LEARNING OBJECTIVES:

• After this course, you should be able to:

• Describe the scope of the problem of CLABSI

• Review the structure of Device-associated Infections using NHSN criteria and the

surveillance methodology used for data collection

• Define key terms and protocol used for collecting CLABSIs and their corresponding

denominator data

• Become familiar with the different types of central lines and sources of contamination

• Differentiate between CLABSI and MBI-LCBI criteria

• Describe how to collect CLABSI data using the BSI form

• Describe how CLABSI rates, device utilization ratios, and standardized infection ratios

are calculated and reported to promote performance improvement

Central Line-associated Bloodstream Infections

(CLABSI)

• It is estimated that 41,000 CLABSIs occur in U.S. hospitalized patients each

year

• Most bloodstream infections are associated with the presence of a central line

or umbilical catheter (in neonates) at the time of or before the onset of the

infection

• Since 2001, the decrease in infections has saved up to $1.8 billion in excess

medical costs.

CR-BSIs

Where do they come from?

Bloodstream Infections (BSIs) and

Device Use

87% of BSIs are associated with device use1

Common devices:

– Central venous catheters (CVCs)– Arterial catheters– Peripherally inserted central catheters (PICCs)– Dialysis catheters and ports– Peritoneal dialysis catheters– Epidural catheters– External fixator pins

1. Richards M, Edwards J, Culver D, Gaynes R. Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System. Critical Care Medicine. 1999;27:853-854.

Evidence-based Choice for Catheter-related Bloodstream Infection (CR-BSI) Prevention- William R. Jarvis, M.D.

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

Examples of Central Lines includes the following:

• Aorta

• Pulmonary artery

• Superior vena cava Inferior vena cava

• Brachiocephalic veins Internal jugular veins

• Subclavian veins External iliac veins

• Common iliac veins

• Femoral veins In neonates, the umbilical artery/vein

REMINDER: Femoral Arteries are NOT great vessels.

Central Lines

Sources of Contamination

1

Skin Organisms

Endogenous

Skin flora

Extrinsic

Health Care Workers

hands

ContaminatedCatheter Hub

Endogenous

Skin flora

Extrinsic

Health Care

Workers hands

2

3

ContaminatedInfusate or Catheter

Extrinsic

FluidMedication

Intrinsic

Manufacturer

1 = 60%

2 = 12%

3 = <1%

Unk = 28%

1. Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters. Int Care Med. 2004;30:62-67.

Biofilm

• Biofilm is a complex, highly organized community of microorganisms enclosed in a self-produced exopolysaccharide matrix attached to tissue or inanimate surfaces.1

• All medical-device-related infections originate as biofilm infections.

• Bacteria in a biofilm are chemically and physically protected by the biofilm structure and are also slow growing and are difficult to kill with antimicrobial therapies

1. Ryder, MA. Catheter-Related Infections: It's All About Biofilm. Topics in Advanced Practice Nursing eJournal. 2005;5(3) ©2005 Medscape

Posted 08/18/2005 . http://www.medscape.com/viewarticle/508109

What we can do to prevent CR-BSIs?

Site checks every shiftVisual inspection of the CVC insertion site

CVC dressing, and the CVC itself at the

start of each shift can help prevent future

complications.

WHAT TO LOOK FOR:

1- Is the dressing clean, dry, intact, & dated?

2- Is the dressing due to be changed?

3-How does the skin integrity under & around the dressing look?

4-Is the catheter in the same position as documented at time of insertion?

5-Are all ports of the CVC in working order? Do they flush easily and draw briskly?

What we can do to prevent CR-BSIs?

Good shift to shift communication

Communicate:

1-Your site check observations.

2-Dressing, tubing, or cap changes you may have performed.

3-Any patient complaints, questions, or concerns.

4-Any tests or procedures that may utilized the patient’s CVC.

5-Any interventions you may have performed, such as a CXR or line de-clot.

Dressing changesThorough cleaning with antiseptic skin prep.

Clean & disinfect the

skin with Antiseptic prep

composed of Chlorhexidine

gluconate 2% and Isopropyl

alcohol 70% .

Use repeated back-and-forth strokes of the applicator for

approximately 30 seconds. Completely wet the treatment

area with antiseptic. Allow the area to air dry for

approximately 30 seconds. Do not blot or wipe away.

