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

2. 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

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

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

5. 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

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

7. 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

8. 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

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

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

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

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

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

15. National definition All jurisdictions adopting as able
New surveillance commencing

16. 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)

17. 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

18. Monthly reporting

19. Annual report

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

21. Improving Central Line Insertion

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

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

24. 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

25. 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

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

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

28. Checklist

29. “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”

31. 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)

32. 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

33. 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

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

35. 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

36. 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

37. 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

40. Thankyou