Central Line-Associated Bloodstream Infections (CLABSI)

This protocol outlines the steps that executives can follow to prevent Central Line-Associated Bloodstream Infections.

More than 700,000 healthcare-associated infections (HAIs) are estimated to occur each year in the US, resulting in 99,000 deaths and $28–$45 billion in extra healthcare costs.

Central line-associated bloodstream infection (CLABSI) is a serious infection that occurs when bacteria or viruses enter the bloodstream through the central line. Researchers estimate that up to 41,000 patients in US hospitals acquire CLABSI each year. CLABSI is a source of serious harm and death in hospitalized patients. Researchers think CLABSIs occur due to:

1. Heavy bacterial colonization at the insertion site.
2. A “non-tunneled” catheter being placed in the arm or leg rather than placement in the chest.
3. Catheterization lasting longer than 3 days.
4. Less stringent barrier precautions for catheter insertions, which significantly increases the risk of a catheter-related infection.
5. The presence of multiple lumens, which may increase the opportunity for infection.
6. Host factors, including complex, chronic illness, immunocompromised state, prolonged hospitalization.

While intensive care unit (ICU) patients have the highest chance of acquiring CLABSIs, central venous catheters are becoming increasingly used outside the ICU, exposing more patients to the risk. In fact, recent data suggest that the greatest numbers of patients with central lines are in hospital units outside the ICU, most notably dialysis units. While central line use is increasing outside the ICU, since 2008, the Centers for Medicare and Medicaid Services (CMS) has implemented a policy of reduced reimbursement for reasonably preventable hospital-acquired conditions, including CLABSIs. This policy change can represent a significant financial burden to a hospital because increased hospital costs due to CLABSIs can be more than $48,000 per case.

CLABSIs and other HAIs, however, are mostly preventable. Interventions that focus on reducing CLABSIs have resulted in reductions ranging from 38% to 80%. In one study, researchers observed a 66% decrease in CLABSIs after implementing a multi-component intervention in the ICUs of 67 Michigan hospitals. In another study conducted across 32 hospitals in Pennsylvania, CLABSIs decreased by 68%, following targeted interventions between April 2001 and March 2005. Other studies have shown similar reductions in CLABSIs, saving lives and dramatically reducing costs.

A variety of guidelines and recommendations have been identified to prevent CLABSI, including those published by:

1. The Healthcare Infection Control Practices Advisory Committee
2. The Institute for Healthcare Improvement
3. The Agency for Healthcare Research and Quality

These recommendations share the following components to reduce and prevent CLABSI:

1. Implementing a method to detect the true incidence of CLABSI, such as information technology to collect and calculate catheter days.
2. Providing adequate infrastructure for the intervention, including an adequately staffed infection prevention and control program, and adequate laboratory support for timely processing of samples.
3. Implementing a catheter insertion and maintenance checklist.
4. Monitoring the continued need for intravascular access on a daily basis and prompt removal when the catheter is no longer needed.
5. Measuring unit-specific occurrence of CLABSI as part of performance evaluations.

Researchers estimate that the use of process change and the use of technology to reduce CLABSI can save up to $2.7 billion per year while significantly improving quality and safety. Closing the performance gap will require hospitals and healthcare systems to commit to action in the form of specific leadership, action, and technology plans, examples of which are delineated below for utilization or reference. This is provided to assist hospitals in prioritizing their efforts when designing and implementing evidence-based bundles for CLABSI reduction.

Hospital governance, senior administrative leadership, clinical leadership, and safety/risk management leadership need to work collaboratively to reduce CLABSI. To achieve a goal of zero preventable deaths, leaders need to commit to taking these key actions.