Several Examples of Properly Placed CHG Disk

Note:

1-All have adequate room between catheter hub

and insertion site for proper CHG disk application.

2-CHG disk has 360o coverage with slit @ the

11 o'clock or 1 o'clock position.

3-Blue side up.

Dressing changes: Examples of proper application of new transparent dressing.

Collecting Blood Culture Specimens

Although blood cultures drawn through central lines have a higher rate of

contamination than blood cultures collected through peripheral venipuncture, all

blood cultures collected, regardless of the site from which they were collected,

must be included when conducting in-plan CLABSI surveillance.

These blood draws should be performed simultaneously or over a short period of

time (i.e., within a few hours).

Why is CVC care and maintenance so

crucial?

Cost

• Incremental cost per episode of CR-BSI ranges from $25,000 to $56,0001.

• Hospitals absorb the majority of these costs

• U.S. hospitals incur as much as $2.3 billion per year as a result of CR-BSI

• CMS will no longer reimburse for CR-BSIs due to recent changes.

1.Centers for Disease Control and Prevention. Guidelines for the prevention of intravascularcatheter-related infections. Morbidity Mortality Weekly Report. 2002;51:1-29.

CLABSI-POA

Date of Event* occurs on the day of admission or the day after admission. The POA time

period continues to include the day of admission, 2 days before and the day after

admission.

NOTE: *Infections that are POA should not be reported as HAIs.

*Physician diagnosis is not an element for the BSI definition, so it

cannot be used to identify a BSI as POA.

Acceptable documentation does not include self-reported symptoms by the patient (e.g.,

patient reporting having a fever prior to arrival to the hospital). Instead, symptoms must

be documented in the chart by a healthcare professional during the POA time frame (e.g.,

nursing home documents fever prior to arrival to the hospital).

MD diagnosis can be accepted as evidence of an infection that is POA only when MD

diagnosis is an element of the specific infection definition.

Date of Event

The date the first element used to meet the CDC NHSN site-specific infection

criterion occurs for the first time within the seven day Infection Window

period.

Infection Window Period

A 7 day period during which all site-specific infection criterion must be met.

It includes the date of the first positive diagnostic test, that is an element of

the site-specific criterion, 3 calendar days before and 3 calendar days afer.

For site-specific criterion that do not include a diagnostic test, the first

documented localized sign or symptom that is an element of the infection

criterion will be used.

HAI

An infection is considered an HAI if all elements of a CDC/NHSN site-specific infection

criterion were first present together on or after the 3rd calendar day of admission to the

facility (the day of hospital admission is Day 1).

For an HAI, an element of the infection criterion may be present during the first 2 hospital

days as long as it is also present on or after calendar day 3.

If all elements of an infection are present within 2 calendar days of transfer from one

inpatient location to another in the same facility or a new facility (i.e. on the day of

transfer or the next day), the infection is attributed to the transferring location

Repeat Infection Timeframe

• A 14 day Timeframe during which no new

infections of the same type are reported.

The date of event is Day 1 of the 14-day

Repeat Infection Timeframe (RIT).

Additional pathogens identified are added

to the event.

CLABSI

A central line-associated bloodstream infection (CLABSI) is a laboratory-confirmed

primary bloodstream infection (LCBI) where central line (CL) or umbilical catheter (UC)

was in place for >2 calendar days on the date of event with day of device placement

being Day 1.

AND

a CL or UC was in place on the date of event or the day before. If a CL or UC was in

place for >2 calendar days and then removed, the date of event of the LCBI must be the

day of discontinuation or the next day. If the patient is admitted or transferred into a

facility with an implanted central line (port) in place, and this is the patient’s only central

line, day of first access in an inpatient location is considered Day 1. “Access” is defined

as line placement, infusion or withdrawal through the line. Such lines continue to be

eligible for CLABSI once they are accessed until they are either discontinued or the day

after patient discharged )as per the Transfer Rule). Note that the “de-access” of a port

does not result in the patient’s removal from CLABI Surveillance.

Patient in MSICU has central line inserted/accessed on June 1.

