Central Line Associated Bloodstream Infection

Central Line Associated
Bloodstream Infection
Central Line Care Bundle to the Rescue
Tanuja M. Parmar, RN, Samantha Rhea, RN,
Tracy Bates, RN, & Nicole Nowlin, RN
Northeastern State University
April 19, 2012

Definitions and Terms
Central Line Associated Blood Stream Infection (CLASBI)
Central Line Infection that occur 48hours after insertion
Central Line Care Bundle (CLCB)
3-5 of 11 practices implemented to reduce CLASBI
Derived from CDC and Healthcare infection control practice Advisory Committee
(Murphy, Andrus, Barnes, Garcia, Juraja Khoury, & Krystafiak, 2009)

Definitions of Terms Cont.
BSI- Blood Stream Infection
CDC- Central of Disease Control (US)
CMS- Center of Medical and Medicaid Services
CVC- Central Venous Catheter
ICU- Intensive Care Unit.
IHI - Institute of Health Care Improvement
IV- Intravenous

PICO Question
Will non-ICU patients have a reduction in
the occurrence of CLABSI by using the
central line care bundles as previously
seen in the ICU patients?

Impact of CLABSI’s
Bloodstream infections (BSIs):
Major cause of healthcare-associated
morbidity
Up to 35% attributable mortality
Increases hospital stay to 7-24 days
Major risk factor is central line use
More than 250,000 (CLABSIs) in US
yearly
Cost to treat ranges from 34,000 to
56,000
Rates of CLABSI vary by type of catheter

Impact of CLABSI’s cont…
Centers for Medicare and Medicaid Services recently rule that it will cease to
reimburse for certain preventable infections. (CMS)
The Joint Commission made CLABSI, a National Patient Safety Goal in 2009.
Very high morbidity and mortality Risks
(Harnage,2008; Murphy et al., 2009)

Impact Outside the ICU
Most work/studies aimed at reducing CLABSIs in
the hospital have been implemented in ICUs
Many Central Lines are found outside ICUs
In one study 55% of ICU patients had Central Lines; 44% of
non-ICU patients had Central lines
However, as more patients are located outside of the ICU, 70%
of hospitalized patients with Central Lines were outside the ICU

Impact Outside ICU cont…
CLABSI rates in non ICU areas are similar to CLABSI
rates in ICUs:
Although data are sparse, in one study CLABSI rates
were:
1. 5.7 per 1,000 catheter-days in non ICU areas.
2. 5.2 per 1,000 catheter-days for medical ICU
Marshall et al. Infect Control Hospital Epidemiol 2007

Impact National Healthcare Safety
Network (NHSN) CLABSI Rates
From 2006 –2008 NHSN report, pooled mean
CLABSI rates were:
1. Medical-Surgical ICUs = 1.5 to 2.1 per 1,000 catheter- days
2. Medical-Surgical Non ICU wards = 1.2 per 1,000 catheter-days
http://www.cdc.gov/nhsn/PDFs/dataStat/2009NHSNReport.PDF

Agency Population
Non ICU patients are in high demand of central line utilization due
to:
1. Extended length of stay
2. Multiple IV medication (vesicants, and multiple drips)
3. TPN
4. Limited vascular assess due to hemiaparesis.
5. Edema
6. Fistula
7. Dehydration
8. Long term antibiotic therapy
9. Trauma

Causes of CLABSI

Causes of CLABSI
More Common Mechanisms
1. Pathogen migration along external surface-more common early (<
7days)
2. Hub contamination with intraluminal colonization-more common >10
days
Less Common Mechanisms
1. Hematogenous seeding from another source (MRSA, VRE)
2. Contaminated infusates

Literature Review
CLABSI outcome related to increase in stay and extra health cost
amounting to $30,000 per case
One study indicated that 250,000 CLABSI occurrence annually
Approximately 80,000 CVC related blood stream infections occur in
the intensive care units due to the way dressing is changed and the
catheter is inserted
(Rosenthal, 2009; Miller and Grady, 2006; Sykora, 2011)

Literature Review cont…
An estimated total of avoidable CLABSI ranged from $1.71 billion to
$21.37 billion dollars
Infection associated with intravascular catheter accounts for 10% to
20% of nosocomial infections, which are mostly preventable
(Murphy et al., 2009. p. 11).

