CLAB HTG final v3 11 11 11 3

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Collaborative

To Prevent Central Line Associated

Bacteraemia

October 2011 to April 2013

“How-to Guide”

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Collaborative to Prevent Central Line Associated Bacteraemia

Zero Patient Harm, a CMDHB initiative aims to dramatically improve the safety of patients

by reducing healthcare associated harm. Healthcare Associated Infections (HAI) are a

leading cause of patient morbidity and mortality. This How-To Guide is designed to give

practical advice on how to reduce Central Line Associated Infections.

Acknowledgements: We wish to thank and acknowledge the following institutions for their

work in this area. This helped us to institute our programme and to write this How-to

Guide:

� The Institute for Healthcare Improvement – the bulk of this How-to Guide is informed

by the original IHI How-to Guide for its Saving 100,000 Lives campaign (available at

www.ihi.org), but has been modified as a result of our local experience.

� New South Wales Health – for their Clinical Indicator Manual on Healthcare

Associated Infection

� The Canadian ICU Collaborative Faculty and their Safer Healthcare Now! Campaign.

How to cite this material:

CMDHB Central Line Associated Bacteraemia How-to Guide. 2011 Ko Awatea, Counties

Manukau.

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Table of Contents Central Line Associated Bacteraemia (CLAB) Prevention in Intensive Care Units (ICU)... 4

Goal.................................................................................................................................... 4 Defining the problem of interest ........................................................................................ 4 Collaborative to Prevent Central Line Associated Bacteraemia ........................................ 7 Rationale for focusing on CLAB ....................................................................................... 7

The Central Line Bundle........................................................................................................ 7 Potential Impact of the Central Line Bundle ..................................................................... 8

International Evidence ................................................................................................... 8 Local Evidence............................................................................................................... 8

Implementing the Central Line Bundle of Care............................................................... 10 Hand Hygiene. ............................................................................................................. 10 Maximal Barrier Precautions ....................................................................................... 11 Chlorhexidine skin antisepsis. ..................................................................................... 12 Optimal Catheter Site Selection................................................................................... 12 Daily review of the necessity of a central line with prompt removal of unnecessary lines.............................................................................................................................. 13

Getting started...................................................................................................................... 13 Forming the team ......................................................................................................... 13 Setting Aims................................................................................................................. 14 “some is not a number, soon is not a time”................................................................. 14 Using the Model for Improvement .............................................................................. 14 Developing Checklists for the CLAB bundle of care .................................................. 15 Ensuring Adequate Blood Culture Collections............................................................ 16

Measurement........................................................................................................................ 18 Sentinel Event Process................................................................................................. 24 Barriers that may be encountered ................................................................................ 24

CLAB Prevention in other Hospital Areas .......................................................................... 25 Goal:................................................................................................................................. 25

Appendix 1 Insertion Checklist ........................................................................................... 27 Appendix 2 Maintenance Checklist ..................................................................................... 29 Appendix 3 CLAB sentinel Event review process .............................................................. 31 Appendix 4 Implementation checklist ................................................................................. 33

References........................................................................................................................ 34 This How-to-Guide is split into two parts: how to reduce CLAB in an Intensive Care Unit, and how to spread this practice to other areas in the hospital. It reflects on some f the lesson’s learnt (and still being learnt) from the CLAB prevention project started at CMDHB in 2008. This How-to-guide is not intended to be prescriptive, but rather a guide and a starting point that may be useful for other organisations.

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Central Line Associated Bacteraemia (CLAB) Preventi on

in Intensive Care Units (ICU).

Goal

To eliminate CLAB in the ICU through implementation of the CLAB Insertion and

Maintenance Checklists within 2 years.

Defining the problem of interest

CLAB is defined as a significant Blood Stream Infection (BSI) with no other apparent

focus of infection, which occurs in a patient who has a central line in place OR in a patient

who has had a central line removed within 48 hours of the BSI diagnosis. (1)

A Central Line is any bloodstream catheter that terminates in a great vessel (includes the

subclavian vein). They may be either centrally or peripherally inserted.

The National Healthcare Safety Network Definition (2) is used to determine whether a

bloodstream isolate is significant (see Table 1) and the hospital’s Infection Prevention &

Control team in conjunction with the Clinical Microbiology team need to establish and

follow a standardised approach to the determination of a CLAB.

The following is an outline of the process used at CMDHB for determining a hospital

acquired Bloodstream Infection (BSI) and whether that infection is primary i.e. related to

the presence of a central or peripheral vascular catheter, or secondary to another site of

infection using the following reference documents:

1. Place of acquisition.

Exclude all BSI that are community-acquired or related to another healthcare facility. So if

the blood culture is taken within 48 hours of admission and is not related to an admission or

surgical procedure within the last 30 days or a device inserted by own facility, this result

does not need further investigation for the purpose of CLAB surveillance.

2. Determine significance of the organism isolated.

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If the isolate is a recognised pathogen, this requires further investigation regardless of the

number of positive blood cultures.

If the isolate is a potential skin contaminant, then 2 or more sets of blood cultures drawn on

separate occasions within a 48 hour period must be positive in addition to signs and

symptoms consistent with a blood stream infection in order to proceed to the next step.

3. Focus of Infection.

If the patient had a central line in situ within 48 hours of the hospital-acquired BSI, then the

surveillance definition for a central line associated infection is met UNLESS infection at

another site meets the CDC definition for organ specific nosocomial infection.

