1. Central Line-Associated Blood Stream Infections (CLABSI)
Good afternoon
My name is….. I have been in the nursing profession for 30 years, 17 of which have been at the Dotter Interventional Radiology institute in Portland, acting as Lead Nurse and Staff Educator.
And Yes…. I’m from England and not Australia 
The Impact of your Practice
PRESENTED BY: Henriette Blanchard R.N, BSN,
Dotter Interventional Radiology, OHSU, Portland, Oregon

2. Objectives
1. CLABSI incidence and burden 2. CLABSI Standards of Care 3. OHSU experience with CLABSI quality improvement initiative
I’m excited to bring the topic of CLABSI to you, but I was daunted at the challenge of distilling so much good information into such a brief presentation, so please feel free to ask questions at the conclusion of my presentation or find me afterwards

3. Central Line - Associated Blood Stream Infection (CLABSI)
Definition:
A laboratory confirmed blood stream infection (not related to an infection at another site) where a central line was in place within 48 hour period before the development of a bloodstream infection (BSI)
So what is the definition of CLABSI?
Read the definition off the powerpoint
For those of you involved with the insertion of central lines, you should be aware that a CLABSI within 14 days of insertion date, can be attributed to insertion technique or practice
Haddadin Y, (2018)

4. HAI Estimates Occurring in US Acute Care Hospitals, 2011
Here’s a little statistical background information
Hospital Acquired Infections are also referred to as HAI’s
This table shows the estimated numbers of HAI’s per year in the US
In 2011 there were an overall estimated 722,000 infections.
Although primary blood stream infections have the lowest incidence, they are one of the most deadly
It is estimated that 75,000 patients with HAI’s died during their hospitalization.
Steps can be taken to control these infections in a variety of settings. Research shows that when healthcare facilities, care team and individual doctors and nurses, are aware of infection problems and take specific steps to prevent them, rates of some targeted HAI’s such as CLABSI can decrease by more than 70 % .
Magill,S et al,. ( 2014)
Magill,S et al,. ( 2014)

5. CLABSI – Did you know? Estimated 30,100 / year in ICU’s
Mortality rate %
Cost per episode of care $3,700 -$36,000
National CLABSI decrease of 50 % between
Here are some tidbits of info…..
CLICK
CLABSI continues to be one of the most deadly and costly hospital-associated infections in the US. Many lives have been saved in the past decade due to improvements
HRET = Health Research & Education Trust
AHA = American Hospital Association
HEN = Hospital Engagement Network
HRET /HIIN = The HRET HIIN is the largest and most diverse HIIN with over 1,600 participating hospitals, 34 state hospital associations, 6 QIN-QIOs and more.
Health Research & Educational Trust. (2017)

6. Observed number of Infections (O) Predicted number of infections (P)
Standardized Infection Ratio (SIR)
Observed number of Infections (O) Predicted number of infections (P)
So, what is standardized Infection Ratio and what does it mean? You will see frequent SIR references by your institution or by reporting agencies, so I thought it useful that I throw this slide in.
SIR is a statistic used to track HAI’s over time, at a national, state or facility level. The SIR compares the actual number of HAI’s at each hospital to the predicted number of infections.
The predicted number is an estimate based on national baseline data, and is risk adjusted. Risk adjustment takes into account that some hospitals treat sicker patients than others
Statistical tests are used to see if the difference between the number of actual infections, and the number of predicted infections are due to just chance alone. If it is extremely unlikely that the difference is due to chance, then the difference is called “statistically significant.” 
To keep things easy, when you review your SIR numbers, Remember <1 good , > 1 not so good
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(If the SIR is 1, then the number of actual infections is the same as the number of predicted infections
If SIR is less than 1, then the number of actual infections is less than the number of predicted infections
If the SIR is greater than 1, then the number of actual infections is greater than the number of predicted infections)
National Center for Emerging Zoonotic Infectious Diseases, (2018)

7. CLABSI Reduction and Location
Hospitals have made a significant progress in preventing CLABSI- nationally there has been a roughly 50% drop in CLABSI between 2008 and 2016 as is demonstrated in the bar graph
The pie chart shows the proportion of CLABSI by location.
37.3 % are attributed to ICU (Grey), whereas 55.3 % are attributed to the ward (black) and 7.4 % to NICU (light grey)
The incredible progress, reflects outstanding collaborative efforts among healthcare providers, supported by national prevention efforts led by the CDC, state health departments, centers for Medicare and Medicaid and Hospital Engagement Networks amongst others
Centers for Disease Control and Prevention, 2016)