On June 3, the central line is still in place and the patient has

positive blood culture with S. aureus. This is a CLABSI because

the central line was in place for >2 calendar days when all

elements of LCBI Criterion 1 were first present together

On Feb. 5, a patient has a CL discontinued which was in place for

17 days. On Feb. 6, the patient spikes a fever of 38.3°C. Two blood

culture sets collected on Feb. 7 are positive for S. epidermidis.

This is a healthcare-associated bloodstream infection but it is not a

CLABSI because the CL was not in place the day of or the day

before all elements of LCBI Criterion 2 were first present together

Central Line-associated Bloodstream Infections (CLABSI)

Temporary Central-Line vs. Permanent Central-Line

TEMPORARY CENTRAL LINE

A temporary central line is a

non-tunneled or non- implanted

vascular catheter that terminates

at or close to the heart or in one

of the great vessels that is used

for infusion, withdrawal of blood,

or hemodynamic monitoring

PERMANENT CENTRAL LINE

A permanent central line is a

tunneled or implantable catheter

(including ports) that terminates at

or close to the heart or in one of

the great vessels that is used for

infusion, withdrawal of blood, or

hemodynamic monitoring

INFUSION

Introduction of a solution through a blood vessel via a

catheter lumen.

INFUSIONS CAN INCLUDE:

• Continuous infusions such as nutritious fluids or medications

• Intermittent infusions such as flushes or IV antimicrobial administration

• Administration of blood or blood products in the case of transfusion or hemodialysis

An introducer is considered an intravascular

catheter, and depending on the location of its tip and

use, may be a central line

In neonates, catheters in the umbilical artery and

vein are considered central lines

Neither the location of the insertion site nor the type

of device may be used to determine if a line qualifies

as a central line

Pacemaker wires and other non-lumened devices

inserted into central blood vessels or the heart are

not considered central lines because fluids are not

infused, pushed, or withdrawn through such devices

Central Line-associated Bloodstream Infections (CLABSI)

The inpatient location where the patient

was assigned on the date of the BSI

event, which is further defined as the

date when the last element used to

meet the LCBI criterion occurred

Location of attribution

If all elements of an LCBI are present within 2 calendar days of transfer from one inpatient

location to another in the same facility or a new facility (i.e., on the day of transfer or the

next day), the infection is attributed to the transferring location or facility. Receiving facilities

should share information about such HAIs with the transferring facility to enable reporting

Example: Patient with a central line in place for 6 days in the SICU is transferred to the

surgical ward. On the next day, all elements of LCBI are first present together. This is

reported to NHSN as a CLABSI for the SICU.

TRANSFER RULE

Identifying Central Line-associated Bloodstream Infections

Laboratory-Confirmed Bloodstream Infection

There are 6 criteria for identifying LCBIs. These are further divided into:

➢ Three criteria that were developed for all patients: LCBI Criteria 1,2, and 3

➢ Three criteria that were developed for a select group of patients identified as high risk of

translocation of intestinal organisms: Mucosal-Barrier Injury Laboratory- Confirmed

Bloodstream Infection (MBI-LCBI) Criteria 1,2,and 3.

Central Line-associated Bloodstream Infections (CLABSI) LCBI

Criterion 1

Example: Mary Jones had a central line inserted on admission Sept 3rd. On Sept 6th and 7th blood

cultures are drawn which grew E. faecalis. No other source of E Faecalis infection is present. Mary

meets the criteria for LCBI Criterion 1 (recognized pathogen).

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.

IMPORTANT NOTES TO REMEMBER

One or more blood cultures means that at least one bottle from a blood draw is reported by the

laboratory as having grown organisms (i.e., is a positive blood culture).

"Recognized pathogen" does not include organisms considered common commensals. A few of the

recognized pathogens are Staph aureus, Enterococcus spp., E. coli, Pseudomonas spp., Klebsiella

spp., Candida spp., etc

Central Line-associated Bloodstream Infections (CLABSI)

LCBI Criterion 2

Criterion 2: Patient has at least one of the following signs or symptoms: fever (>38.0°C), chills,

or hypotension

and

Organisms cultured from blood are not related to an infection at another site

and

the same common commensal (i.e., diphtheroids [Corynebacterium spp. not C. diphtheriae],

Bacillus spp. [not B. anthracis], Propionibacterium spp.,

coagulase-negative staphylococci [including S. epidermidis], viridans group

streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures

drawn on separate occasions (same or consecutive days) within the 7 day Infection Window

Period.