Table 1 Definition of a central line associated bacteraemia for adults and paediatrics.

The bloodstream event must meet one of the following three criteria (criteria 1 and 2 may be used for

patients of any age, including < 1 year of age):

Criterion 1: Patient has a recognised pathogen

cultured from one or more blood cultures and

organism cultured from blood is not related to an

infection at another site. (See Notes 1 and 2 below.)

Criterion 2: Patient has at least one of the following

signs or symptoms:

� fever (>38°C); � chills; � or hypotension;

and displays:

� signs and symptoms of infection and positive

laboratory results are not related to an infection at

another site and common skin contaminant is

cultured from two or more blood cultures drawn

on separate occasions. (See Notes 3 and 4

below.)

Criterion 3: Patient < 1 year of age has at least one

of the following signs or symptoms:

• fever (> 38°C, rectal);

• hypothermia (<37°C, rectal);

• apnea;

• or bradycardia

and displays:

• signs and symptoms or infection and positive

laboratory results are not related to an infection

at another site and common skin contaminant is

cultured from two or more blood cultures drawn

on separate occasions. (see Notes 3, 4 and 5

below.)

Notes:

1. In criterion 1, the phrase “one or more blood cultures” means that at least one bottle from a blood draw

is reported by the laboratory as having grown organisms (i.e. is a positive blood culture.

2. In criterion 1, the term “recognised pathogen” does not include organisms considered common skin

contaminants (see criteria 2 and 3 for a list of common skin contaminants). A few of the recognised

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pathogens are S. aureus, Enterococcus spp., E. coli, Pseudomonas spp., Klebsiella spp., Candida spp.,

etc.

3. In criteria 2 and 3, the phrase “two or more blood cultures drawn on separate occasions,” means 1) that

blood from at least two blood draws were collected within two days of each other (e.g. blood draws on

Monday and Tuesday or Monday and Wednesday would be acceptable for blood cultures drawn on

separate occasions, but blood draws on Monday and Thursday would be too far apart in time to meet this

criterion), and 2) that at least one bottle from each blood draw is reported by the laboratory as having

grown the same common skin contaminant organism (i.e. is a positive blood culture). (See Note 4 for

determining sameness of organisms.)

a For example; an adult patients has blood drawn at 8 am and again at 8.15 am of the same day. Blood from each blood draw is inoculated into two bottles and incubated (four bottles total). If one bottle from each blood draw set is positive for coagulase-negative staphylococci, this part of the criterion is met.

b For example, a neonate has blood drawn for culture on Tuesday and again on Saturday and both grow the same skin contaminant. Because the time between these blood cultures exceeds the two-day period for blood draws stipulated in criteria 2 and 3, this part of the criteria is not met.

c A blood culture may consist of a single bottle for a paediatric blood draw due to volume constrains. Therefore, to meet this part of the criterion, each bottle from two or more draws would have to be culture-positive for the same skin contaminant.

Examples of common skin contaminants include diphtheroids [Corynebacterium spp.] Bacillus [not B.

anthracis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis],

viridans group streptococci, Aerococcus spp., Micrococcus spp.

4. There are several issues to consider when determining sameness of organisms.

a If the common skin contaminant is identified to the species level from one culture, and a companion culture is identified with only a descriptive name (i.e. to the genus level), then it is assumed that the organisms are the same if the antiobiogram is the same. The speciated organism should be reported as the infecting pathogen (see examples below).

b If common skin contaminant organisms from the cultures are speciated but no antibiograms are done or they are done for only one of the isolates, it is assumed that the organisms are the same.

c If the common skin contaminants from the cultures have antibiograms that are different for two or more antimicrobial agents, it is assumed that the organisms are not the same (see table below).

d For the purpose of antibiogram reporting, the category interpretation of intermediate (1) should not be used to distinguish whether two organisms are different.

5. For patients < 1 year of age, the following temperature equivalents for fever and hypothermia may be

used:

Fever: 38°C rectal/tympanic/temporal artery = 37°C oral = 36°C auxiliary Hypothermia: 37°C rectal/

tympanic/temporal artery = 36°C = 35°C axillary.

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Rationale for focusing on CLAB

Central Line Associated Bacteraemia (CLAB) is a serious iatrogenic infection, often

occurring in vulnerable, sick patients. Approximately 50% of ICU patients have a Central

Line in situ and in New Zealand there are 19,000 ICU admissions/year. CLAB account for

40-60% of nosocomial Blood Stream Infections (BSI) in intensive care units.

The mortality rate from CLAB has been estimated to be between 10 and 50% (3) (4) (5)

and nosocomial bloodstream infections prolong hospitalisation by a mean of 7 days. (4)

CLAB infections are also a significant cost to the healthcare system - the cost of each

CLAB has been estimated to be between $NZ 20,000 (6) and $54,000. (7)

The majority of CLAB are preventable. In the state of Michigan, 103 ICU units

implemented the CLAB checklists and bundle in 2004 and reduced the CLAB rate from a

mean of 7.7/1,000 line days to 1.4 (median rate fell from 2.7 to zero). (8) When re-

surveyed, the median CLAB rate was zero at 16-18 months, and remained zero at 34-36

months post implementation. It was estimated that the initiative saved over 1500 lives,

81,000 hospital days and $165 million dollars. (9)

So not only was zero CLAB a realistic target, but the gains were substantial and

sustainable.

