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in Patient Safety

The impact of central line insertion bundle and maintenance bundle on Central line-Associated Bloodstream Infection.

Dr.Renuka devi.K, Sister Prasanthi.D, Sister Navya.A

Background:
The Impact of each central line insertion and maintenance bundle on central line-associated bloodstream infection (CLABSI).

Methods:
A comprehensive quality-improvement intervention, including education, central venous catheter (CVC) insertion bundle, and process and outcome surveillance have been introduced since MARCH 2016 to FEBRUARY 2017. Outcome surveillances, including CLABSI per 1,000 catheter-days, CLABSI per 1,000 inpatient-days were monitored and measured. As a baseline of measurement for comparison, we have collected data from November 2015 to FEBRUARY, 2016.

Results:
During this 11-month period, there was a total of 611 CVC insertions. The rate of CLABSI significantly declined from 4.69 per 1000 catheter-day during the pre-intervention period to 0.00 per 1000 catheter-day post-intervention period. Many patients in non-ICU settings have central lines in place for prolonged periods of time, which supports the use of interventions to improve central line use and maintenance practices as a means to prevent infection. Reported CLABSI rates in non-ICU settings range from 2 to 6 per 1000 line-days, which is similar to rates observed in non-ICUs before implementation of interventions to reduce CLABSI.

Conclusions:
This multidisciplinary infection control intervention, including a central line insertion care bundle and maintenance practices, can effectively reduce the rate of CLABSI.

Background:
In conjunction with an increase in usage of central venous catheters (CVC) among the critically ill patients, the incidence of central line-associated bloodstream infections (CLABSI) is also increasing. Recent studies have shown that this serious complication could result in increased mortality, morbidity and length of stay in the hospital [1, 2, 3, 4, 5, 6]. Therefore, several evidence-based interventions were introduced, such as use of chlorhexidine gluconate (CHG) for skin preparations and maximal sterile barriers during the insertion and use of the subclavian or internal jugular vein instead of femoral vein, hand hygiene, and daily review of line necessity, to prevent CLABSI [7, 8, 9, 10]. Nationally-published guidelines provide specific catheter care recommendations including education of healthcare personnel responsible for catheter maintenance; disinfection of hubs, needleless connectors, and injection ports before catheter access; and routinely changing transparent dressings or gauze dressings every whenever soiled, loose, or damp. Yet, despite recognition of the importance of central line maintenance in relation to CLABSI prevention, adherence to best practices may be inadequate in non-ICU wards, which have not generally been included in CLABSI prevention efforts.

To reduce the CLABSI rate, we introduced a multidimensional program, which included the implementation of central line bundle, education and surveillance investigations in APOLLO HOSPITALS, VIZAG. The aim of this study was to evaluate the different impacts of each bundle CLABSI rate from March 2016 to February 2017. To clarify the overall effectiveness of this multidisciplinary team care bundle, we used the rate of CLABSI in the same period (March 2016 to February 2017) as the reference for the purpose of comparison.
Methods

This study was conducted in APOLLO HOSPITALS VISAKHAPATNAM. Beginning in November scope and practice of each central line bundle. This education program included several lectures for all ICU personnel and the creation of teaching video which had instruction for site selection, skin preparation, draping, insertion and dressing the central venous catheter. All the staff members of ICU were asked to watch the video. The insertion bundle consisted of four major components: maximal sterile barriers upon insertion, use of CHG for skin preparations, hand hygiene and avoidance of the femoral vein as the access site. The maintenance bundle with hand hygiene, proper dressing changes, the aseptic techniques are needed for a daily review of catheter necessity. Process surveillance with the use of a checklist was developed to assess the compliance of bundle practices and it was defined as the frequency of the number of each bundle performed to the number of CVC insertions. Outcome surveillance, including CLABSI per 1,000 catheter-days, CLABSI per 1,000 inpatient-days, was measured. The data were collected on a routine basis and the analysis was carried out retrospectively.

Definition:
The CLABSI is defined as a laboratory confirmed bloodstream infection (bacteraemia or fungemia) in a patient where a central line is placed at the time of (or within 48-hours prior to) onset of symptoms and the infection is not related to an infection from another site. The diagnosis was made jointly by a team of that included the infection control practitioner and intensivists. As a baseline of measurement for a comparison, we retrospectively collected the same data from November 2015 to March 2016.

