1. © 2009 CSTS: The Cardiovascular Surgical Translational Study Using the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN) for CLABSI Surveillance in Adult ICUs

2. © 2009 Learning Objectives To review the NHSN definition of a central line To review the NHSN definition of bloodstream infection (BSI) To review the NHSN denominator definition for calculating CLABSI rates in adult ICUs

3. © 2009 What is a Central Line? An intravascular catheter that terminates at or close to the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring. – Great vessel: aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins, and common femoral veins – Infusion: introduction of a solution through a blood vessel via a catheter lumen The location of the insertion site and type of device are NOT relevant

4. © 2009 What is a Central Line? Non-tunneled central lines Tunneled central lines Introducers Implanted ports Hemodialysis catheters Peripherally inserted central catheters (PICCs) Femoral artery catheter Pacemakers Implanted cardiac defibrillators Radial, dorsalis pedis, brachialis, ulnar arterial lines The following are examples of central lines, as long as they terminate at or close to the heart or in one of the great vessels NOTE: This list is not inclusive The following are examples of devices that are not central lines NOTE: This list is not inclusive

5. © 2009 Data That Need to Be Collected For determining CLABSI rate – Numerator: number of CLABSIs – Denominator: number of central line-days – Expressed as a rate of X CLABSI/1,000 central line days #CLABSI/# central line days X 1000 For determining the Central Line Utilization Ratio – Numerator: number of central line-days – Denominator: number of patient-days

6. © 2009 The Numerator

7. © 2009 Definition of BSI in Adults Criterion 1: Patient has a recognized pathogen cultured from one or more blood cultures AND Organism cultured from blood is not related to an infection at another site.

8. © 2009 Definition of BSI in Adults Criterion 2: Patient has at least one of the following signs or symptoms: fever (>38oC), chills, or hypotension AND Signs and symptoms and positive laboratory results not related to an infection at another site AND Common skin contaminant is cultured from two or more blood cultures drawn on separate occasions. – Blood from ≥ 2 blood draws collected within 2 days

9. © 2009Microbiology Diphtheroids: Corynebacterium spp. Bacillus spp. – Not B. anthracis Propionibacterium spp. Coagulase-negative staphylococci – Including S. epidermidis Viridans group streptococci Aerococcus spp. Micrococcus spp. S. aureus Enterococcus spp. E. coli Pseudomonas spp. Klebsiella spp. Enterobacter spp. Citrobacter spp. Serratia marcescens Acinetobacter spp. Candida spp. Examples of Common Skin Contaminants (not inclusive) Examples of Common Recognized Pathogens (not inclusive)

10. © 2009 When Are Organisms the Same? If isolates are identified to the species level in one culture, and with only a descriptive name (i.e., to the genus level) from the other culture If isolates are speciated but no antibiograms are done or done for only one of the isolates

11. © 2009 When Are Organisms Not the Same? If isolates have different antibiograms for two or more antimicrobial agents – For the purpose of NHSN antibiogram reporting, the category interpretation of intermediate (I) should NOT be used to distinguish whether two organisms are different

12. © 2009 Timing of CLABSI Central line-associated BSI – A central line was in place at the time of onset of the event OR – A central line was in place within 48 hours before onset of the event There is no minimum period of time that the central line must be in place in order for the BSI to be considered central line-associated

13. © 2009 Location of Attribution The patient care area where the event became evident – CLABSIs in patients with central lines placed in non- inpatient areas (emergency department, operating room) are attributed to the inpatient unit – Transfer Rule: If a CLABSI develops within 48 hours of transfer from one inpatient location to another in the same facility, the infection is attributed to the transferring location

14. © 2009 Entering Numerator Data The Primary Bloodstream Infection (BSI) Form (CDC 57.108) is used to collect and report each CLABSI that is identified during the month Other data requested – Specific criteria met for identifying the primary BSI – Whether the patient died – Causative organisms – Organisms’ antimicrobial susceptibilities.

15. © 2009 The Denominator

16. © 2009 Collecting Central Line Days For ICUs, the number of patients with one or more central lines of any type is collected daily, at the same time each day, and then summed – The total is reported for the month on the Denominators for Intensive Care Unit (ICU)/Other Locations (Not NICU or Specialty Care Area (SCA)) (CDC 57.118).

17. © 2009 Collecting Central Line Days: Multiple Lines in an ICU Patient If a patient has more than one central line (permanent or temporary) on a given day, count the day as only one central line day.

18. © 2009 Action Items Verify that the infection control group in your institution is collecting CLABSI rates based on the NHSN definitions for what is a central line and what is a BSI Verify that both catheters days and patient days are being collected correctly in the ICU(s)

19. © 2009References National Healthcare Safety Network (NHSN): Overview of the Patient Safety Component, Device-associated module (CLASI) – http://www.cdc.gov/nhsn/PDFs/pscManual/4P SC_CLABScurrent.pdf http://www.cdc.gov/nhsn/PDFs/pscManual/4P SC_CLABScurrent.pdf