Essential practices

• The subclavian vein is considered the preferable site for central venous catheter (CVC) insertion in the intensive care setting to reduce infectious complications. Previously, the primary recommendation was to avoid the femoral vein for access. Although this remains valid, it has been replaced by a positively formulated recommendation regarding the subclavian site.

• The recommendation to use ultrasound guidance for catheter insertion is backed by better evidence than was available previously; however, the procedure itself may jeopardize the strict observation of sterile technique.

• The use of chlorhexidine-containing dressings is now considered an “essential practice”; in the past, it was listed under special approaches that should only be employed if CLABSI rates remain high despite the implementation of basic practices.

• Routine replacement of administration sets not used for blood, blood products, or lipid formulations can be performed at intervals of up to 7 days. Previously, this interval was no longer than 4 days.

Additional approaches

• Antimicrobial ointment for the catheter site, which is geared toward the population of hemodialysis patients, has been moved to “additional practices” given the focus on a specific population.

• Despite currently being supported by high-level evidence, antiseptic-containing caps remain an “additional practice” because they are not considered superior to the manual disinfection, an essential practice.

• The importance of infusion teams has been highlighted by listing it under “additional practices” (previously considered unresolved).

• Sutureless securement of catheters was not discussed in the previous version of this section.

Burden of outcomes associated with hospital-acquired CLABSI

1. 1. Increased length of hospital stay ^{Reference Digiovine, Chenoweth, Watts and Higgins3–Reference Leistner, Hirsemann, Bloch, Gastmeier and Geffers6}

2. 2. Increased cost. The adjusted variable costs for patients with CLABSI were $32,000 (2010 US dollars) higher on average than for patients without CLABSI ^{Reference Stevens, Geiger, Concannon, Nelson, Brown and Dumyati7}

3. 3. Increased morbidity and mortality ^{Reference Ziegler, Pellegrini and Safdar8}

Risk factors for CLABSI

1. 1. Patients at risk for CLABSI in acute-care facilities are those with a CVC in place:

   1. a. Intensive care unit (ICU) population: The risk of CLABSI in ICU patients is high. Reasons for this include the frequent insertion of multiple catheters ^{Reference Dube, Jacob and Zheng9,Reference Mermel10} ; the use of specific types of catheters that are almost exclusively inserted in ICU patients and associated with substantial risk (eg, pulmonary artery catheters with catheter introducers); and the fact that catheters are frequently placed in emergency circumstances, repeatedly accessed each day, and often needed for extended periods. ^{Reference Maki, Kluger and Crnich11,12}

   2. b. Non-ICU population: Although the primary focus of attention over the last 20 years has been the ICU setting, most CLABSIs occur in hospital units outside the ICU or in outpatients. ^{Reference Marschall, Leone, Jones, Nihill, Fraser and Warren13–Reference Rhee, Heung, Chen and Chenoweth17}

2. 2. Infection prevention and control efforts should include other vulnerable populations such as patients receiving hemodialysis through catheters, ^{Reference Nguyen, Shugart and Lines18} intraoperative patients, ^{Reference Loftus, Brown and Koff19} and oncology patients. ^{Reference Zakhour, Chaftari and Raad20}

3. 3. In addition to CVCs, short-term peripheral catheters, ^{Reference Mermel21} peripherally inserted central venous catheters (PICCs), midline catheters, and peripheral arterial catheters also carry a risk of infection. ^{Reference O’Horo, Maki, Krupp and Safdar22}

4. 4. Independent risk factors for CLABSI (in at least 2 published studies) ^{Reference Almuneef, Memish, Balkhy, Hijazi, Cunningham and Francis23–Reference Timsit, Mimoz and Mourvillier45}

   1. a. Prolonged hospitalization before catheterization

   2. b. Prolonged duration of catheterization

   3. c. Heavy microbial colonization at insertion site

   4. d. Heavy microbial colonization of the catheter hub

   5. e. Multilumen catheters

   6. f. Concurrent catheters

   7. g. Neutropenia

   8. h. Body mass index (BMI) >40

   9. i. Prematurity (ie, early gestational age)

   10. j. Reduced nurse-to-patient ratio in the ICU

   11. k. Parenteral nutrition

   12. l. Substandard catheter care (eg, excessive manipulation of the catheter)

   13. m. Transfusion of blood products (in children)

Surveillance methods and definitions for CLABSI

1. 1. Use consistent surveillance methods and definitions to allow comparison to benchmark data.