The Central Line Bundle

The central line bundle is a group of evidence-based interventions that, when implemented

together, result in better outcomes that when implemented individually. The science

supporting each bundle component is established and can now be considered standard care.

(10)

The Central Line Bundle has five key components:

1. Hand hygiene

2. Maximal Barrier Precautions

3. Chlorhexidine skin antisepsis

4. Optimal Catheter site selection, with avoidance of the femoral vein approach

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5. Daily review of the necessity for the line, with prompt removal of unnecessary

lines.

The easiest way to ensure that all the elements of the bundle are used is to codify them into

two checklists – one for insertion and one for maintenance of a central line.

Potential Impact of the Central Line Bundle

International Evidence

In 2002 a study by Coopersmith et al (11) showed that a focussed education campaign for

ICU nurses was associated with a 66% reduction in CLAB rates. Higuera et al (12) showed

that a programme incorporating education, process control and feedback could significantly

reduce intravascular device bloodstream infections and mortality in Mexico. Berenholz et

al (13) showed in 2004 that five interventions could substantially reduce CLAB rates. The

interventions were:

• educating staff;

• creating a line insertion cart;

• asking providers daily whether lines could be removed;

• implementing a checklist; and

• empowering nurses to stop the insertion if the checks were not followed.

The CLAB rate dropped from 11.3/1000 line days to 0/1000 line days in Johns Hopkins

Hospital. The same team then showed that the process could be replicated in multiple ICU

sites, with a reduction of CLAB rates by 66% (2.7/1000 line days to 0/1000) in 103 ICUs in

Michigan state. (9)

Local Evidence

Implementation of the Central Line Bundle at CMDHB’s Critical Care Complex (ICU and

HDU) resulted in a reduction in CLAB. The programme started in December 2008 with the

insertion checklist; in July 2009 the maintenance checklist was added. Prior to this work

the absolute number of CLAB in 2008 was 14 at a rate of 6.6/1000 line days. In 2009 and

2010 despite a near doubling of admissions there were 4 CLAB and the rate had fallen to

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0.9/1000 line days (see Figure 1)1. In the first 6 months of 2011 there were no CLAB (a

rate of zero). However we then had a cluster of 5 CLAB in July/August and when these

were investigated it became apparent that our processes had slipped (see Figure 2). This

was an important reminder for the need to build in sustainability in processes.

Figure 1 CLAB rate per 1,000 line days (6 month rolling rate)

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Figure 2 CLAB rate per 1,000 line days (6 month rolling rate) – up-dated

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1 It was at this point that we submitted our paper to the NZMJ. Mary E Seddon, Catherine J Hocking, Pat Mead, Catherine Simpson Aiming for zero: decreasing central line associated bacteraemia in the intensive care unit. New Zealand Medical Journal. 29-July-2011, 124 No 1339

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Implementing the Central Line Bundle of Care

An important part of implementing the Bundle of Care is to use the evidence supporting

each component to appeal to medical staff in particular. The second approach is to stress

that standardisation for a procedure like central line insertion does not threaten a doctor’s

autonomy in other facets of the care provided.

“When placing a catheter, reliability not autonomy is needed.” (14)

And finally to relate the evidence of where the process has worked and the fact that many

areas are now seeing CLAB as mostly avoidable.

"Catheter-related infections should no longer be considered as an indirect tribute to

sophisticated care or regarded as a fate, but must become one of the priority targets of a

multidisciplinary approach emphasizing quality-of-care improvement.” (15)

Organize an education campaign for nursing staff, focussing on how to use the checklists

and general line care. Part of this education looks at how to work with the clinicians

inserting central lines, how to use the checklist as a supportive aid, and how to respectively

challenge non-adherence.

Hand Hygiene.

This first element in the bundle is well known, but not necessarily done effectively.

Washing hands or using alcohol-based gel to decontaminate the hands is important in

preventing central line sepsis.

Hand hygiene should be performed before and after palpating the catheter insertion site as

well as before and after inserting, replacing, accessing or dressing an intravascular catheter.

(16)

What changes can be made to increase compliance with hand hygiene?

• Include hand hygiene as part of Insertion Checklist

• Institute “naked below the elbow” in the ICU for doctors and nurses – this means no

watches, rings or bracelets (see figure 3)

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• Create an environment where reminding each other about hand hygiene is

encouraged

• Keep hand gel on insertion cart or at the end of every bed

• Monitor hand hygiene rates and post on patient safety boards.

Figure 3 The Naked Unit

Maximal Barrier Precautions

The maximal barrier precautions apply to both the patient and the inserter of the line.

Maximal barrier precautions - inserter:

• Cap – should cover all hair

• Mask – should cover nose and mouth tightly

• Sterile gown

• Sterile gloves

Maximal barrier precautions – patient:

• Head-to-toe sterile drape with opening for line insertion

• Different drapes can be sourced for different conditions e.g. larger aperture for

tunnelled renal lines, smaller drapes and apertures for neonatal lines.

At least two studies have confirmed the benefits of maximal barrier precautions. Mermal et

al found the odds ratio of developing a bloodstream infection two times greater if maximal

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barrier precautions were not used when placing a Swan-Ganz catheter. (17) The study by

Raad et al found that the rate of infection was six times higher for central lines placed

without maximal barrier precautions. (18)

What changes can be made to increase compliance with maximal barrier precautions?