8. CLABSI Reduction
I wanted to give you some perspective on what difference your practice makes
This first table shows data from the Hospital Engagement Network (HEN. It shows the results of CLABSI initiatives in acute care hospitals from 2011 – 2014, submitted by over 1,600 participating hospitals spanning 34 state hospital associations.
It shows an astounding 46 % CLABSI reduction and $15 million in cost savings
The second table continues tracking the CLABSI reduction work from with an additional 11 % reduction and $7.5 million in cost savings
(If you are looking to bring about change at your institution and are overwhelmed by the amount of information available on the CDC web site, then I encourage you to review the source for this data from the Health Research & Education Trust “Change Packet”. The “change packet is easily digestible and has many links to further resources.)
HRET = Health Research & Education Trust
AHA = American Hospital Association
HEN = Hospital Engagement Network
HRET /HIIN = The HRET HIIN is the largest and most diverse HIIN with over 1,600 participating hospitals, 34 state hospital associations, 6 QIN-QIOs and more.
Health Research & Educational Trust, (2017)

9. CLABSI Prevention Bundles
Insertion bundle: procedural pause, hand hygiene, aseptic technique, optimal site selection chlorhexidine skin prep and maximum sterile barrier precautions
Maintenance bundle: CVC dressing changes, tubing changes, IV fluid changes, daily review of line necessity with timely removal
Much of the success in the overall HAI and CLABSI reduction rates, can be given to the introduction of “bundles”
Click
The two bundles for CLABSI are the insertion and maintenance bundles. These have standardized the approach to central line insertion and care, based on evidence based practice.
In our department we looked at what other aspects we could optimize or augment for the CLABSI insertion bundle.
Most patients can expect to use their tunneled central lines for at least 3 months, which translates into over 2,000 hours. These patients are in our care for just minutes and yet the brief time they spend with us during their catheter insertion, can set them up for a CLABSI free experience
Health Research & Educational Trust, (2017)

10. “Houston, we have a problem...”
As a department, we thought we were doing a pretty good job with our insertion practice, until a cluster of CLABSI infections was bought to our attention in 2014
This prompted an immediate in depth review of each case and led to many multidisciplinary meetings with infection preventionists, our medical director, managers, nurses, techs and quality improvement. We observed our practice, audited it, interviewed staff, brain stormed and tried to eliminate any overlooked weak links in the bundle.
Our general findings found we were inconsistent or omitting some key aspects of the insertion bundle, such as ensuring patients had received a chlorhexidine wipe pre procedure, or providing maximum barrier protection
This timeline briefly highlights some key points in our journey, when we reviewed how well we were implementing our bundle, when we reinforced aspects of it, or when we introduced new CLABSI prevention strategies.
Our CLABSI reduction success can be attributed to our multidisciplinary work and the “buy in” from all levels, particularly from leadership. All staff - Attendings, fellows, residents, techs and nurses, were educated into the why and how. This was a pivotal moment in taking our CLABSI reduction to the next level.

11. What did our observations reveal and what did we do about it?
Pre Procedure
No hat/crown
Facial hair
Did her majesty use a CHG wipe?
Wearing bling
Here’s Liz, my BFF modeling some dont’s
Pre procedure:
We identified some frequent inconsistencies
1). The CHG wipe pre procedure may not have been done or may have omitted key areas as behind earlobes and armpits
2)Patients were arriving with bling: earrings, necklaces….
3) Patients with long hair did not have their hair up in hats especially after their chlorhexidine wipe
4) Men with long beards were not being prompted to use beard covers or sometimes even refusing to clip their beards to chin level
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CLICK
Showing my age here…..This is what my uniform looked like in England. Wearing scrubs and tennis shoes here….PROGRESSIVE!!
So lets’ pretend this group of nurses are assessing their procedure room and practice, and are looking for ways for improve their CLABSI numbers
Some of the observations and subsequent changes we made were obvious and some more subtle:
We switched from multi-use ultra sound gel bottles to single use packets
We wipe off gel and then cleanse the skin with soapy towelettes to remove residue in order to maximize CHG skin contact
We changed to larger CHG prep sticks
We ensure the order of events when prepping the patient. Ie Applying all monitoring, nasal cannula BEFORE skin prepping starts
We ensure that the sterile drape reaches below the table
We stopped “cutting windows” into the drape for patient comfort. Now we use a nifty device to hold the drape away from the face that still allows us to maintain the integrity of the sterile field and visualize the patient
We ensure all dressings and catheter flushing is done BEFORE the sterile drape is dc’d
Intra Procedure
Photos courtesy of my personal archive