Central Line-associated Bloodstream Infections (CLABSI)

LCBI Criterion 2 and 3

The phrase “two or more blood cultures drawn on separate occasions” means:

1. That blood from at least 2 blood draws were collected within two calendar

days of each other, and

2. That at least one bottle from each blood draw is reported by the laboratory

as having grown the same common commensal (i.e., is a positive blood

culture).

Note: If special pediatric blood culture bottles are used, only one bottle may be

inoculated per blood draw. Therefore, to meet this part of the criterion, two

would have to be culture-positive.

Example: Edith Smith had a central line

inserted on admission September 3rd. On

September 6th and 7th she was hypotensive

and had an elevated WBC. On September 7th

two blood cultures are drawn one grew

coagulase negative Staphylococcus and the

other Staphylococcus epidermidis . No other

source of infection is present.

Mary meets the criteria for LCBI Criterion 2

(common commensal).

Central Line-associated Bloodstream Infections (CLABSI)

Examples

A neonate has blood drawn for culture

on Tuesday and again on Thursday and

both grow the same common

commensal. Because the time between

these blood cultures exceed the two-

day period for blood draws, this part of

the criteria is not met.

An adult patient has blood drawn at 8

a.m. and again at 8:15 a.m. of the same

day. Blood from each blood draw is

inoculated into two bottles and

incubated (four bottles total). If one

bottle from each blood draw set is

positive for coagulase negative

staphylococci, this part of the criteria is

met.

Central Line-associated Bloodstream Infections (CLABSI)

LCBI Criterion 2: Examples

Example 1:

Mr. Smith developed a fever (38.6°C) on day 6 of his admission. Blood cultures

drawn 2 hours apart both grew coagulase-negative staphylococci. Mr. Smith had

no signs or symptoms or laboratory evidence of infection at the time of blood

cultures.

Mr. Smith meets Criterion 2 for LCBI.

Example 2:

Mrs. Green was admitted to the MICU for a myocardial infarction. A subclavian

central line was inserted on admission. She developed chills and a fever

(38.8°C) on day 4. One blood culture grew Staph epidermidis and the physician

ordered vancomycin to be given IV.

Mrs. Green does not meet either criteria for LCBI.

If Mrs. Green had another blood culture from day 4 or day 5 that was positive for

Staph epidermidis, she would meet the criteria for LBCI.

Criterion 3:

Patient <1 year of age has at least one of the following signs or symptoms : fever

(>38.0°C, core) hypothermia (<36°C, core), apnea, or bradycardia

and

Organisms cultured are not related to an infection at another site

and

the same common commensal (i.e., diphtheroids [Corynebacterium spp. not C.

diphtheriae], Bacillus spp. [not B. anthracis], Propionibacterium spp.,

coagulase-negative staphylococci [including S. epidermidis], viridans group

streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more blood

cultures drawn on separate occasions (same or consecutive days) within the 7 day

Infection Window Period.

Baby Girl Lorelei admitted to NICU

following vaginal delivery at 32 weeks, on

8/4 with respiratory distress. Umbilical

central line inserted, placed on NAVA. • On

8/7, baby Lorelei is more irritable with

increasing respiratory distress. Afebrile

BCx1 grows viridans group Streptococci. •

8/8 repeat BCx1 grows viridans group

Streptococci. Temp 39° C. Periods of

apnea documented. No other source of

infection . Baby Lorelei meets LCBI 3

criterion.

A Note About Neonates/Infants

• Criterion 3 only applies to patients who are 1 year of age or less (before or on

their birthday).

• Although LCBI Criterion 3 can only be used for infants and neonates, Criteria 1 or

2 can also be used in this population

Example:

Baby Boy Jones was afebrile at birth and had

no signs/symptoms of an infection. At 4 days

of age, the infant became very fussy and

irritable. A blood culture was drawn which

grew Pseudomonas aeruginosa, and no

other sources of infection were identified

Baby Boy Jones met Criterion 1 for LCBI.

Culture Companion Culture

Report

Report as...

coagulase-positive

staphylococci

S. aureus S. aureus

S. epidermidis Coagulase-negative

staphylococci

S. epidermidis

Enterococcus spp. E. faecium E. faecium

Bacillus spp. (not anthracis) B. cereus B. cereus

S. salivarius Strep viridans S. salvarius

• Assume that the organisms are the same if the organism from one culture is identified to

both genus and species level and the companion culture identifies only the same genus

with or without other attributes.

• Antibiograms are no longer utilized to determine the sameness of two organisms.

• If there is a difference in the resistance patterns, report the more resistant organism

Criteria 2 & 3

Determining "sameness" of common commensals

If these are the results from two blood draws, we would assume that they are

the same organisms.

Indicate which result would be reported:

- Coagulase-negative staphylococci

- Staph epidermidis

Central Line-associated Bloodstream Infections (CLABSI)

Mucosal Barrier Injury Laboratory-Confirmed Bloodstream Infection

(MBI-LCBI)

PURPOSE:

To address need more specific BSI definition in oncology

• To reduce misclassification of BSI resulting from translocation of intestinal

organisms as BSI associated with the central line

• These BSIs are not impacted by CLABSI prevention measures

• Are aimed at patients with mucosal barrier injury at high risk for translocation

of intestinal organisms

• Development was led by CDC with input from external subject matter experts

• Considerations given to data collection, burden, use of objective criteria,

availability of data components, clinical credibility

MBI-LCBI Criterion 1

Patient of any age meets criterion 1 for LCBI with at least one blood culture growing any of the

following intestinal organisms with no other organisms isolated: Bacteroides spp., Candida spp.,

Clostridium spp., Enterococcus spp., Fusobacterium spp., Peptostreptococcus spp., Prevotella

spp., Veillonella spp., or Enterobacteriaceae

AND

Patient meets at least one of the following:

Is an allogeneic hematopoietic stem cell transplant recipient within the past year with one of the

following documented during same hospitalization as positive blood culture:

• Grade III or IV gastrointestinal graft versus host disease (GI GVHD)

• ≥1 liter diarrhea in a 24 hour period (or ≥20 mL/kg in a 24 hour period for patients <18 years of age) with

onset on or within 7 calendar days before the date the positive blood culture is collected.

Is neutropenic, defined as at least 2 separate days with values of absolute neutrophil count (ANC)

or total white blood cell count (WBC) <500 cells/mm3 within a 7 day period which includes the date

the positive blood culture was collected (Day 1), the 3 calendar days before and the 3 calendar days

after.

MBI-LCBI Criterion 2

Patient of any age meets criterion 2 for LCBI when the blood cultures are growing only

viridans group streptococci with no other organisms isolated:

AND

Patient meets at least one of the following:

Is an allogeneic hematopoietic stem cell transplant recipient within the past year with one

of the following documented during same hospitalization as positive blood culture:

• Grade III or IV gastrointestinal graft versus host disease (GI GVHD)

• ≥1 liter diarrhea in a 24 hour period (or ≥20 mL/kg in a 24 hour period for patients <18 years of

age) with onset on or within 7 calendar days before the date the positive blood culture is

collected.

Is neutropenic, defined as at least 2 separate days with values of absolute neutrophil

count (ANC) or total white blood cell count (WBC) <500 cells/mm3 within a 7 day period

which includes the sate the positive culture was collected (Day 1), the 3 calendar days

before and the 3 calendar days after.

MBI-LCBI Criterion 3

Patient < 1 year of age meets criterion 3 for LCBI when the blood cultures are growing only

viridans group streptococci with no other organisms isolated:

AND

Patient meets at least one of the following:

Is an allogeneic hematopoietic stem cell transplant recipient within the past year with one of

the following documented during same hospitalization as positive blood culture:

• Grade III or IV gastrointestinal graft versus host disease (GI GVHD)

• ≥20mL/kg diarrhea in a 24 hour period for patients with onset on or within 7

calendar days before the date the positive blood culture is collected.

Is neutropenic, defined as at least 2 separate days with values of absolute neutrophil count

(ANC) or total white blood cell count (WBC) <500 cells/mm3 within a 7 day period which

includes the date of the positive blood culture was collected (Day 1), the 3 calendar days

before and the 3 calendar days after.