• Include maximal barrier precautions as part of insertion checklist

• Develop a central line pack that incorporates the components (except gloves as

these need to be variable sizes) of maximal barrier precautions

• Educate medical staff on evidence for the use of maximal barrier precautions and

get the clinical leader to set the standard

Chlorhexidine skin antisepsis.

Chlorhexidine skin antisepsis has been shown to be superior to other antisepsis, including

povidone-iodine. (19, 20) It is important that the solution is allowed to dry for 2 minutes

prior to insertion.

What changes can be made to ensure that appropriate chlorhexidine antisepsis is used?

• Include 2% chlorhexidine and 70% isopropyl alcohol in Central Line Insertion

Checklist

• Include 2% chlorhexidine and 70% isopropyl alcohol in Central Line insertion pack

• Make stores of antisepsis compliant with 2% chlorhexidine and 70% isopropyl

alcohol

• Where there is good reason not to use 2% chlorhexidine and 70% isopropyl alcohol,

such as a documented allergy – note this on the insertion checklist and use

alternative.

Optimal Catheter Site Selection

This is somewhat controversial as a study in 2005 concluded that in expert hands, the site

of insertion was not a factor in CLAB. (21) However, other studies have shown that the

subclavian approach is associated with lower CLAB rates than either the internal jugular or

femoral routes (the risk of CLAB with femoral insertions may be increased in obese

patients). (22-24) (25) The recommendation to use the subclavian site is based solely on

the likelihood of reducing infectious complications. However, CLAB is only one risk factor

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associated with Central Line insertion and others such as pneumothorax may be

particularly important in already compromised, sick patients. In CMDHB’s Critical Care

Complex, we measured the insertion site preference and have not included the subclavian

approach as the preferred site on the insertion checklist, but all insertions sites continue to

be documented.

Daily review of the necessity of a central line wit h prompt removal of

unnecessary lines

Many lines are left in because they provide a backstop should the patient’s condition

decline and require reliable intravenous access, and many are left in because no one has

actively questioned whether they are needed. The risk of infection is less if lines that are

not clinically needed are removed.

There is however, no evidence that catheter replacement at scheduled time intervals will

decrease CLAB rates. It is not CDC guidance to routinely remove CVLs that are clinically

needed if they are functioning and if there is no evidence of local or systemic

complications. (26)

What changes can be made to ensure that central lines are reviewed daily and removed if

no longer needed?

• Include daily review of line necessity in the Maintenance Checklist

• Include date and time of line removal on the Maintenance Checklist

• State the line day during rounds and at nursing handover e.g. “today is line day 6”

Getting started Forming the team

The team must be small enough to be effective, but must also include opinion leaders from

each stakeholder group - doctors, nurses, Infection Prevention & Control staff.

“Improvement teams should be heterogeneous in make-up, but homogeneous in mindset’

(10)

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It is important to be multidisciplinary and extra effort may be needed to secure time for

medical clinicians to be involved.

When starting out it is important to identify those who want to work on the project and

work with them, rather than try to persuade detractors at the outset – work with the willing

and expand as the results show credibility. It is however important to have all stakeholders

at the table in order to establish buy-in and cooperation from all parties.

Leadership of the various disciplines need to be on board and able to back the general

thrust of the programme.

It is useful to have a named coordinator of the team – a ‘go to’ person for questions and a

coordinator of meetings etc.

Setting Aims

“some is not a number, soon is not a time”

Improvement programmes require a clear aim – it focuses the work and identifies what

needs to be measured to prove that aims have been met. The aim should be time-specific

and measurable. It should be unambiguous and clearly identify the specific population of

patients involved.

“Setting numerical goals clarifies the aim, helps create tension for change, directs

measurement, and focuses initial changes.” (10) An example of an aim for CLAB

reduction could be:

“Decrease the rate of CLAB by 50% within one year by achieving greater than 95%

compliance with the Insertion and Maintenance Checklists”

In order to show improvement it is important to have a system to measure the baseline

rate of CLAB (see later section).

Using the Model for Improvement

There are three fundamental questions that the CLAB programme needs to answer:

1) What are we trying to achieve (set clear aims)?

2) How will we know that we have made an improvement (establish measures)?

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3) What changes can we implement to improve?


The third question is answered in an iterative process. There are several models to achieve

this and the Institute for Healthcare Improvement suggests using

Plan-Do-Study-Act cycles to conduct small-scale tests of change. The general principle is

that after testing a change on a small scale, learning from each test, and refining the change

through several PDSA cycles, the team can implement the change on a boarder scale. For

the CLAB programme, the principle can be applied to how the checklists are implemented,

how the checklists are formulated etc. We recommend starting to testing changes using the

insertion bundle and, as progress is made, add testing of the maintenance bundle. This

order is recommended as the insertion bundle is often easier to measure. The maintenance

bundle is less straightforward and less predictable to measure due to the nature of the care

and environment.

