of clinical leadership and support readily apparent and vice versa• ‘I don’t believe the evidence’
– Mistake promoting one high profile study – 4 ICUs refused to wear hats – Why fully drape the patient?– Excuse for not changing
• Data collection/reporting requirements – ‘Where’s the money? – excuse for not engaging in project, other ICUs used checklist but didn’t follow up lines or submit data
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HATS!!!
• ‘As in OT’ argument didn’t work• Not a lot in literature but found:
– Hair reservoir for organisms in proportion to length, oiliness & curliness– Clinicians acquire transient flora in hair
– Fletcher et al J Bone & Joint Surg 2007– Owers et al J Hosp Inf 2004– Nicolay Int J Surg 2006
• Studies linking hair to surgical site infection:– Mastro et al New Engl J Med 1990– Dineen, Drusin Lancet 1973– Summers et al J Clin Path 1965
• Studies linking max sterile barrier precautions to CLAB less clear:– Raad et al Inf Control & Hosp Epid 1994– Carrer et al Minerva Anesth 2005
Marghie Murgo, Eda Calabria CEC
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Impact of compliance
• Non compliance with the ‘clinician bundle’: – relative risk of CLABSI was RR 1.62 (95% CI 1.1-2.4, p=0.0178)– For central lines RR 1.99 (95% CI 1.2-3.2 , p=0.0037)– For PICC RR 5.08 (95% CI 1.03-25 , p=0.059)– Dialysis catheters – no difference
• If compliant with both ‘clinician bundle’ and ‘patient bundle’ then risk of CLAB was RR 0.6 (95%CI 0.4-0.9, p=0.0103)
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Survival analysis
• In non-referral ICUs lowest probability of CLABSI (1 in 100) was at day 3 in first 12 months – this was extended to day 8 in last 6 months
• In referral ICUs the lowest probability of CLABSI was extended from day 7 to day 9
• 75% central lines in place for less than 7 days• ‘Zero-risk’ (<1/1000 line days) is possible
– McLaws, Burrell Crit Care Med 2011 epub Oct
• Many ICUs do not have CLABSIs for months at a time• Other strategies ie BioPatch, coated catheters best reserved for
longterm lines, ICUs where CLABSI is a continuing problem
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Improvement multi-factorial
• Increased awareness of need for scrupulously aseptic insertion• Increasing compliance with clinician bundle (if non hat wearers excluded)• Not due to ↓femoral lines or ↓time in situ• Significantly better communication between intensive care & infection
control• Greater understanding of surveillance definition• Increasing ownership by intensive care clinicians following reporting of
individual ICU CLABSI data