Results:
During the pre intervention period from November 2105 to FEBRUARY 2016, there were a total of 281 inpatient days and 701 catheter days among the total of 61 CVC insertions. During this pre interventional period, there was a CLABSI of 4.69 per 1000 catheter-day. This rate was detected in non ICU areas due to improper maintenance of central line care.

During the interventional period of 11-months, there were a total of 4602 inpatient-days and 2369 catheter-days among a total of 611 CVC insertions. During this intervention period, there were 0 CLABSI .

The number of CLABSI, catheter-day and patient-day per month during the pre- and post-intervention period.

The impact of central line insertion bundle - 1

Discussion:
We found that implementation of the central-line care maintenance bundle was associated with improved insertion-site care on both intervention and control wards. The intervention was also associated with a decline in CLABSI incidence on non-ICU areas also.

Improvement in catheter care practices on intervention wards following introduction of the central line care maintenance bundle was correlated with a decrease in CLABSI .There was marginally significant decrease in the CLABSI rate on control wards, along with improvement in catheter care practices during the study period.

Strengths of this study includes a focus on CLABSI prevention in non-ICU settings, direct observation of catheter insertion site care practices, and detailed microbiology data. The main limitation of this study was the small number of patients who developed CLABSI, which made it difficult to determine the impact of the central line care maintenance bundle on CLABSI incidence.

Conclusions:
Finally, the multidisciplinary infection control intervention, including a central line insertion care bundle can effectively reduce the rate of CLABSI. The impact of different care bundle varies. Maximal sterile barrier upon insertion is an essential component of the care line insertion bundle. Employing relatively simple evidence-based practices to reduce, if not eliminate, CLABSIs appears to be within the reach of even in resource-limited settings.

References:

  1. Centres for Disease Control and Prevention (CDC): Vital signs: central line-associated bloodstream infection – United States, 2001, 2008, and 2009. MMWR Morb Mortal Wkly Rep 2011, 60:243–248.
  2. Fagan RP, Edwards JR, Park BJ, Fridkin SK, Magill SS: Incidence trends in pathogen-specific central line-associated bloodstream infections in US intensive care units. Infect Control Hosp Epidemiol 2013, 36:893–899.
  3. Boyce JM: Prevention of central line-associated bloodstream infections in hemodialysis patients. Infect Control Hosp Epidemiol 2012, 33:936–944.
  4. Rosenthal VD: Central line-associated bloodstream infections in limited-resource countries: a review of the literature. Clin Infect Dis 2009, 49:1899–1907.
  5. Rosenthal VD, Guzman S, Migone O, Crnich CJ: The attributable cost length of hospital stay, and mortality of central line-associated bloodstream infection in intensive care department in Argentina: a prospective, matched analysis. Am J Infect Control 2003, 34:475–480.
  6. Higuera F, Rangel-Frausto MS, Rosenthal VD, Soto JM, Castañon J, Franco G, Tabal-Galan N, Ruiz J, Duarte P, Graves N: Attributable cost and length of stay for patients with central venous catheter venous catheter-associated bloodstream infection in Mexico City intensive care units: a prospective, matched analysis. Infect Control Hosp Epidemiol 2007, 28:31–35.
  7. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C: An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006, 355:2725–2732.
  8. Coopersmith CM, Rebmann TL, Zack JE, Ward MR, Corcoran RM, Schallom ME, Sona CS, Buchman TG, Boyle WA, Polish LB, Fraser VJ: Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit. Crit Care Med 2002, 30:59–64.
  9. Merrer J, De Jonghe B, Golliot F, Lefrant JY, Raffy B, Barre E, Rigaud JP, Casciani D, Misset B, Bosquet C, Outin H, Brun-Buisson C, Nitenberg G, French Catheter Study Group in Intensive Care: Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA 2001, 286:700–707.
  10. Raad II, Hohn DC, Gilbreath BJ, Suleiman N, Hill LA, Bruso PA, Marts K, Mansfield PF, Bodey GP: Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol 1994, 15:231–238

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