Developing Checklists for the CLAB bundle of care

To ensure that the elements of the bundle are clear and adhered to, it is useful to codify

them into a checklist. Most of the bundle elements refer to insertion of the central line and

it is useful to have an Insertion Checklist – this also has basic patient information, and

information on the type and site of the line. As the line is inserted the checklist is used as

an aid memoire with the assistant checking with the inserting clinician that each of the parts

of the bundle are adhered to:

� Hand hygiene

� Skin prep with 2% chlorhexidine and 70% alcohol

� Maximal barrier precautions for inserter (hat, mask, cloves) and patient (full body

drape)

An example of the CMDHB checklist is shown in appendix 1.

As a result of investigating the CLABs in 2010, it was decided to modify the Insertion

Checklist to include:

� Identification of High Risk patients (immunocompromised, extensive burns) and to

recommend a chlorhexidine- impregnated dressing (27) be used

� Identification of High Risk lines (lines inserted in other hospitals or under

emergency conditions) and recommend early replacement

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It is also useful to develop a central line Maintenance Checklist (see appendix 2). This will

need to include the elements of the bundle and be adapted to incorporate the different

nursing shifts used in the area (8 or 12 hour shifts). The bundle element included in the

Maintenance Checklist is the need for a central line to be reviewed daily. We have also

added a number of elements of general line care:

i) Cleaning port with 2% chlorhexidine and 70% alcohol prior to access.

The ports on central venous lines are a common source of bacterial colonisation. Accessing

the lumen aseptically has also been shown, through the work of the Canadian ICU

Collaborative, (28) to decrease the risk of infection.

ii) Dedicated lumen for Intravenous Nutrition (IVN)

Although the evidence is limited, providing a dedicated lumen for IVN has been

recommended to decrease CLAB by minimizing access to that lumen of the central venous

catheter, thereby reducing contamination. (28) To this end, the Maintenance Checklists

checks if the patient is on IVN, and if they are, whether there is a dedicated lumen.

Emerging Trends:

Antibiotic Impregnated Central Venous Lines. Most authorities do not advocate using these

lines routinely and we would suggest using them only if the CLAB bundle has first been

fully implemented. There are specific patient groups who may benefit from these lines (e.g.

those who are immunocompromised). (29)

Ensuring Adequate Blood Culture Collections.

In order to accurately diagnose blood stream infections and monitor the impact of a CLAB

prevention program, the collection of blood cultures should be optimised. After clinical

assessment, blood cultures are recommended as part of the evaluation of a patient with new

elevated temperature in the ICU.

The volume of blood cultured is the most important variable in detecting bacteraemia. The

recommended volume that should be collected from adults whenever blood cultures are

indicated is at least 40mL, i.e. 2 sets of 20mLs. Single blood cultures should not be drawn

from adults since inadequate volume is cultured and interpretation of single positive

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cultures is more difficult. A Middlemore Laboratory audit during September 2010 found

that 70% of blood cultures from adults consisted of a single set when collected by non-

phlebotomists. Compliance with blood culture collection of ≥2 sets is now reported

monthly and displayed for staff it the CC (see figure 4).

Figure 4. Compliance with Blood Culture standards

Blood CulturesGoal: 100% of blood cultures w ill have 2 sets

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For paediatrics, less data are available, but yield also increases in proportion to the volume

of blood cultured. Suggested volumes are related to the weight or age of the child and

should be no more than 1% of blood volume.

Blood for culture is preferably obtained by venepuncture. The 2 sets collected from adults

are ideally collected from separate venepuncture unless access is difficult. Blood cultures

obtained from intravascular catheters are associated with greater contamination rates than

are blood cultures obtained by venepuncture. If cultures are drawn from a central venous

catheter, then at least one other set should be collected by venepuncture and distinguished

from the catheter culture. Blood culture contamination is associated with increased

laboratory costs and unnecessary IV antibiotic use. The venepuncture site should be

prepared with an antiseptic and allowed to dry. Tincture of iodine or chlorhexidine

glucanate products perform better than povidone-iodine products. The blood culture septum

is not sterile and should be disinfected with alcohol and allowed to dry. Contamination

rates should be <3% and are lower when cultures are collected by phlebotomists versus

non-phlebotomists. In an attempt to increase compliance with adequate blood collection

for blood culture purposes, the CCC has bundled together the 4 bottles required to ensure

that 40mL is collected.

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Figure 5: Blood Culture bottles

Measurement

“the only way to know whether a change represents a n improvement”

It is vital to be able to measure CLAB rates over time and all measurement should be for

the express purpose of continuing improvement, not for performance accountability or

punishment. To foster improvement, it is important that the measures are rapidly and

regularly relayed to staff and the project team.

Work with your Clinical Microbiology, Infectious diseases and/or Infection Prevention and

Control staff - to start collecting data of your unit’s baseline CLAB rate and how it is

determined and reported.

Measures:

1. Rate of CLAB per 1,000 line days

2. Compliance with Insertion and Maintenance Checklists

3. Days since last CLAB

Rate of CLAB per 1,000 line days

1. Tally Method.

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Many hospitals will not know their rate of CLAB, as the denominator (line days) may not

be routinely collected. Until such time that the insertion and removal of CVLs is collected

we recommend the tally method to calculate line days. (30) (1)

This method involves counting patients with central lines 3-5 days per week and using this

sampling to estimate the total central line days for the month. If a patient has multiple lines

only one line per patient is counted.