2. 2. Refer to the National Healthcare Safety Network (NHSN) Patient Safety Component Manual for information on the appropriate surveillance methodology, including information about blood specimen collection and surveillance definitions of CLABSIs. The relevant chapter of the manual is “Chapter 4: Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and Non-Central Line-Associated Bloodstream Infection).” ⁴⁶

   1. a. Recent data suggest that interrater reliability using NHSN definitions is lower than expected. ^{Reference Grooth, Timsit and Mermel47–Reference Mayer, Greene, Howell, Ying, Rubin and Trick50} This may also affect the reliability of public reporting.

   2. b. The NHSN surveillance definition for CLABSI is different than the clinical definition for catheter-related bloodstream infection (CRBSI). The latter is subject to various factors (eg, laboratory capabilities, catheter removal, and submitting the catheter tip for culture). ^{Reference Mermel, Allon and Bouza51} The evidence presented here includes studies that used either CLABSI or CRBSI as an outcome measure and the lesser accuracy of CLABSI may impact the validity of the evidence.

Summary of existing guidelines and recommendations

1. 1. Several governmental, public health, and professional organizations have published evidence-based guidelines and/or implementation aids regarding the prevention of CLABSI including the following:

   1. a. Healthcare Infection Control Practices Advisory Committee (HICPAC), Centers for Disease Control and Prevention (CDC) ^{Reference O’Grady, Alexander and Dellinger52,Reference O’Grady, Alexander and Burns53}

   2. b. Institute for Healthcare Improvement (IHI) ^{Reference Masse, Elkalioubie and Blazejewski54}

   3. c. Agency for Healthcare Research and Quality, Making Health Care Safer ^{Reference Saint55}

   4. d. American Pediatric Surgical Association, Outcomes and Clinical Trials Committee ^{Reference Huang, Chen and Abdullah56}

   5. e. The Joint Commission ⁵⁷

   6. f. APIC, Implementation Guide to Preventing Central Line-Associated Bloodstream Infections ^{Reference Barnes, Olmsted and Monsees58}

   7. g. Infusion Nurses Society, Infusion Nursing Standards of Practice ^{Reference Gorski, Hadaway and Hagle59}

2. 2. The recommendations in this document focus on CVCs unless noted otherwise. These recommendations:

   1. a. Are not stratified based on the type of catheter (eg, tunneled, implanted, cuffed, non-cuffed catheter, dialysis catheter).

   2. b. May not be applicable in their entirety for prevention of bloodstream infections with other intravascular devices.

Infrastructure requirements

Facilities undertaking CLABSI interventions should have the following elements in place:

1. 1. An adequately staffed infection prevention and control program responsible for identifying patients who meet the surveillance definition for CLABSI.

2. 2. Infection prevention staff and, preferably, information technology support to collect and calculate catheter days as a denominator when computing rates of CLABSI and patient days to allow calculation of CVC utilization. Catheter days from information systems should be validated against a manual method, with a margin of error no greater than ±5%. ^{60–Reference Woeltje, McMullen, Butler, Goris and Doherty62}

3. 3. Resources to provide appropriate education and training.

4. 4. Adequate laboratory support for timely processing of specimens and reporting of results, as specified by the supervisor of the surveillance program.

Essential practices for preventing CLABSI recommended for all acute-care hospitals

Some of the following measures have been combined into a “prevention bundle” that focuses on catheter insertion. ^{Reference Pronovost, Watson, Goeschel, Hyzy and Berenholtz63,64} Numerous studies have documented that use of such bundles is effective, sustainable, and cost-effective in both adults and children. ^{Reference Pronovost, Watson, Goeschel, Hyzy and Berenholtz63,Reference Kim, Holtom and Vigen65–Reference Ista, van der Hoven and Kornelisse68} Bundles are most likely to be successful if implemented in a previously established patient safety culture and their success depends on adherence to individual measures. ^{Reference Richter and McAlearney69} However, data suggests that not all components of bundles may be necessary to achieve an effect on CLABSI rates. ^{Reference Furuya, Dick, Perencevich, Pogorzelska, Goldmann and Stone70} After catheter insertion, maintenance bundles have been proposed to ensure optimal catheter care. ^{Reference Guerin, Wagner, Rains and Bessesen71} More data are needed to determine which components of the maintenance bundle are essential in reducing risk. ^{Reference Miller, Niedner and Huskins72,Reference O’Neil, Ball and Wood73}

Additional approaches for preventing CLABSI

Several additional approaches are currently available for use. Perform a CLABSI risk assessment before considering implementation of any of these approaches, taking potential adverse events and costs into consideration. Although it is reasonable to evaluate the utility of technology-based interventions when CLABSI rates are above the institutional- or unit-based threshold, this is also an opportunity to review practices and consider behavioral changes that may be instituted to reduce CLABSI risk. These additional approaches are recommended for use in locations and/or populations within the hospital with unacceptably high CLABSI rates despite implementation of the essential CLABSI prevention strategies listed above. These measures may not be indicated if institutional goals have been consistently achieved.