12. Reasons for Premature Dressing Changes
1. Bleeding from site: Dressing changed < 7 days
2. Dressings not adhering well: Dressing changed < 7 days
3. Dressings not applied correctly: Dressing changed < 7 days
4. Dressings, sutures or site choice uncomfortable or painful for patient: Dressing changed < 7 days
For a long time we were measuring just our overall CLABSI numbers…
Assuming we were sticking to our standard work, we were still seeing far too many dressings being changed prematurely. We realized that the next step would be to measure how many dressings were being changed early and for what reason. Some of the reasons were in our control and some not. For example…. It became apparent that the floors did not have a large enough waterproof dressing cover for showers and dressings were being changed as they were getting wet. Appropriate supplies were brought in , and floor staff educated.
This surveillance gave us valuable insight into the many reasons for premature dressing changes. The data and feedback allowed us to tailor and target IR specific actions. We have little control over certain reasons, such as dressings getting wet in showers, but we do have control over some of the other top identified culprits.
Poor hemostasis;
We serve a high risk population that are prone to bleeding- oncology and dialysis patients
We realized that antimicrobial discs have no hemostatic properties
We therefore started to use a hemostatic agent that happened to also lower the PH of the skin beneath it to <2. This agent comes in a disc or powder form and is left in place for the first 7 days, after which it would be switched to an antimicrobial disc
2) Dressings not adhering well:
We found a better performing dressing and switched manufacturer.
3) Dressings not applied correctly:
We provided extensive staff education of correct application technique
Dressing, sutures or site choice uncomfortable:
We again provided extensive staff education, which included reminders to not stretch dressings, ensure that no “skin folds” were caught in dressing and to carefully consider the exit site and where the dressings, catheter tails and clamps will be. It was not uncommon that the dressing, tails or clamps would be positioned directly over nipples or in the armpits

13. Observations? Here’s a quick example of one of our audits
A floor nurse contacted us regarding a new central line dressing that was causing the patient significant pain and discomfort that she was about to change. Thanks to her reaching out to us, we were able to photograph the dressings and identify some key issues. We could give immediate feedback to providers and staff involved.
1) Disc tilted- no 360 degree contact. The disc efficacy has not been optimized
2) There is no room between the catheter exit site and the sutured wing. The disc is forced to tilt.
3) The dressing is “stretched”, pulling on the patients skin
4) There is some old oozing from the suture sites. The suture sites have no contact with the disc. It therefore provides a friendly habitat for your neighborhood microbe
This photograph gave us a wealth of information that lead onto our next steps

14. Vertical Mattress Suture Technique
2.0 VICRYL SUTURE
Dissolvable
Keeping in mind the main reasons for premature dressing changes, we introduced the Vertical mattress suture technique with a dissolvable 2.0 Vicryl suture.
Our goals were to
Minimize oozing from the catheter tract, which is achieved here by the suture cinching around the catheter to create a tight fit
Eliminate the risk of oozing from the suture sites, because we no longer need to use sutures to secure the catheter to the skin
Allow us to place a disc or powder with full 360 degree contact to maximize the hemostatic and antimicrobial properties
By not having the catheter sutured to the skin we can maneuver the catheter tails to a more comfortable position before pacing the dressing.
This has made it easier to turn the catheters away from armpits, nipples etc and has thereby reduced the number of dressing changes for patient comfort
Eliminate the need for suture removal follow up. We were finding that many patients were being lost to follow up or were returning with infected suture sites
Optimize long maintenance care: Now the floor nurses can lift the catheter up and clean all the way around it and replace a disc with a 360 contact
Dissolvable vertical mattress suture used. 2.0 Vicryl

15. Our New Quality Improvement Goal
This table shows the results of our audits to minimize premature dressing changes. The arrows shows at what time point we introduced changes such as standard work, our hemostatic disc or powder and our new suture technique. We are making steady progress.
I am very excited to tell you that we are currently 140 days CLABSI free for IR insertion related CLABSI’s.