Show leadership’s commitment to reducing CLABSI:

1. Hospital governance and senior administrative leadership must commit to becoming aware of major performance gaps in their own organization.
2. Hospital governance, senior administrative leadership, and clinical/safety leadership must close their own performance gap by implementing a comprehensive approach.
3. Healthcare leadership must demonstrate their commitment and support by:
   1. Taking an active role in championing process improvement
   2. Giving their time, attention, and focus
   3. Removing barriers
   4. Providing necessary resources
4. Healthcare leadership must reinforce their commitment by:
   1. Shaping a vision of the future
   2. Clearly defining goals
   3. Embracing and reinforcing a Culture of Safety so that staff feel empowered to actively participate in CLABSI prevention activities
   4. Supporting staff as they work through improvement initiatives
   5. Measuring results
   6. Communicating progress toward goals

Actions speak louder than words. As role models, leadership must “walk the walk” as well as “talk the talk” when it comes to supporting process improvement across the organization. There are many types of leaders within a healthcare organization, and for process improvement to truly be successful, leadership commitment and action are required at all levels. The board, the C-suite, senior leadership, physicians, directors, managers, and unit leaders all have important roles and need to be engaged.

Create the infrastructure needed to make changes:

Change management is a critical element that must be included to sustain any improvements. Recognizing the needs and ideas of the people who are part of the process—and who are charged with implementing and sustaining a new solution—is critical in building the acceptance and accountability for change. A technical solution without acceptance of the proposed changes will not succeed. Building a strategy for acceptance and accountability of a change initiative greatly increases the opportunity for success and sustainability of improvements. “Facilitating Change,” the change management model The Joint Commission developed, contains four key elements to consider when working through a change initiative to address HAIs:

1. Plan the Project:
   1. At the start of project, build a strong foundation for change by:
      1. Assessing the culture for change
      2. Defining the change
      3. Building a strategy
      4. Engaging the right people
      5. Painting a vision of the future
      6. Inspiring people
   2. Ask for support and active involvement in the plan to reduce:
      1. HAIs
      2. Get agreements.
      3. Build accountability for the outcomes.
      4. Identify a leader for the HAI initiative (this is critical to the success of the project).
      5. Understand where resistance may come from.
2. Launch the Initiative:
   1. Align operations and guarantee the organization has the capacity to change, not just the ability to change.
   2. Launch the HAI initiative with a clear champion and a clearly communicated vision by leadership.
3. Support the Change:
   1. Have all leaders within the organization be a visible part of the HAI initiative.
   2. Communicate frequently regarding all aspects of the HAI initiative to enhance the initiative’s chance for success.
   3. Celebrate success as it relates to a reduction in HAIs or a positive change in HAI organizational culture.
   4. Identify resistance to the HAI initiative as soon as it occurs.
4. In addition to the change management model, leaders must:
   1. Include fundamentals of change outlined in the National Quality Forum safe practices, including:
      1. Awareness
      2. Accountability
      3. Ability
      4. Action
   2. Meet with the ICU team, infection control staff, quality and safety leaders, nurse educators, and physician champions to:
      1. Understand barriers (walk the process).
      2. Use 4E grid to develop a strategy to:
         • Engage—use stories and show baseline data.
         • Educate—teach staff about the evidence.
         • Execute—practice change.
         • Evaluate—assess feedback performance and view infections as defects.
      3. Use surveillance data to drive improvement.
      4. Monitor and provide feedback of compliance with best practices over time.
   3. Utilize patient stories—written and recorded on video—to identify gaps and inspire change in your staff.
      1. The story of Nora Bostrom, daughter of Claire McCormick and Thomas Bostrom, is an inspiring story about a CLABSI which can be freely viewed: https://www.youtube.com/watch?v=-DNuFp6KDVM.

Engage staff and use data to find areas for improvement:

1. Develop a standardized educational plan for doctors and nurses to cover key curriculum about the insertion and maintenance of central lines.
2. Encourage continuous process improvement through the implementation of quality process measures and metrics.
3. Complete a root cause analysis (RCA) or multidisciplinary review when CLABSIs are identified in the unit where the infection occurred using a multidisciplinary approach, including nurses, doctors, and infection prevention professionals.
4. Implement—and share—all learnings from the RCA.
5. Use patient stories—written and recorded on video—to help teach and inspire change in your staff.