Procedure for using the tally system:

� Record the number of patients in the unit that have a central line in situ at

approximately the same time on each of the 3-5 days per week. Tally on the last day

of the month to obtain the number of central line days for that month

� When calculating the central line rate, all types of lines (cuffed, non-cuffed,

implanted etc) are counted.

� Patients with 2 central lines in place on one day are counted as only one central line.

� If there is a peripherally inserted and a centrally inserted line in situ on the same

patient, count the centrally inserted line only.

Table 1. Central line days – worked example of tally method

Day of month Central lines

1 2 3

25 19 27

4 5 6 7

8 9

10

27 28 28

11 12 13 14

15 16 17

24 22 26

18 19

20

20 21

22 23 24

28 28 25

25 26 27 28

29 30 31

27 25 23

Total number of lines (centrally inserted and peripherally inserted)

a = 382

Number of days counted in the month b = 15 Average number of central lines per day

c=(a/b) = 382/15

= 25.46 Number of days in the month d =31 Total central line days for month e=c x d

= 25.46 x 31 = 789.46

CLAB 2 CLAB/1,000 line days =2/789.46 * 1,000

=2.53 CLAB per 1,000 line days

2. Actual Line Day data.

If a system is set up that reliably collects line data (date/time of line insertion and

removal) then this can be used to calculate the rate.

For example, a unit has 2 CLAB cases in a month and 25 patients had central lines

during that time (each line stayed in 3 days):

CLAB number =2

Line days = 25 x 3

= 75

Rate per 1,000 line days = Total number of CLAB x 1,000

no. of line days

therefore:

Rate per 1,000 days = (2/75) x 1,000

= 26.6 CLAB/1,000 line days

21

We have set up a database (see figure 6) that will automatically calculate the CLAB rate

per 1,000 line days using the insertion and removal dates. When the first entry is made, a

unique number is allocated to each line.

Figure 6. Entry page to database

22

Central Line Checklist Compliance

This is a measure of how well the team is adhering to the bundle of care (formatted into the

checklist). Although the checklist itemizes the individual components of the bundle, the

measure is whether the entire bundle has been implemented each time – an ‘all or nothing’

indicator. If even one element is missing then the case is not in compliance with the bundle.

Separate measures for Insertion Checklist and Maintenance Checklist compliance are

calculated.

This measure can either be done as a random sample of checklists, or all checklists can be

assessed (this is easier if the data is being entered into a central database). For example:

If there are 7 patients with central lines, and 6 have all elements of checklist completed,

then compliance = 6/7 x 100 = 86%

Compliance with checklist = no. with all elements of bundle completed

Days since last CLAB

As the CLAB programme progresses, CLAB will become a rare event. A useful way to

capture this data and keep staff engaged is to prominently display the number of days since

the last CLAB, and celebrate the major milestones (e.g. 100 days), figure 7.

Figure 7. Days since last CLAB

23

Track results over time.

As improvement occurs over time, it is important to record the progress against the

measures over time as well. Furthermore using statistical process control charts can allow

the teams to assess when changes are significant.

It is important to post your rates so staff can see the improvement. It is useful to have a

comparator as competition is a healthy behaviour for improvement. Dedicate an area to

post compliance to bundles data.

Figure 8. Insertion and Maintenance Checklist compliance.

Insertion ComplianceGoal: 100% of CVL's will be inserted using the inse rtion bundle

0

2040

6080

100

June

1st

June

2nd

June

3rd

June

4th

July

1st

July

2nd

Ju

ly 3

rdJu

l 4th

Aug

1st

Aug

2nd

Aug

3rd

Aug

4th

Sep

1st

Sep

t2nd

Sep

t3rd

Sep

t4th

Oct

1st

Oct

2nd

Oct

3rd

Oct

4th

Nov

1st

Month/week

% c

ompl

ianc

e

Goal ICU HDU

Maintenance ComplianceGoal: 100 % of central lines w ill be compliant to t he maintenance bundle

020406080

100

June

1st

June

2nd

June

3rd

June

4th

July

1st

July

2nd

Ju

ly 3

rdJu

l 4th

Aug

1st

Aug

2nd

Aug

3rd

Aug

4th

Sep

1st

Sep

t 2nd

Sep

t 3rd

Sep

t 4th

O

ct1s

tO

ct 2

ndO

ct 3

rdO

ct 4

thN

ov 1

st

Month/week

% c

ompl

iant

Goal ICU HDU

24

Figure 9. Days between CLAB

CMDHB CCC Days between CLAB surveillance

21

78

37

155

517

10 115

44

86

182

164

66

100 107

7

50

8 14

29

56

11

33 30

613

41

75

80

20

40

60

80

100

120

140

160

180

200

03-N

ov-0

7

21-J

an-0

8

28-J

an-0

8

18-M

ar-0

8

26-M

ar-0

8

10-A

pr-0

8

09-M

ay-0

8

05-J

ul-0

8

16-J

ul-0

8

23-A

ug-0

8

26-S

ep-0

8

26-O

ct-0

8

02-N

ov-0

8

15-N

ov-0

8

26-D

ec-0

8

11-M

ar-0

9

16-A

ug-0

9

26-N

ov-0

9

04-D

ec-0

9

21-M

ar-1

0

05-S

ep-1

0

11-N

ov-1

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16-N

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18-M

ay-1

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05-J

un-1

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Date of CLAB

Day

s in

Bet

wee

n C

LAB

Days since last CLAB in ICU Mean Upper Control Lim it LCL

Not

a C

LAB

dat

e

Sentinel Event Process

In the CCC every CLAB is viewed as a sentinel event and the case is discussed with the

staff involved. We use a CLAB review form to structure this (see appendix 3). The

Insertion and Maintenance Checklists are reviewed for completeness and any patient

factors are discussed. This process has lead to a number of improvements in the checklists

and the processes around them.

