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The current methodology for calculating central-line–associated bloodstream infection (CLABSI) rates, used for pay-for-performance measures, does not account for multiple concurrent central lines.
To compare CLABSI rates using standard National Healthcare Safety Network (NHSN) denominators to rates accounting for multiple concurrent central lines.
Descriptive analysis and retrospective cohort analysis.
We identified all adult patients with central lines at 2 academic medical centers over an 18-month period. CLABSI rates were calculated for intensive care units (ICUs) and non-ICUs using the standard NHSN methodology and denominator (a patient could only have 1 central-line day for a given patient day) and a modified denominator (number of central lines in 1 patient in 1 day count as number of line days). We also compared characteristics of patients with and without multiple concurrent central lines.
Among 18,521 hospital admissions, there were 156,574 central-line days and 239 CLABSIs (ICU, 105; non-ICU, 134). Our modified denominator reduced CLABSI rates by 25% in ICUs (1.95 vs 1.47 per 1,000 line days) and 6% (1.30 vs 1.22 per 1,000 line days) in non-ICUs. Patients with multiple concurrent central lines were more likely to be in an ICU, to have a longer admission, to have a dialysis catheter, and to have a CLABSI.
Using the number of central lines as the denominator decreased CLABSI rates in ICUs by 25%. The presence of multiple concurrent central lines may be a marker of severity of illness. The risk of CLABSI per lumen of a central line is similar in ICUs compared to wards.
To assess the impact of a novel, silver-coated needleless connectors (NCs) on central-line–associated bloodstream infection (CLABSI) rates compared with a mechanically identical NCs without a silver coating.
Prospective longitudinal observation study
Two 500-bed university hospitals
All hospitalized adults from November 2009 to June 2011 with non-hemodialysis central lines
Hospital A started with silver-coated NCs and switched to standard NCs in September 2010; hospital B started with standard NCs and switched to silver-coated NCs. The primary outcome was the difference revealed by Poisson multivariate regression in CLABSI rate using standard Centers for Disease Control and Prevention surveillance definitions. The secondary outcome was a comparison of organism-specific CLABSI rates by NC type.
Among 15,845 hospital admissions, 140,186 central-line days and 221 CLABSIs were recorded during the study period. In a multivariate model, the CLABSI rate per 1,000 central-line days was lower with silver-coated NCs than with standard NCs (1.21 vs 1.79; incidence rate ratio=0.68 [95% CI: 0.52–0.89], P=.005). A lower CLABSI rate per 1,000 central-line days for the silver-coated NCs versus the standard NCs was observed with S. aureus (0.11 vs 0.30, P=.02), enterococci (0.10 vs 0.27, P=.03), and Gram-negative organisms (0.28 vs 0.63, P=.003) but not with coagulase-negative staphylococci (0.31 vs 0.36) or Candida spp. (0.42 vs 0.40).
The use of silver-coated NCs decreased the CLABSI rate by 32%. CLABSI reduction efforts should include efforts to minimize contamination of NCs.
Measurement of central line-associated bloodstream infection (CLABSI) rates outside of intensive care units is challenged by the difficulty in reliably determining central venous catheter (CVC) use. The National Healthcare Safety Network (NHSN) allows for use of electronic data for determination of CVC-days, but validation of electronic data has not been studied systematically.
To design and validate a process to reliably measure CVC-days outside of the intensive care units that leverages electronic documentation.
Thirty-four inpatient wards at 2 academic hospitals using a common electronic platform for nursing documentation were studied. Electronic queries were created to capture patient and CVC information, and tools and processes for tracking and reporting errors in documentation were developed. Strategies to validate electronic data included comparisons with manual CVC-day determinations and automated data validation using customized tools. Interventions included redesign of documentation interface, real-time audit with feedback of errors, and education. The primary outcome was patient-level total error rate in electronic CVC-day measurement compared with manually counted CVC-days.
At baseline, there were a mean (± standard deviation) of 0.32 ± 0.25 electronic CVC-day errors (omission and commission errors summed and counted equally) per manually counted CVC-day. After several process improvement cycles over 7 months, the error rate decreased to <0.05 errors per CVC-day and remained at or below this level for 2 years.
Baseline electronic CVC-day counts had a high error rate. Stepwise interventions reduced errors to consistently low levels. Validation of electronic calculation of CVC-days is essential to ensure accuracy, particularly if these data will be used for interinstitutional comparison.
Many bloodstream infections (BSIs) occurring in patients with febrile neutropenia following cytotoxic chemotherapy are due to translocation of intestinal microbiota. However, these infections meet the National Healthcare Safety Network (NHSN) definition of central line-associated BSIs (CLABSIs). We sought to determine the differences in the microbiology of NHSN-defined CLABSIs in patients with and without neutropenia and, using these data, to propose a modification of the CLABSI definition.
Two large university hospitals over 18 months.
All hospital-acquired BSIs occurring in patients with central venous catheters in place were classified using the NHSN CLABSI definition. Patients with postchemotherapy neutropenia (500 neutrophils/mm3 or lower) at the time of blood culture were considered neutropenic. Pathogens overrepresented in the neutropenic group were identified to inform development of a modified CLABSI definition.
Organisms that were more commonly observed in the neutropenic group compared with the nonneutropenic group included Escherichia coli (22.7% vs 2.5%; P < .001) but not other Enterobacteriaceae, Enterococcus faecium (18.2% vs 6.1%; P = .002), and streptococci (18.2% vs 0%; P < .001). Application of a modified CLABSI definition (removing BSI with enterococci, streptococci, or E. coli) excluded 33 of 66 neutropenic CLABSIs and decreased the CLABSI rate in one study hospital with large transplant and oncology populations from 2.12 to 1.79 cases per 1,000 line-days.
Common gastrointestinal organisms were more common in the neutropenia group, suggesting that many BSIs meeting the NHSN criteria for CLABSI in the setting of neutropenia may represent translocation of gut organisms. These findings support modification of the NHSN CLABSI definition.
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