1. 1. Use antiseptic- or antimicrobial-impregnated CVCs (Quality of Evidence: HIGH in adult patients ^{Reference Raad, Darouiche and Dupuis38,Reference Hanna, Benjamin and Chatzinikolaou39,Reference Wang, Tong and Liu169–Reference Novikov, Lam, Mermel, Casey, Elliott and Nightingale171} and MODERATE in pediatric patients ^{Reference Gilbert, Mok and Dwan172,Reference Lai and Yue173} )

   1. a. The risk of CLABSI is reduced with some currently marketed antiseptic-impregnated (eg, chlorhexidine-silver sulfadiazine) catheters and antimicrobial-impregnated (eg, minocycline-rifampin) catheters. Use such catheters under the following conditions:

      1. i. Hospital units or patient populations have a CLABSI rate above institutional goals despite compliance with essential CLABSI prevention practices. Some evidence suggests that use of antimicrobial CVCs, along with other preventive technologies, may have no additional benefit in patient care units that have already established a low incidence of catheter infections. ^{Reference Cherry-Bukowiec, Denchev and Dickinson174,Reference Ullman, Paterson and Schults175}

      2. ii. Patients have limited venous access and a history of recurrent CLABSI.

      3. iii. Patients are at heightened risk of severe sequelae from a CLABSI (eg, patients with recently implanted intravascular devices such as a prosthetic heart valve or aortic graft).

   2. b. Monitor patients for adverse effects such as anaphylaxis. ^{Reference Guleri, Kumar, Morgan, Hartley and Roberts176}

   3. c. Many studies investigating antimicrobial-impregnated catheters were performed before infection preventive bundles were routine. Whether such catheters have an impact on CLABSI in such settings remains unknown.

2. 2. Use antimicrobial lock therapy for long-term CVCs (Quality of Evidence: HIGH^{)Reference Carratala, Niubo and Fernandez-Sevilla177–Reference Sheng, Zhang and Li184}

   1. a. Antibiotic and antiseptic locks are created by filling the lumen of the catheter with a supratherapeutic concentration of an antibiotic solution and leaving the solution in place until the catheter hub is re-accessed. Such an approach can reduce the risk of CLABSI. The optimal antimicrobial agent or combination of agents, their concentration, and duration of lock therapy are matters of ongoing research. Due to concerns regarding the potential for the emergence of resistance in exposed organisms, use antimicrobial locks as a preventative strategy for the following:

      1. i. Patients with long-term hemodialysis catheters who have a history of recurrent CLABSI. ^{Reference Arechabala, Catoni and Claro185}

      2. ii. Prophylaxis for patients with limited venous access and a history of recurrent CLABSI.

      3. iii. Patients who are at heightened risk of severe sequelae from a CLABSI (eg, patients with recently implanted intravascular devices such as a prosthetic heart valve or aortic graft).

   2. b. To minimize systemic toxicity, aspirate rather than flush the antimicrobial lock solution after the dwell time has elapsed. ^{Reference Opilla, Kirby and Edmond186–Reference Heng, Abdelkader and Diaconita189} The potential of adverse effects associated with ethanol locks should be carefully considered before use. ^{Reference Mermel and Alang190,Reference Wolf, Connell and Allison191}

3. 3. Use recombinant tissue plasminogen activating factor (rt-PA) once weekly after hemodialysis in patients undergoing hemodialysis through a CVC (Quality of Evidence: HIGH) ^{Reference Hemmelgarn, Moist and Lok192}

4. 4. Utilize infusion or vascular access teams for reducing CLABSI rates (Quality of Evidence: LOW) ^{Reference Miller, Goetz, Squier and Muder193,Reference Taylor, Massaro and Williams194}

   1. a. Studies have shown that an infusion/vascular access team responsible for insertion and maintenance of peripheral intravenous catheters reduces the risk of bloodstream infections ^{Reference Soifer, Borzak, Edlin and Weinstein195} ; however, few studies have been performed regarding the impact of intravenous therapy teams on CLABSI rates. ^{Reference Carr, Higgins, Cooke, Mihala and Rickard196}

5. 5. Use antimicrobial ointments for hemodialysis catheter insertion sites (Quality of Evidence: HIGH) ^{Reference Levin, Mason, Jindal, Fong and Goldstein197–Reference James, Conley, Tonelli, Manns, MacRae and Hemmelgarn201}

   1. a. Apply polysporin “triple” (where available) or povidone-iodine ointment to hemodialysis catheter insertion if compatible with the catheter material.