What is the Solution
to Prevent CLABSI?
Introducing the Care
Bundles

What is the Care Bundle?
Care Bundle- packet of three to five
individual practices from 11 different
interventions which is derived from CDC
and Health care infection control practices
advisors committee

Successes of the Care Bundle
Michigan Keystone Project (Implemented in all ICU areas)
Decrease in CLABSI in 103 ICUs in Michigan (66% reduction)
Pittsburgh Regional Health Initiative
Decrease in CLABSIs in 66 ICUs (68% decrease) Interventions
Promotion of best practices by the use of central line care
bundle.

Successes of the Care Bundle
cont…
One PICC team in Sutter Roseville Medical Center California
implemented a Central line bundle in their facility and emphasized
the usage of PICC lines.
In 2005- 11 CLABSI with 757 PICC lines placed- Implemented Care
Bundle
In 2006- 1558 PICC lines placed with Central line Bundle with the
success of 0% CLABSI
In 2007- 2278 PICC lines placed with 0 CLABSI with the utilization
of care line bundles.

Care Bundle Success cont…
Further evidence of using the care line bundles is at one
ICU in one institution, implementation of a central line
bundle resulted in reduction of CRBSIs from 10.77 to
1.67 per 1000 central line days over a three year period.
Another institution that implemented the central line
bundle in their ICU achieved a success of reduction of
central line infection rates to zero percent and then
persistently below 1/1,000 line days.
(Segreti 2009 & Render 2008)

Our Goal
To implement and introduce Central Line Care Bundle to
this specific non-ICU area of the hospital.
This unit has an average of 5-8 CLABSI a year due to the severity of
the patients.
Stroke patients with multiple drips, dehydrated, TPN, edema,
antibiotics and hemiparesis on one side
Short Term Goal:
Our goal is to reduce CLABSI rates in half or maybe even eliminate.
Long Term Goal:
Implement Care Line bundles house wide to reduce and or eliminate
CLABSI.
(Quality report from institution, 2012)

Our Central Line Care Bundle
Proper hand washing
Assessing and documenting daily
Dressing change and Flushing protocol
Scrubbing the hub of each lumen
Education of professional staff and patients.

Hand Washing
Care Bundle
The importance of rigorous hand hygiene is very important to remove
transient hand flora that may have been picked up from other patients or
environment surfaces
Assessing and Documenting Daily
As stated by Institute for Health Care Improvement, daily and continuous
monitoring of CVC decreases complication and increases good patient
outcomes
Dressing change and Flushing protocol
Proper aseptic techniques needs to be used while changing dressing.
(Halter, Hebden, Daler, & Zack, 2010)

Care Bundle cont…
Flushing helps keep the line patent and infection free.
Pulsatile push-pause method on all flushes, as this technique will again
promote patency by reducing fibrin clots at the end of the catheter.
Research also indicating that thrombotic occlusions increase patients risk
for infection, so not only does one want to keep the line patent, but also
want to keep the infection risk low
Scrubbing the hub of each lumen
Blood stream infection “outbreaks” have been associated with failure to
adequately decontaminate catheter hubs or failure to change them at
appropriate intervals
Since the septum of the connectors is made with hard plastic, studies
have shown an increase in bio-film growth
(Halton & Graves, 2007)

Education of professional
staff/patient
As of January 1, 2010, the Joint Commission requires that hospitals
must implement CVC policies along with CDC and evidence based
standards on the floor for nurses to access.
It has also stated that an educational plan for health care workers
who work with CVC must be provided resources and be competent
to perform job responsibilities
Always educate your patient on Central lines care that they should
be receiving and never be afraid to question.
Pennsylvania Patient Safety Advisory [PTSV], 2010

How to Implement Central Line
Care Bundle
Institute for Healthcare Improvement(2012),
quality model for improvement.
This model has two parts:
1. Asks questions to guide the central line bundle implementation
Team to establish a clear goal
Implementing a tool that shows that implementation of bundle practices
is resulting in care along with identifying changes that are likely to lead
to improvement
Leadership involvement, clear goals and agenda, plan of an audit tool
2. Plan-do-check-act cycle