16. OHSU House-Wide CLABSI SIR by Quarter
If you recall from my previous slide explaining Standardized Infection Ratio where Anything <1 is “good” and > 1 “not so good”.
I just got our Q3 data yesterday which I’d like to share
This last quarter we hit green for the second time this year….ie it is statistical significant
Our 2018 data shows we have had a 53 % decrease in CLABSI’s.
What this translates into, is that we have had 25 fewer patients with CLABSI infections this year compared to this time last year!!
Stop and think about this…. These are 25 patients who’s lives we have directly impacted by our CLABSI work
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SW drafted in Aug 2016
Stat seal disc Feb 2017
Powder june 2017
New suture technique April 2018

17. CDC Recommendations Educate healthcare personnel
Periodically assess knowledge and adherence to guidelines
Designate only trained personnel for insertion and maintenance
Ensure appropriate nursing staffing levels
So what are the CDC’s recommendations? The following are category 1A recommendations, ie data that has shown to make an impact
Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections category 1A
Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters [7–15]. Category IA
Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters. [14–28]. Category IA
Ensure appropriate nursing staff levels in ICUs. Observational studies suggest that a higher proportion of “pool nurses” or an elevated patient–to-nurse ratio is associated with CRBSI in ICUs where nurses are managing patients with CVCs [29–31]. Category IB

18. What’s your Attitude to CLABSI’s?
Inevitable
Major Catastrophe
Before I conclude, I’d like to ask you to reflect on your attitude to all HAI’s including CLABSI
If you drive a car you, have a pretty high chance of being in some sort of fender bender sometime in your lifetime, or you may know of someone involved in a car crash or witness a major crash. It may not be unusual to hear “it wasn’t my fault” After all ….You’re a good driver. It’s all the other careless drivers out there that cause the accidents. They are distracted. They are on their phones, they are not paying attention. They are in a hurry.
Now think back to all those occasions you witnessed “little things” in the healthcare setting or even participated in. Little things such as not taking the time to wash your hands, not using an alcohol wipe before accessing a central line, or in the case of other HAI’s being more than a little blasé or lax in wearing isolation gowns and gloves.
Now view this though the eyes of your patient or their family. They don’t know about CLABSI or HAI’s. They trust their healthcare professionals to keep them safe. They trust you!
And then ……they get a CLABSI and learn it could have been prevented….. What would be going through their head?
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However, Now view CLABSI as if a major airline has crashed. It would make internationally news.
EVERYONE pays attention and there are exhaustive inquiries.
Airlines are held accountable for the safety and well being of all their staff and passengers.
In the event of an accident or near miss, they want to learn everything there is about the cause to prevent it from happening again.
There is a different EXPECTATION, CULTURE, ATTITUDE
WHY?????
In 2011 an estimated 75,000 people died from HAI’s in the US. That would be the equivalent of over 200 large passenger planes crashing EVERY YEAR in the US alone!
It’s a sobering thought …..

19. Conclusion What is CLABSI Incidence and burden of CLABSI
CLABSI bundles
A brief description of our quality improvement initiative
Reflect on your practice
Inspired you to learn more about CLABSI
So in conclusion…
I hope you will be able to walk away knowing a little more about CLABSI and the impact of your practice
Thank you!
Click through reference and on to quote page

20. Your practice makes a difference….
Everyday, you touch the lives of people who are at their weakest, frightened and uncertain of what is about to happen to them.
Getting an avoidable hospital infection is the last thing on their mind.
Be your patient’s advocate, especially when they don’t even know they need one.

21. References
Centers for Disease Control and Prevention. (2011). Guidelines for the Prevention of Intravascular Catheter-Related Infections. Retrieved from
Centers for Disease Control and Prevention. (2016). Healthcare-associated Infections in the United States, : A Story of Progress. Retrieved from
Centers for Disease Control and Prevention. (2018). Healthcare–associated Infections (HAI). HAI Data and Statistics. Retrieved from
Haddadin Y, Regunath H. Central Line Associated Blood Stream Infections (CLABSI) [Updated 2017 Mar 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Retrieved from :
Health Research & Educational Trust. (2017). Central Line-Associated Infections (CLABSI) Change Package: 2017 Update. Chicago, IL. Retrieved from
Magill, S.S., Edwards, J.R., Bamberg,W., Beldavs, Z,. Dumyati, G., Kainer, M.A,…et al (2014). Multistate Point Prevalence Survey of Health Care Associated Infections. The New England Journal of Medicine, 370: