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CLABSI Tony Burrell.

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Presentation on theme: "CLABSI Tony Burrell."— Presentation transcript:

1 CLABSI Tony Burrell

2 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: MROs and Antimicrobial Stewardship (AMS) Hand Hygiene Vascular access devices common cause CLABSI Attributable mortality – 12-25% Significant increase in ICU LOS Largely preventable

3 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

4 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: Berenholtz et al Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 32 (10) Quality not research

5 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; 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: 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: 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’

6 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

7 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

8 Checklist detail

9 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%

10 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

11

12 Results

13 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

14 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

15 Impact of compliance Non compliance with the ‘clinician bundle’:
relative risk of CLABSI was RR 1.62 (95% CI , p=0.0178) For central lines RR 1.99 (95% CI , p=0.0037) For PICC RR 5.08 (95% CI , 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 , p=0.0103)

16 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

17 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


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