PDSA/PDCA

Planning
Interview nurses to see their knowledge on CLABSI.
Get the numbers of CLABSI on this unit from the quality department
of this institution.
Chief nursing officer (CNO), director, manager, team lead along with
four charge nurses involved as champions of care bundle
Budget will be discussed with the manager, director, and the CNO
Use of care bundles to eliminate CLABSI.
Process will start May1st, 2012 and it will go live on June 1st, 2012.
Agenda will be posted of all the meetings held to achieve our goals.
Will try on 9th floor of this institution only and if successful will
proceed to other units.
Timeline posted on appendix and e-mails will be sent out for
communication of progress and meeting times.

Implementation Agenda
Initial Meeting with the leaders @ April 23, 2012 @ 1230
CNO
Director of floor
Manager
Team Lead
2nd Meeting to discuss and share plan and give responsibility
@ April 25, 2012 @ 1500
Manager
Team Lead
2 day shift charge nurses
1 weekend option day charge nurse
2 night shift charge nurse
1 weekend night charge nurse
Clinical educator

Do
Everyone’s tasks will be identified.
Initial meeting held with CNO, manager, team lead, and the director
Second meeting will require the manager, team lead, charge nurses
and clinical educator. Tasks will be given at this time.
Mass e-mail and advertisement.
Nursing 102 care bundle education required for all nurses and
agreement signed.
Reference education materials for all nurses.
Competency check for all nurses in using care bundle.
Roll out Care bundle
Audits on progress.

Mandatory Nursing 102 Classes
Who……. All Staff Nurses
What…… Care Bundles for Central Lines
Where…. 9th floor Classroom
Why…… Central Line Associated Bloodstream
Infection (CLABSI)
When……
May 1, 2012 @ 0530 and 1900
May 2, 2012 @ 0530, 1100, and 1900
May 4, 2012 @ 0530, 1100 and 1900
May 6, 2012 @ 0530, 1100 and 1900
May 8, 2012 @ 0530 and 1900
May 12, 2012 @0530, 1300 and 1900
ALL NURSES PLEASE MAKE IT A PRIORITY TO ATTEND ONE OF
THE ABOVE CLASSES!!!

Nursing 102 Agreement
I _______________________________________
agree and understand this care bundle process
and will abide by it every time I have a central
line patient. If I have any questions or concerns
I will go to the care line bundle champion or the
manager or team lead.
I _______________________________________
do not agree or understand this care bundle
process and will need extra education

Nursing 102 Quiz for the Care
Bundle
1. Name two reasons why hospital should implement this care bundles?
______________________________________________.
2. Name all components of the care bundle?
_____________________________________________________________
__________________________.
3. When will this care bundle be used and for which patients?
_____________________________________________________________
___________________________________________________________
________________.
4. Who is our champions on care bundle and who can you ask for help?
_____________________________________________________________
___________________________________________________________
___________.
5. When is the GO LIVE for the use of care bundle?
_____________________________________________________________
___.

Study/Check
Study all audit tools
Graphs to show the difference
Meet with the manager, team lead, and the
director and discuss the progress of the care
bundle.
Send results to the staff and keep them notified
about the progress.
Make any changes that need to be made
Meet with the RN’s for opinions

Audit Tool for Care Bundle
Fin # ____________________ Age _________________________ Gender
__________
Type of Central Line _____________________________________
Admit Date ______________________________
Date of Line Insertion ___________________________________
Prior infection ____________________________________
Documentation Audit
Every shift assessment of Central Line done _____________________________
Line flushed every 8 hours _________________________________________
Documentation match patient assessment _____________________________
Central Line education documented _____________________________
Was the hub scrubbed for 10 to 15 second __________________________
Hand washing Audit
Did the nurse wash hands before touching patient or central line __________________
Did the nurse flush line after each medicine ______________________
Did the nurse scrub the hub 10-15 second before giving medicine?
___________________
At the Patient
Is the dressing clean, dry and intact _____________________
Is the dressing dated _______________________
Any sign of phlebitis or infection _____________________________

Act:
ACT
Action plan on any changes that need to be made
If no changes need to be made, proceed to implement this cycle on
another unit.
If plan did not work, go back to plan cycle and start the process
over