Important Information Regarding MBI-LCBI

"no other organisms isolated" means there is not isolation in a blood

culture of another recognized pathogen (e.g., S. aureus) or common

commensal (e.g., coagulase-negative staphylococci) other than listed

in MBI criterion 1,2, or 3 that would otherwise meet LCBI criteria*.

If this occurs, the infection should not be classified as MBI-LCBI.

Grade III/IV GI GVHD is defined as follows:

• In adults: > 1 L diarrhea/day or ileus with abdominal pain

• In pediatric patients: > 20mL/kg/day of diarrhea

Calculating Absolute Neutrophil Count (ANC)

The ANC is not always reported directly in the chart

• The WBC in the chart is usually reported in terms of thousand cell/mm3

ANC = Absolute Segs + Absolute Bands

EXAMPLE:

WBC: Segs: Bands: ANC = 2000 X (20+20)/100 =

2 K/mm3 20% 20% 800cells/mm3

OR

Example: MBI-LCBI Criteria

Ms. Trinket was discharged from the ED with

antibiotics for an infected wound on February 5,

but returns on February 10th after passing out at

a party. Her symptoms on admission are fever,

generalized pain, nausea and hypotension. A

central line is inserted in the ED and blood

cultures are drawn, which are negative. She is

admitted to ICU. On hospital day 4, February

13th, repeat blood cultures grow E.coli.

Example: MBI-LCBI Criteria for Neutropenia

Is the infection POA or HAI?

A. HAI

B. POA

Date of Event determines POA or HAI.

Date of Event (date of first element of LCBI 1

present after Day 2 (pathogen cultured from blood

with no other recognized source)

Example: MBI-LCBI Criteria for Neutropenia

Is the infection POA or HAI?

A. HAI

B. POA

Date of Event determines POA or HAI.

Date of Event (date of first element of LCBI 1

present after Day 2 (pathogen cultured from blood

with no other recognized source)

Primary BSI vs. Secondary BSI

Primary BSI

("not related to an infection at another site")

• A primary BSI is identified by ruling out all non-blood sites as the source of the

bloodstream infection

• A BSI that is associated with an infection at another site is referred to as a Secondary

BSI and never reported as a BSI or CLABSI

Secondary BSI

• A culture-confirmed BSI associated with a documented infection at another site

AND

• Primary infection must meet one of the CDC/NHSN infection definitions (Chapter 17)

AND

• BSI and other sites must be related according to the culture guidelines provided in the

next few slides

Forms used for CLABSI

Calculating the CLABSI Rate

CLABSI rate equals the number of CLABSIs identified* divided by the number of central line

days*, multiplied by 1000.

* Stratify by --

• Type of ICU or other location

• Specialty Care Area (SCA)/Oncology

• Temporary line

• Permanent line

• NICU

• Birthweight category

NOTE: There is no multiplier for the DU Ratio

The DU Ratio measures the proportion of patient days in which central lines were used. It is a

measure of the patient's exposure to risk in this location.

Device Utilization (DU) Ratio

CLABSI Standardized Infection Ratio (SIR)

While the CLABSI SIR can be calculated for single locations, the measure

also allows you to summarize your data across multiple locations,

adjusting for differences in the incidence of infection among the location

types.

Note: The SIR will be calculated only if the number of expected

HAIs (numExp) is > 1.

Analysis

In NHSN, you can generate:

• Line listings

• Rate tables• Frequency tables

• Bar charts

• Pie charts

• Control charts

Click on each button to the right

to see an example of CLABSI

output

CLABSI

Line Listing

CLABSI Rate

Table & DU Ratios

CLABSI

Pie Chart

CLABSI

SIR

Interpretation: Turn the Data into Information

• This table shows data for a Neonatal ICU (NICU).

• During the time period, the NICU reported 4 central line-associated BSIs and a

total of 214 days in which patients had central lines (central line days) in

birthweight category B (751-1000 grams).

• Dividing 4 (numerator) by 214 (denominator) and multiplying by 1000 gives this

birthweight category in the NICU a CLABSI rate of 18.7 per 1000 central line

days.

QUESTIONS??