Central Line Associated Blood Stream Infection Prevention Project Gabrielle Hanlon, Project Manager Tony Burrell, Chair ANZICS Steering Committee

Background ~ 300 ICU CLABSI/yr in Australia Costs $14,000 per case extra $AU4.3 million 3,000 extra bed days Attributable mortality 4-20% CLABSI preventable

Background CLABSI reduction projects Pronovost (2006) & others (15yrs) NSW CLAB ICU (2007-08) 3.0 → 1.2/1,000 WA Safety and Quality Investment for Reform (SQuIRe) Program 2006 → 0.55/1000

This project ACSQHC funded ANZICS National project Adult & paed ICU Public & private Build on existing work

Objectives Decrease rate of CLABSI in Australian ICUs to <1/1000 line days Accurately and consistently measure the rate of CLABSI in ICUs throughout Australia Timely reporting to clinicians Benchmarking

Preparation Review current practice (April/May 2010) Surveillance ICU Definition Reporting method & timeframe ICU CVL insertion Knowledge of surveillance

Surveillance Across Australia Majority data collected by ICPs A few ICUs collected some data Not all jurisdictions did CLABSI surveillance Inconsistent definitions, reporting (method & timing), benchmarking Variable practises in private sector No national reporting or benchmarking

ICU practice ICU Directors/Nurse Managers Survey 53/100 ICUs: 24 doctors, 39 RNs (not NSW, ACT) Variable knowledge of surveillance processes Some did not know CLABSI rate “but it’s low” Variable compliance with “best practice” re CVL insertion

ICU practice CVL insertion – total 51 ICUs have trolley/pack 76% wear hats 43% wear masks 43% Chlorhex handwash 88% sterile gown & gloves 100% Chlorhex & alcohol skin prep 100% full body draping 41%

Clinical practice CVL insertion & maintenance Chlorhex patch 20% Impregnated CVC 59% Chlorhex body-wash 25%

Schedule First Outcome assessment & national reporting both require national definition implementation/interpretation guide Then improve CVL insertion practises

National definition minimise change if possible numerator - NHSN 2008 denominator - line days implementation guide inc “other infection” definitions

National definition Am J Infect Control 2008:36;309-32

National definition All jurisdictions adopting as able New surveillance commencing

National reporting No duplication at any step Jurisdictions forward data to ANZICS if they already collect it (hospital-level data only) Some individual public & private hospitals forward data to ANZICS (if above n/a)

National reporting ANZICS generate reports Secure log-in Access: Self vs other SA ICUs Self vs other in same CICM level/other PICUs nationally Self vs all in Australia Secure log-in Access: ICU director & NUM Inf Cont ? other

Monthly reporting

Annual report

Interim goals Foundations National definition √ Implementation (interpretation) guide √ National reporting √ Now Improve CVL insertion practises

Improving Central Line Insertion

Quality not research However.... Based on evidence derived from research Focus on sustainable practice vs short intervention process & outcomes ongoing measurement

Method - Clinical Practice Improvement Too complex & time-consuming ...

Method Keep It Simple Measure CLABSI Incorporate change into usual practise Review individual cases (ICU & IC +/- ID) Check compliance with insertion process Keep measuring CLABSI & review

Approach Assumptions relevant to Australia multidisciplinary clinical team ward rounds occur twice/day Establish multi-disciplinary project teams ICU director & nurse manager or senior dr & ns Infection Control/ID support Others as appropriate

Intervention Joint medical & nursing responsibility Insertion & maintenance guideline based on NHMRC/ACSQHC Guidelines CDC Expert group Core items Optional items

Insertion Maximum barrier precautions Hat Mask CHG handwash Sterile gloves & gown CHG & ETOH skin prep & allow to dry Full-body drape Maintain aseptic technique

Checklist

“Reminder” Proceduralist acknowledges he/she would like to be reminded if he/she misses one of the steps below; eg. “ I would like you to watch me and if you see that I forget an important step in the procedure I want you to tell me”

Other suggestions CVC (inc swan & vascath) trolley Appropriate site Options if rate higher than goal chlorhexidine patch at insertion site impregnated CVC daily chlorhexidine body wash Maintenance Very limited re-wiring of existing lines Replace lines with a blocked lumen No disconnection & re-connection of lines (inc HF)

Guideline contents Scope Definitions Selecting a central line Selecting a site Aseptic technique Maximum barrier precautions Stopping the procedure if asepsis breached Daily review local infection need for line

Guideline contents Line replacement inc re-wiring Blocked lumens Changing fluids & administration sets Needleless connectors Dressings CHG patches Drug administration (CHG & ETOH swabs) CHG body wash

Support Website CVC insertion & maintenance guideline References Audit tools/checklist Line day calculator Secure discussion forum ANZICS CLABSI Reporting Program

What now? Establish CLABSI reporting process Form the team - Dr, Ns, ICP, ?other Review your protocol Identify changes required & materials needed (eg. trolley, big drapes, ?culture) Develop education strategies for all staff Implement changes Check compliance Review CLABSI rate & compliance

Counting line-days Line day counts should be done 3 times a week, eg. Mon, Wed, Fri At the same time By asking the question: Does this patient have a central line, PA catheter/swan, swan sheath, vascath (or other haemofiltration catheter), or a PICC? This job does not require nursing/technical knowledge This is done by Infection Control in Vic & WA public ICUs

Counting line-days Mon Tues Wed Thurs Fri Sat Sun Bed 1 1 Bed 2 Bed 3 Bed 2 Bed 3 Bed 4 Total 2 3 1 means the patient in that bed has at least 1 central line 0 means either the bed is empty, or the patient doesn’t have a central line

Thankyou gabrielle.hanlon@anzics.com.au www.clabsi.com.au