   2. b. Ingredients in ointments may interact with the chemical composition of some catheters. Thus, ensure the selected ointment will not interact with the catheter material before any such product is applied to the catheter insertion/exit site. For example, ointments containing glycol should not be applied to insertion/exit sites of polyurethane catheters.

   3. c. Mupirocin ointment should not be applied to the catheter insertion site due to the risks of facilitating mupirocin resistance and the potential damage to polyurethane catheters.

6. 6. Use an antiseptic-containing hub/connector cap/port protector to cover connectors (Quality of Evidence: MODERATE) ^{Reference Oto, Imanaka, Konno, Nakataki and Nishimura202–Reference Flynn, Larsen, Keogh, Ullman and Rickard208}

   1. a. The utility of routinely disinfecting hub connectors and ports when using antiseptic-containing hub/connector cap/port protectors is unknown.

Internal reporting

These performance measures are intended to support internal hospital quality improvement efforts ^{Reference Bizzarro, Sabo and Noonan229,Reference Sawyer, Weeks and Goeschel230} and do not necessarily address external reporting needs.

The process and outcome measures suggested here are derived from published guidelines, other relevant literature, and the opinion of the authors. Report process and outcome measures to senior hospital leadership, nursing leadership, and clinicians who care for patients at risk for CLABSI.

Process measures (Table 3)

1. 1. Compliance with CVC insertion guidelines as documented on an insertion checklist

   1. a. Assess compliance with the checklist in all hospital settings where CVCs are inserted (eg, ICUs, ED, OR, radiology, general patient care units) and assign HCP familiar with CVCs to this task.

   2. b. Documenting compliance using the insertion checklist upholds accountability and compliance with the proper procedure steps and identifies gaps to be mitigated. The Institute for Healthcare Improvement (IHI) provides an example of a central catheter checklist. ²³¹

   3. c. Documentation of CVC insertion procedures in compliance with appropriate hand hygiene, use of maximal sterile barrier precautions, and use of chlorhexidine-based cutaneous antisepsis of the insertion site:

      1. i. Numerator: Number of CVC insertions that have documented the use of all 3 interventions (hand hygiene, maximal barrier precautions, and chlorhexidine-based cutaneous antiseptic use) performed at the time of CVC insertion.

      2. ii. Denominator: Number of all CVC insertions.

      3. iii. Multiply by 100 so that the measure is expressed as a percentage.

2. 2. Compliance with documentation of daily assessment regarding the need for continuing CVC access.

   1. a. Measure the percentage of patients with a CVC where there is documentation of daily assessment:

      1. i. Numerator: Number of patients with a CVC who have documentation of daily assessment.

      2. ii. Denominator: Number of patients with a CVC.

      3. iii. Multiply by 100 so that the measure is expressed as a percentage.

3. 3. Simulation of catheter maintenance as an alternative to address HCP competency ^{Reference Fakih, Jones and Rey232,Reference Fakih, Jones and Rey233}

   1. i. Numerator: Number of HCP properly simulating the aseptic infusion of medications.

   2. ii. Denominator: Number of HCP simulating the aseptic infusion of medications.

   3. iii. Multiply by 100 so that the measure is expressed as a percentage.

4. 4. Device utilization can be evaluated over time to assess any changes. Utilization may be compared at the hospital and unit level. It provides a surrogate for patient exposure risk. ^{Reference Fakih, Gould and Trautner234} The standardized utilization ratio (SUR) is an NHSN measure that accounts for facility- and location-level factors that may affect device use.

   1. i. SUR: Observed device days divided by predicted device days.

Table 3. CLABSI Prevention Process Measures

Outcome measures (See Table 4)

1. 1. CLABSI rate: Use NHSN definitions.

   1. a. Numerator: Number of CLABSIs in each unit assessed (using NHSN definitions).

