From the 2024 HVPA National Conference
Shohan Shetty BS (University of Chicago Pritzker School of Medicine), Matthew Cerasale MD (The University of Chicago)
Background
A central-line associated bloodstream infection (CLABSI) is an infection attributed to an existing central line in the circumstances of a positive blood culture and lack of confirmed primary infectious site. CLABSIs lead to prolonged hospital stays, increased healthcare costs, and mortality. In the U.S., the CLABSI rate in intensive care units (ICU) is estimated to be at 0.8 per 1000 central line days. Due to their prevalence and serious consequences, minimizing the occurrence of CLABSIs is incredibly important. CLABSI cases can be preventable with proper aseptic techniques, surveillance, and effective management strategies.
Objective
The aim of this project is to implement a multimodal intervention to improve the use of practices that are known to decrease the incidence of CLABSI in our adult patient population by the start of fiscal year 2025.
Methods
The project is based in an urban academic tertiary referral center. The opportunities for decreasing CLABSI were identified after a review of the current state and available best practices. To support the review, a sample of CLABSI cases at the institution were evaluated for opportunities in improvement. The cases were evaluated by two reviewers on half of cases to ensure consistent assessments of appropriate initial central line type, appropriate ongoing need for central access, and situationally appropriate blood culturing practices. The opportunities and related potential interventions from the reviews and stakeholder discussions are summarized in Figure 1. The chosen interventions focused on providers, as nursing best practices were already in place. The specific opportunities were provider education on appropriate culturing practices led by physician champions, updated central line ordering set based on the Michigan Appropriateness Guide for Intravenous Catheters Recommendations, and provider documentation prompts for ongoing need for central access integrated into note templates. These interventions are planned for implementation by May-June 2024.
Results
A random sample of 20/35 (57%) adult CLABSI cases from fiscal year 2024 was chosen for detailed review. During that period of time, there were 4,961 line days. Within the sample, 100% (20/20) had appropriate initial line placement, 90% (18/20) had appropriate duration, and 60% had completely appropriate culture orders. Of the remaining, 40% (8/20) were deemed to be questionable based on suspected infection at the time, but no cultures were completely inappropriate. Overall improvement opportunities in CLABSI cases are summarized in Figure 2. Implementation process measures, including use of the order set and provider documentation of line necessity, will be assessed, in addition to a review of all subsequent CLABSI utilizing the same assessment methodology.
Conclusions
Central line type and duration were not major drivers of CLABSI cases, but were not perfect. Culture practices were identified as a larger opportunity than initially estimated during the stakeholder discussions. The planned multimodal provider intervention has measurable potential to improve practices and reduce future CLABSIs.
Clinical Implications
Changing provider practices related to central line use and cultures has the potential to impact CLABSI rates. Implementation of known best practices can have additional benefits to the patient, such as fewer line days and decreased frequency of inaccurately collected blood cultures.