Barriers that may be encountered

• Fear of change. It is common for staff to feel anxious and defensive when they are being

asked to change their practice. It is important that the team anticipates this reaction and

that there is strong leadership to help the staff through the process. “The antidote to fear is

knowledge about the deficiencies of the present process and optimism about the potential

benefits of a new process.” (10)

• Questioning the evidence for each component of the checklist. This is a

common reaction from medical staff and is not necessarily negative – it is

important to keep coming back to the issue of standardisation, and be

prepared to adjust components that do not stack up, as we did with the

optimal site of insertion component. But the important thing is not to waste

25

time and energy debating every aspect of the bundle – aim for a standard

approach and collect the data.

• Denial that CLAB is a problem. It is important to share baseline data that

shows the number (and if possible the rate) of CLAB. Useful to pull the

charts of patients that had CLAB during their ICU stay and personalise the

impact on them.

• “It won’t work here”. Endless arguments occur about why the process might

have worked elsewhere, and why it might not work locally. Leadership is

required to move the group on to trying the process and commitment to

measuring both baseline data and whether change occurs.

• “There are much more pressing issues in ICU than CLAB.” This might well

be true, but the CLAB process is relatively simple to implement, is very

cost-effective and it may be a useful learning phase for other projects that

the ICU staff want to work on.

• Staff partial buy-in (“is this just another flavour of the week?”). In order to

enlist support and engage staff, it is important to share baseline data and to

show the results of improvement efforts. Again having a dedicated,

enthusiastic person as the “face” of the campaign, helps to convince staff

that this campaign is going to the distance.

CLAB Prevention in other Hospital Areas

Goal:

To decrease hospital-wide CLAB by 20% within 1 year

After starting the campaign in the Critical Care Complex, we decided to spread the

learning’s to other areas. Some of these areas would do ‘insertion’ only (Emergency Care,

Theatres), some would do ‘maintenance’ only (National Burns Unit, Surgical Wards) and

some would do both (Renal Unit, Neonatal Unit). We decided that the core steering group

would work with a representative from each of the areas (and they would be invited to be

on the expanded steering group).

A staged rollout was proposed and a checklist for implementation (see appendix 4) was

developed. This ensured that each area was ready to go with the programme by the time the

26

rollout date arrived. The core elements of this ‘rollout’ checklist were that there was an

identified clinical champion in each area, that the key managerial personnel were informed

(General Manager, Clinical Nurse Director and Clinical Directors), and that those involved

(inserters of lines and observers of the checklist) were informed and trained. It was also

considered important to identify who would be inputting the checklist compliance data into

the database, and who would be informed of each case of CLAB (in order to review care in

a timely fashion). Finally it was checked that all the equipment that would be available.

The team worked with each area for as long as it took to ensure buy-in and readiness. Some

things were customised for the different areas. For instance the standard ICU drape did not

work for the Renal Unit (they required a larger aperture for their tunnelled lines), or the

Neonatal Unit. Sometimes this work encouraged further buy-in. The drape being used by

the Renal Unit cost $100 per drape – when the Renal Central Line Pack was introduced, the

whole pack cost less than the cost of their drapes. The Neonatal Unit had not had a specific

drape and usually tried to clip (using bull clips) 4 small drapes together. This was flimsy

and prone to movement. The CLAB steering group worked with the neonatal team and

managed to procure a drape that met their needs.

The educational component of the rollout was tailored to the individual areas. For the

general surgical wards this involved education on the general care of central lines as well as

the specifics of the Maintenance Checklist. A crucial component was getting reliable data

on when the line was removed so that we could get accurate line data.

The data collection and analyse needs of the different areas were a challenge as we spread

beyond the confines of the Critical Care Complex. Each unit had to identify a person for

data entry and to review reports. An Access database was developed to allow each area to

input their data and to produce reports on CLAB rates/1,000 line days and compliance with

the checklists.

We focussed on areas that were involved in CVL insertion or who had a large number of

patients with CVLs (we have started with surgical wards as they seem to have more

patients with CVLs than the medical wards do). We also worked with units that were

willing and we continue to work with areas that cannot bring themselves to be part of the

campaign.

27

Appendix 1 Insertion Checklist Preventing Central Line infections in CMDHB

Patient Name NHI Number Use patient Label

PLEASE COMPLETE FOR ALL CENTRAL LINE INSERTIONS ON ALL PATIENTS Catheter Type:

Non-Tunnelled PICC Vas Cath

Tunnelled Implanted Vascular Device

Other: _____________________________

Line Coating:

Antibacterial Antiseptic None

Where was the line inserted? ICU HDU

Ward 1 EC

Radiology NNU

Theatre MSC Theatre MMH

Other DHB Other: _____________________

Insertion site:

Right Left

Subclavian Jugular

Basilic Cephalic

Femoral Saphenous

UAC UVC

Other: ______________

NNU or PICC Line (if applicable) Placement confirmed by X-ray � Catheter Length: ____________________

Date Line Inserted:

Time Line Inserted:

INSERTION BUNDLE: To be completed by the observer and signed by both proceduralist and observer.

1. Hand Hygiene - Did the proceduralist? Yes No Perform hand hygiene using chlorhexidine(CHG) solution

2. Chlorhexidine Skin Antisepsis - Did the proceduralist? Yes No Prep the procedural site using chlorhexidine 2% in 70% alcohol (In NNU CHG % is titrated for weight/age) for 30 seconds and allow solution time to dry completely

3. Maximum Barrier Precautions - Did the proceduralist? Yes No Wear a hat

Wear a mask

Wear a sterile gown

Wear sterile gloves

Use a large sterile drape that covered the entire patient

Maintain sterile technique during procedure and when applying the dressing

Where high-risk patients have a CVC (e.g. burns, emergency insertion, TPN, ICU stay >7 days, immunocompromised, rewired line) consider using other preventative strategies e.g. Chlorhexidine Impregnated Dressing , Antibacterial Line

Applied � YES � NO

Proceduralist Name:

Proceduralist Signature:

Observer Name:

Observer Signature:

MAINTENANCE BUNDLE CHECKLIST – DAY OF INSERTION

Ward/Unit: Insertion Day 0 Insertion Time: Yes No Comments Is IVN/TPN being infused? If yes, is there a dedicated port being used for the IVN/TPN Before accessing injection ports did you clean with 2% CHG in 70% alcohol

Central Line Definition:

Any catheter whose tip terminates in a great vessel

ID

28

Please check which shifts the line was in place for on the day of insertion AM Shift

�

PM Shift

�

Night Shift

�

PLEASE RETURN FORM TO WARD CLERK ONCE COMPLETED

29

Appendix 2 Maintenance Checklist

MAINTENANCE BUNDLE CHECKLIST

(Cont.)

To be completed on all central lines

Place Patient Label here

Ward/Unit: Line Day: Yes No Today’s Date: Yes No

Was the Central Line reviewed for necessity today?

Was the Central line removed today?

Is IVN/TPN being infused? If yes, is dedicated port being used for the IVN/TPN?

Time removed:

Did you check the site today for inflammation?

(If any signs of infection present review the catheter promptly

High Risk Patient – Is there a prevention measure in place? e.g. Chlorhexidine Impregnated Dressing Not a high risk patient

AM Shift 8hr 12hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?

Not accessed

PM Shift 8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?

Not accessed

Night Shift 8hr 12hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?

Not accessed

Comments: Ward/Unit: Line Day: Yes No Today’s Date: Yes No




Time removed:





Not accessed


Not accessed


Not accessed

Comments:





Time removed:



High Risk Patient – Is there a prevention measure in place? e.g. Chlorhexidine Impregnated Dressing Not a highpatient


Not accessed


Not accessed


Not accessed

Comments:

30





Time removed:





Not accessed


Not accessed


Not accessed

Comments:





Time removed:





Not accessed


Not accessed


Not accessed

Comments:





Time removed:





Not accessed


Not accessed


Not accessed

Comments:

PLEASE RETURN FORM TO WARD CLERK ONCE COMPLETED

31

Appendix 3 CLAB sentinel Event review process

Date of CLAB: _______________ Organism Identified: :_____________ (please use date blood culture drawn)

Date Line inserted: ______________ Where line inserted:____________________

Site inserted: ___________________

Brief summary of patients journey:_____________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Did pt meet criteria for high risk? � Yes � No

Were high risk interventions put in place? � Yes � No

What high risk interventions were used? � Chlorhexidine impregnated dressing � Antibiotic Line � Antimicrobial lock

Was insertion checklist compliant? � Yes � No If no what was incomplete? ________________________________________________________________________________________________________________________________________________________________

Was maintenance checklist compliant? � Yes � No If no what was incomplete? ________________________________________________________________________________________________________________________________________________________________

Issues identified 1. __________________________________________________________________ 2. __________________________________________________________________ 3. __________________________________________________________________

High risk factors identified 1. __________________________________________________________________ 2. __________________________________________________________________

Place ID label here

CLAB Incidence Review Form

32

3.

__________________________________________________________________

Opportunities for improvement (Learning’s) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

33

Appendix 4 Implementation checklist

Item # Issue Progress Date Implemented Comment

1 Identification of clinical leaders to support introduction

2 Key personnel consulted e.g. Service Manger, CND, Clinical Head

3 Proceduralists informed and in agreement with the insertion bundle

4 Observers of procedure informed, educated around and in agreement re

monitoring of compliance with insertion bundle checklist.

5 Equipment in place e.g.

Availability of CVC catheter pack (includes PPE except gloves)

CHG 2% with 70% alcohol for insertion skin prep

Process to ensure additional equipment items are attachment to CVL

pack. To include the insertion checklist.

6 Education plan in place 2 weeks prior to introduction

7 Person and process for collection/collation of CVL checklist

identified.

8 Person to enter data identified and CLAB data base training

organised with Terry Rings (Infection Prevention and Control)

9 Review of process for collection of blood cultures – ensure blood

cultures X2 from different sites are taken routinely

10 Process for reporting of surveillance and checklist result process

identified

11 Process to review CLAB identified that is timely and process for

identifying risks and response identified

34

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