   2. b. Denominator: Total number of catheter days in each unit assessed (using NHSN definitions).

   3. c. Multiply by 1,000 so that the measure is expressed as number of CLABSIs per 1,000 catheter days.

2. 2. Risk adjustment: Stratify CLABSI rates by type of patient-care unit. ^{Reference Widmer, Nettleman, Flint and Wenzel235–Reference Pittet and Wenzel237}

   1. a. Report comparisons based on historic data and NHSN data, if available. ^{Reference Sunkesula, Kundrapu, Knighton, Cadnum and Donskey167}

   2. b. Use the NHSN device standardized infection ratio (dSIR) to evaluate hospital and unit CLABSI rates.

      1. i. dSIR: Observed CLABSI events divided by predicted CLABSI events based on actual device days.

   3. c. Consider measures that address device risk at the patient population level. A population SIR (pSIR) ^{Reference Fakih, Huang and Bufalino238} accounts for both device SIR and SUR, reflecting both the care of the device, and interventions to reduce utilization.

      1. i. pSIR: Observed CLABSI events divided by predicted CLABSI events based on predicted device days.

Table 4. CLABSI Prevention Outcome Measures

External reporting

Many challenges exist in providing useful information to consumers and other stakeholders and in preventing unintended consequences of public reporting of HAIs. ^{Reference Wong, Rupp and Mermel239,Reference Aswani, Reagan, Jin, Pronovost and Goeschel240} Recommendations for public reporting of HAIs have been provided by the Healthcare Infection Control Practices Advisory Committee (HICPAC), ^{Reference Talbot, Bratzler and Carrico241} the Healthcare-Associated Infection Working Group of the Joint Public Policy Committee, ^{Reference Evans, Kralovic, Simbartl, Jain and Roselle242} and the National Quality Forum. ^{Reference Hamill, Reed and Fogel243}

State and federal requirements

1. 1. Hospitals in states that have mandatory reporting requirements for CLABSI must collect and report the data required by the state.

2. 2. For information on state and federal requirements, contact your state or local health department.

Engage

Historically, efforts have been centered around having a champion to support CLABSI reduction initiatives. Champions are often very effective in initial phases of adoption, but their efforts may not be enough for integration of processes and sustainability. ^{Reference Hendy and Barlow250} It is important to engage both frontline and senior leadership champions in the process and outcome improvement plan, ^{Reference Weaver, Lubomksi, Wilson, Pfoh, Martinez and Dy251} but institutionalizing the work and garnering the support of stakeholder groups facilitates successful, long-lasting results. ^{Reference Fakih, Krein, Edson, Watson, Battles and Saint252}

Educate

HCP, patients, and caregivers involved in care of a CVC should be trained in and competent, relative to their role, with the following:

1. 1. Appropriate indications prior to insertion.

2. 2. Use of full barrier precautions at the time of insertion.

3. 3. Daily evaluation of necessity of the device.

Execute

A standardized competency assessment checklist should be used to assess and document competency of each individual performing CVC insertion and procedures related to care and maintenance (eg, dressing changes). ^{Reference Wathen, Kshettry and Krishnaney253–Reference Evans and Dodge255} In addition, education of the patient and/or family, as appropriate, is required for all CVC care procedures especially when transfer to an alternative setting (eg, home care, ambulatory setting) is planned. ^{Reference Segreti, Garcia-Houchins and Gorski256,Reference Nailon, Rupp and Lyden257}

Evaluate

Evaluation involves both process and outcome measurement. ^{Reference Wheeler, Giaccone and Hutchinson258} Multidisciplinary teams should set clear goals and identify the key factors to be measured. It is important for members of the healthcare team to receive feedback on their performance. Feedback should include periodic (eg, monthly, quarterly) communication (eg, e-mail messages, written reports) of process measurement data via posters, reports, or other forms of communication with graphs showing cumulative compliance with process measures. ^{Reference Marra, Cal and Durao259–Reference Assanasen, Edmond and Bearman262} Differences between age groups should also be considered (eg, neonates, pediatrics, and adults). ^{Reference Powers and Wirtschafter260,Reference Miller, Griswold and Harris263,Reference Stevens and Schulman264} Central line data can be used to capture trends over time. The standardized utilization ratio (SUR) provides a method for the hospital’s units to compare themselves to others with similar characteristics. CLABSI events are important to discuss with the different members of the team caring for the patient to have a clear understanding of gaps and ways to mitigate them in the future.