CLABSItoolkit.ppt

CentralLine-AssociatedBloodstreamInfections(CLABSI)inNon-IntensiveCareUnit(non-ICU)SettingsToolkitActivityC:ELCPreventionCollaboratives,Draft-1/22111/09-Disclaimer:ThefindingsandconclusionsinthispresentationarethoseoftheauthorsanddonotnecessarilyrepresenttheofficialpositionoftheCentersforDiseaseControlandPrevention.,AlexKallen,MD,MPHandPritiPatel,MD,MPHDivisionofHealthcareQualityPromotionCentersforDiseaseControlandPrevention,Outline,BackgroundImpactHHSPreventionTargetsPathogenesisEpidemiologyPreventionStrategiesCoreSupplementalMeasurementProcessOutcomeToolsforImplementation/Resources/References,Background:Impact,Bloodstreaminfections(BSIs)areamajorcauseofhealthcare-associatedmorbidityandmortalityUpto35%attributablemortalityBSIleadstoexcesshospitallengthofstayof24daysCentralLine(CL)useamajorriskfactorforBSIMorethan250,000centralline-associatedBSIs(CLABSIs)inUSyearlyRatesofCLABSIappeartovarybytypeofcatheter,Pittetetal.JAMA1994;2711598-1601.Klevensetal.PublicHealthReports2007;122:160-6.,Background:HHSPreventionTargets,PreventionofCLABSIsinIntensiveCareUnits(ICUs)and“otherlocations”have2associatedgoalsinHHSHAIPreventionPlan:-ReduceCLABSIsby50%-100%adherencewithCLinsertionpracticesinnon-emergentsituations,Background:ImpactOutsidetheICU,MostworkaimedatreducingCLABSIsinthehospitalhasbeendoneinICUsManyCLsarefoundoutsideICUsInonestudy55%ofICUpatientshadCL;24%ofnon-ICUpatientshadCLHowever,asmorepatientsarelocatedoutsideoftheICU,70%ofhospitalizedpatientswithCLswereoutsidetheICU,Climoetal.ICHE2003;24:942-5.,Background:ImpactCLABSIRates,CLABSIratesoutsideICUsmaybesimilartoratesoftheseinfectionsinICUsAlthoughdataaresparse,inonestudyCLABSIrateswere:5.7per1,000catheter-daysin4inpatientwards5.2per1,000catheter-daysformedicalICU,Marschalletal.InfectControlHospitalEpidemiol2007;28:905-9.,Background:ImpactNationalHealthcareSafetyNetwork(NHSN)CLABSIRates,From20062008NHSNreport,pooledmeanCLABSIrateswere:Medical-SurgicalICUs=1.5to2.1per1,000catheter-daysMedical-Surgicalwards=1.2per1,000catheter-days,EdwardsJR,etal.AmJInfectControl2009;37:783-805.,Background:ImpactCLABSIinOutpatientSettings,Anumberofpatientgroupsmayhavelong-termCLsasoutpatientsHemodialysisMalignancyGastrointestinaltractdisordersPulmonaryhypertensionRatesofCLABSImaybeashighasthoseseeninICUsInhemodialysis-1to4per1,000catheter-days,Background:PathogenesisCLABSI,MoreCommonMechanisms1.Pathogenmigrationalongexternalsurface-morecommonearly(10daysLessCommonMechanisms1.Hematogenousseedingfromanothersource2.Contaminatedinfusates,HICPAC.GuidelineforPreventionofIntravascularDevice-RelatedInfections.1996,HubContamination,ContaminatedInfusate,Hematogenousspread,ExtraluminalContamination,HealthcarePersonnelHandContamination,Contaminationofinsertionsite,-49.6%*,-70.1%*,*P=0.02*P0.0001,Background:EpidemiologyALLICUTYPES:RatesofMethicillin-ResistantandMethicillin-SusceptibleStaphylococcusaureusCLABSIsUnitedStates,1997-2007,Burtonetal.JAMA2009;301:727-36.,MRSACLABSI,MSSACLABSI,AreCLABSIRatesfalling?DatafromNHSNforICUssuggestratesofMRSAandMSSAcentralline-associatedBSIsarefallingintheU.S.,Background:EpidemiologyModifiableRiskFactors,Background:PreventionStrategiesInterventions,PittsburghRegionalHealthInitiativeDecreaseinCLABSIsin66ICUs(68%decrease)InterventionsPromotionofbestpracticesMaximalbarrierprecautionsUseofchlorhexidineforskincleansingpriortoinsertionAvoidanceoffemoralsiteforCLUseofrecommendedinsertion-sitedressingpracticesRemovalofCLwhennolongerneededEducationalmoduleaboutBSIpreventionEngagementofleadershipandcliniciansStandardtoolsforrecordingadherencetobestpracticesStandardizingcatheterinsertionkitsMeasurementofCLABSIandreportingofratesbacktofacilities,CDC.MMWR2005;54:1013-6.,Background:PreventionStrategiesInterventions,MichiganKeystoneProjectDecreaseinCLABSIin103ICUsinMichigan(66%reduction)Basicinterventions:HandhygieneFullbarrierprecautionsduringCLinsertionSkincleansingwithchlorhexidineAvoidingfemoralsiteRemovingunnecessarycathetersUseofinsertionchecklistPromotionofsafetyculture,Pronovostetal.NEJM2006;355:2725-32.,Background:OntheCUSP:StopBSIproject,ThisnationalprogramisacollaborationbetweenHealthResearchandEducationalTrustJohnsHopkinsUniversityQualityandSafetyResearchGroupMichiganHealthandHospitalAssociationKeystoneCenterforPatientSafetyandQualityBuildsonsuccessesinMichiganKeystoneprojectCLABSIpreventionbundleCollaborativemodelPromotionofsafetycultureHospitalsinall50states,theDistrictofColumbia,andPuertoRicoareeligibletoparticipate,PreventionStrategies,CoreStrategiesHighlevelsofscientificevidenceDemonstratedfeasibility,SupplementalStrategiesSomescientificevidenceVariablelevelsoffeasibility,*TheCollaborativeshouldataminimumincludecorepreventionstrategies.Supplementalpreventionstrategiesalsomaybeused.MostcoreandsupplementalstrategiesarebasedonHICPACguidelines.StrategiesthatarenotincludedinHICPACguidelineswillbenotedbyanasterisk(*)afterthestrategy.HICPACguidelinesmaybefoundat,PreventionStrategies:Core,RemovingunnecessaryCLFollowingproperinsertionpracticesFacilitatingproperinsertionpractices*ComplyingwithhandhygienerecommendationsAdequateskinantisepsisChoosingproperCLinsertionsitesPerformingadequatehub/accessportdisinfectionProvidingeducationonCLmaintenanceandinsertion,*Notpartof2002HICPACGuidelinesforthePreventionofIntravascularCatheter-RelatedInfections,PreventionStrategies:CoreRemovingUnnecessaryCL,Inonestudy,9%ofCLsoutsideofICUdeemedinappropriatePerformdailyassessmentoftheneedfortheCLandpromptlydiscontinueCLsthatarenolongerrequiredNursingstaffshouldbeencouragedtonotifyphysiciansofCLsthatareunnecessaryUseperipheralcathetersinsteadThesegenerallyhavelowerratesofBSIsthanCL,Tricketal.InfectControlHospitalEpidemiol2004;25:266-8.,PreventionStrategies:CoreProperInsertionPractices,Ensureutilizationofinsertionbundle:ChlorhexidineforskinantisepsisMaximalsterilebarrierprecautions(e.g.,mask,capi.e.,similartothosewornintheO.R.,gown,sterilegloves,andlargesteriledrape)HandhygieneManyCLsinpatientsonnon-ICUhospitalwardsareplacedoutsidethosewards(Emergencyroom,ICU,Operatingroom,orPre-operativeareas)Inonestudy,49%ofCLswerepresentonadmissiontotheward.RatesofBSIinthisstudywerehigherinCLsplacedinEmergencyRoomDefinewhereplacementoccursandreviewtechniqueinthoseareas,Tricketal.AmJInfectControl2006;34:636-41.,PreventionStrategies:CoreFacilitatingProperInsertionPractices*,“Bundling”allneededsuppliesinonearea(e.g.,acartorakit)helpsensureitemsareavailableforuseUseofa“checklist”toensureallinsertionpracticesarefollowedmaybebeneficialEmpoweringstafftostopanon-emergentCLinsertionifproperproceduresarenotfollowedPromotingsafetyculture,*Notpartof2002HICPACGuidelinesforthePreventionofIntravascularCatheter-RelatedInfections,PreventionStrategies:CoreHandHygiene,HandhygieneshouldbeacornerstoneofCLABSIpreventioneffortsForbothinsertionandmaintenanceAspartofahandhygieneintervention,consider:Ensuringeasyaccesstosoapandwaterandalcohol-basedhandgelsEducationforHCPandpatientsObservationofpractices-particularlyaroundhigh-riskprocedures(beforeandaftercontactwithCL)Feedback“Justintime”feedbackiffailuretoperformhandhygieneobserved,PreventionStrategies:CoreChlorhexidineSkinCleansing,ChlorhexidineisthepreferredagentforskincleansingforbothCLinsertionandmaintenanceTinctureofiodine,aniodophor,or70%alcoholarealternativesRecommendedapplicationmethodsandcontacttimeshouldbefollowedformaximaleffectPriortouseshouldensureagentiscompatiblewithcatheterAlcoholmayinteractwithsomepolyurethanecathetersSomeiodine-basedcompoundsmayinteractwithsiliconecatheters,PreventionStrategies:CoreCLSiteChoice,Foradultpatientsreceivingnon-tunneledCL,femoralsiteshouldbeavoidedduetoanincreasedriskofinfectionanddeepvenousthrombosisNote:Inpatientswithrenalfailure,subclaviansiteshouldbeavoidedtominimizestenosiswhichmaylimitfuturevascularaccessoptions,PreventionStrategies:CoreHub/accessportcleansing,BSI“outbreaks”havebeenassociatedwithfailuretoadequatelydecontaminatecatheterhubsorfailuretochangethematappropriateintervalsCleansehubspriortousewithanappropriateantiseptic(e.g.,70%alcohol)Manufacturerrecommendationsregardingcleansingandchangingconnectorsshouldbefollowed,PreventionStrategies:CoreCLMaintenanceandInsertion:Education,PersonnelresponsibleforinsertionandmaintenanceofcathetersshouldbetrainedanddemonstratecompetenceRecurrenteducationalsessionsforstaffwhocareand/orinsertCLs,PreventionStrategies:Supplemental,Supplementalstrategiesinclude:Chlorhexidinebathing*Antimicrobial-impregnatedcathetersChlorhexidine-impregnateddressings*,*Notpartof2002HICPACGuidelinesforthePreventionofIntravascularCatheter-RelatedInfections,PreventionStrategies:SupplementalChlorhexidineBathing*,InanICUatasinglecenter,dailybathingwith2%chlorhexidine-impregnatedclothsdecreasedtherateofBSIscomparedtosoapandwaterNodataoutsidetheICU,Bleasdale,etal.ArchInternMed2007;167:2073-9.,*Notpartof2002HICPACGuidelinesforthePreventionofIntravascularCatheter-RelatedInfections,PreventionStrategies:SupplementalAntimicrobial-ImpregnatedCatheters,2typeswithmostsupportingevidence:Minocycline-RifampinChlorhexidineSilverSulfadiazinePlatinum-SilvercatheteravailablebutlessevidencetosupportuseThesemaybeappropriateforpatientswhosecatheterisexpectedtobeusedformorethan5daysandwhenCorestrategieshavenotdecreasedratesofCLABSItoestablishedgoals.,PreventionStrategies:SupplementalChlorhexidineDressings*,Chlorhexidine-impregnatedspongedressingshavebeenshowntodecreaseratesofCLABSIsinsomestudiesandnotinothers.ThesedressingsmaybeanoptionwhenCoreinterventionshavenotdecreasedratesofCLABSItoestablishedgoals,*Notpartof2002HICPACGuidelinesforthePreventionofIntravascularCatheter-RelatedInfections,SummaryofPreventionStrategies*,RemovingunnecessaryCLFollowingproperinsertionpracticesFacilitatingproperinsertionpractices*ComplyingwithhandhygienerecommendationsPerformingadequateskincleaningChoosingproperCLinsertionsitesPerformingadequatehub/accessportcleaningProvidingeducationonCLmaintenanceandinsertion,Implementingchlorhexidinebathing*Usingantimicrobial-impregnatedcathetersApplyingchlorhexidinesitedressings*,CoreMeasures,SupplementalMeasures,*Notpartof2002HICPACGuidelinesforthePreventionofIntravascularCatheter-RelatedInfections,Measurement,WithCLABSImeasurementitisimportanttoHaveadefinitionthatisconsistentbetweensitesCollectingbloodculturesinasimilarfashionForrecommendedindicationsViaaperipheralvenipuncturevs.viaaCL,Measurement:ProcessMeasures,ProcessmeasurescanhelpdetermineifinterventionsarebeingfullyimplementedEnsuringinterventionsarebeingperformedisitselfa“core”interventionPotentiallyimportantprocessmeasurestoconsiderare:HandhygieneadherenceProportionofpatientswithCLs,and/ordurationofCLuseProportionofCLinsertionsinwhichmaximalbarrierprecautionswereusedConsiderusingNHSNCentralLineInsertionPractices(CLIP)option,Measurement:OutcomeCalculatingCLABSIRates,Stratifyby:TypeofICU/OtherLocationForspecialcareareasCathetertype(temporaryorpermanent)ForneonatalintensivecareunitsBirthweightcategoryCathetertype(umbilicalorcentral),Measurement:OutcomeDeviceUtilization(DU)Ratio,CLDURatio,=,#centralline-days,#patient-days,DURatiomeasurestheproportionoftotalpatient-daysinwhichcentrallineswereused.,Measurement:ProcessCLIPAdherenceRates,UsingNHSN,adherenceratescanbecalculatedfor:HandhygieneBarrierprecautionsusedincludingmasks,steriledrape,gownsandsterileglovesSkinpreparationincludingtypeofagentandwhetheragentwasallowedtodryOthermeasurescollectedintheNHSNCLIPoptionthatcanbesummarizedinclude:CLtype,location,andnumberoflumensAntisepticointmentappliedtosite,HandHygieneAdherenceRate,=,#handhygieneperformedforCLinsertion,#CLinsertionsrecordscompleted,AdherenceratescanalsobemeasuredforeachofthebarrierandpreventionpracticesbyusingthenumberofCLIPrecordscompletedasthedenominator.,Measurement:ProcessCalculatingCLIPAdherenceRates,ToolsforImplementationNHSNCLIPOption:InsertionPractices,EvaluationConsiderations,AssessbaselinepoliciesandproceduresAreastoconsiderSurveillancePreventionstrategiesMeasurementCoordinatorshouldtracknewpolicies/practicesimplementedduringcollaboration,References,BleasdaleSC,TrickWE,GonzalezIM,etal.Effectivenessofchlorhexidinebathingtoreducecatheter-associatedbloodstreaminfectionsinmedicalintensivecareunitpatients.ArchInternMed2007;67:2073-9.BurtonDC,EdwardsJR,HoranTC,etal.Methicillin-resistantStaphyloccusaureuscentralline-associatedbloodstreaminfectionsinUSintensivecareunits,1997-2007.JAMA2009;301:727-36.CDC.Reductionincentralline-associatedbloodstreaminfectionsamongpatientsinintens