We previously reviewed reducing the rate of catheter-associated urinary tract infections. Now, we will address how hospitals can prevent central line-associated bloodstream infections (CLABSIs).
As previously discussed, acute care hospitals participating in the Centers for Medicare and Medicaid Services’ (CMS) Quality Reporting Program must now report all CAUTIs and CLABSIs that occur on adult and pediatric medical, surgical and medical/surgical wards, in addition to the previously required reporting from ICUs. Changes to reimbursement policies will have up to 5% of a hospital’s Medicare reimbursement tied to healthcare-associated infections (HAIs) and readmission rates (often related to HAIs) and 1% specifically linked to CAUTI and CLABSI rates.
CLABSIs by the numbers: According to the CDC, almost 72,000 patients developed healthcare-associated primary bloodstream infections in 2011. Of those patients, about 30,100 were related to central lines.1,2 CLABSIs rank as the most expensive of the common HAIs at an average cost of $45,814 per infection. 3 Medicare and many private payers will not reimburse for CLABSIs or many other HAIs, leaving hospitals to absorb the cost.
Risk factors: Patients in (ICUs) have the highest risk of developing CLABSIs as they often have multiple catheters that require frequent access and extended use. More CLABSIs occur in non-ICU settings, however.4
To minimize the risk of CLABSI, the Society for Healthcare Epidemiology of America (SHEA) and Infectious Disease Society of America (IDSA) recommend restricting use of central venous catheters (CVCs) and removing them as soon as possible. To do that, provide a readily accessible evidence-based list of indications for CVC use.
Educate all staff involved in CVC insertion, care and maintenance of central lines about CLABSI prevention and require credentialing to ensure competence in CVC insertion.
Bathe all ICU patients over the age of two months in chlorhexidine solution daily.
Create a checklist for insertion and document aseptic technique at insertion as well as hand hygiene.
Use an all-inclusive catheter kit.
Use ultrasound guidance for internal jugular catheterization to reduce the risk of both CLABSI and other complications.
Employ maximum sterile barrier precautions at insertion, including preparing skin with chlorhexidine solution.
Restrict use of float nurses in ICUs and target a nurse to patient ratio of 1:2 in ICUs when nurses manage patients with CVCs.
Ensure disinfection of catheter hubs, needleless connectors and injection ports prior to accessing the catheter, using mechanical friction and an alcoholic chlorhexidine preparation. Under standard practice, nearly 50% of catheter components are colonized, so close monitoring of compliance is highly recommended.
Remove catheters when no longer essential.
Change transparent dressings and clean site with chlorhexidine solution every 5-7 days or when damp, loose or soiled for nontunneled CVCs.
Change administration sets that are not used for blood products or lipids at least every 96 days.
Special practices to consider: If the above practices fail to bring CLABSI rates down sufficiently, hospitals may consider using antiseptic- or antimicrobial-impregnated CVCs for adult patients, particularly those with a history of CLABSIs and those at high risk of serious complications from CLABSI such as patients with recently implanted intravascular devices. Chlorhexidine-containing dressings may also cut CLABSI rates, although the incremental benefit in hospitals that already bathe patients daily in chlorhexidine remains unclear. SHEA and IDSA guidelines also recommend employing an antiseptic-containing hub, connector cap or port protector to cover connectors. Antimicrobial locks for CVCs may reduce CLABSIs, but could also increase emergence of multidrug resistant organisms, so should be restricted to patients with recurrent CLABSIs or at high risk of severe sequelae from CLABSI.
Practices to avoid: Using the femoral vein in adults increases the risk of CLABSI and should be avoided, when possible.4 Do not use peripherally inserted CVCs to reduce the risk of CLABSIs as their rates of infection approach those of CVCs inserted in subclavian or internal jugular veins. Antimicrobial prophylaxis is not recommended, neither is routine replacement of CVCs or arterial catheters.
Measuring success: In addition to measuring CLABSI rates as required for National Healthcare Safety Network reporting, hospitals may want to track process metrics such as compliance with CVC insertion guidelines and daily assessment of continuing necessity. Monitoring compliance with cleaning and disinfection guidelines will help to address the high rates of colonization common on catheter components.
What steps have you taken to reduce CLABSI rates?
1. Healthcare-associated infections (HAIs). Data and Statistics. CDC. Last updated January 12, 2015.
2. 2012 CDC National and State HAI Progress Report. CDC.
3. Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, Keohane C, Denham CR, Bates DW. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013 Dec 9-23;173(22):2039-46.
4. Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O'Grady NP, Pettis AM, Rupp ME, Sandora T, Maragakis LL, Yokoe DS; Society for Healthcare Epidemiology of America. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Jul;35(7):753-71.