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Accounting for presence of concurrent central lines decreases CLABSI rates
Accounting for the presence of multiple, concurrent central lines when calculating central line-associated bloodstream infections, or CLABSIs, lowered CLABSI rates by 25% over the course of 18 months in the ICUs at two hospitals, researchers reported in Infection Control & Hospital Epidemiology.
In the study, the researchers calculated CLABSI rates for ICU and non-ICU patients using a modified denominator — which counted the number of central lines in one patient in 1 day as the number of line days — and the standard National Healthcare Safety Network (NHSN) denominator, which counts only the number of days when any central line is present.
“Current surveillance definitions for CLABSI may not accurately assess the intrinsic risk of central lines, and modifications to the definition should be considered,” Jesse T. Jacob, MD, associate professor of medicine in the division of infectious diseases at the Emory University School of Medicine, told Infectious Disease News. “Removal of unnecessary central lines should remain a priority.”
For the study, Jacob and colleagues retrospectively identified all adult patients with central lines hospitalized at two medical centers from December 2009 to June 2011. Patients who had multiple concurrent central lines were more likely to have a dialysis catheter, have a longer admission, to be in an ICU and to have a CLABSI, they reported.
Among 18,521 hospital admissions, there were 239 CLABSIs (ICU, 105; non-ICU 134) in 156,574 central line days. When the modified denominator was used, there was a 25% lower CLABSI rate in ICU patients (1.95 vs. 1.47 per 1,000 line days) and a 6% lower rate in non-ICU patients (1.30 vs 1.22 per 1,000 line days), Jacob and colleagues reported.
Findings also indicated that the presence of multiple concurrent central lines may be an indicator for severity of illness, they said.
In the past, reducing central venous catheters, using silver-plated nylon dressings for catheters, and using chlorohexidine gluconate wipes for patient hygiene have been shown to reduce CLABSI rates.
“We have made great strides in reduction, but much work needs to be done,” Jacob said. “Risk adjustment beyond the basic factors currently used in CDC’s modeling is an area of active research since hospitals caring for more complex patients may have higher CLABSI rates.” – by Eamon Dreisbach
References:
Couk J, et al. Infect Control Hosp Epidemiol. 2019;doi:10.1017/ice.2019.180.
Disclosures: Jacob reports no relevant financial disclosures. Please see the full study for the other authors’ relevant financial disclosures.
Perspective
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This paper by Couk and colleagues adds to prior literature showing that multiple concurrent central lines, including multiple lumens in the same central line, can increase the risk for CLABSIs. This has raised concern among some in the infection prevention community about poor risk adjustment and unfair penalization of hospitals with a higher proportion of high-risk units (eg, ICUs, oncology wards). In these units, multilumen central venous catheters (CVCs) and/or multisite CVCs may be required to manage medically complex patients.
Thus, some have proposed modifying the denominator to account for the total number of CVCs (or lumens), as opposed to just looking at the number of days when any CVC was present. Couk and colleagues demonstrate that this type of modified denominator reduced the ICU CLABSI rate in the two study hospitals by 20%. One might argue, though, that this is really important only if there is variability across ICUs. If the CLABSI rates drop by 20% across all ICUs being compared, then the relative performance compared with other ICUs remains the same. If instead, the relative performance changes, then the modified denominator may allow for better comparison of modifiable prevention practices, assuming that all hospitals are inserting only the minimum number of lines/lumens to meet clinical needs.
Worth noting is that the CDC’s NHSN now includes inpatient locations when calculating the standardized infection ration, which assesses a hospital’s observed-to-expected CLABSI ratio. CMS also discusses risk adjustment at the patient care unit level in its fact sheet on the Hospital-Acquired Condition Reduction Program. Thus, there appears to be a movement toward better risk adjustment in publicly reported health care-associated infection metrics impacting hospital payment.
References:
Aslakson RA, et al. Infect Control Hosp Epidemiol. 2011;doi:10.1086/657941.
CDC. The NHSN standardized infection ratio (SIR). https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/nhsn-sir-guide.pdf. Accessed July 30, 2019
CMS. Hospital-acquired condition reduction program fiscal year 2020 fact sheet. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/HAC-Reduction-Program-Fact-Sheet.pdf. Accessed July 30, 2019.
Concannon C, et al. Infect Control Hosp Epidemiol. 2014;doi:10.1086/677634.
Scheithauer S, et al. Am J Infect Control. 2013;doi:10.1016/j.ajic.2012.02.034.