Executive Summary Checklist

In  order  to  implement  a  program  to  eliminate  central  line-associated  bloodstream  infections  (CLABSIs)  the following  implementation  plan  will  require  these  actionable  steps.  The  following  checklist  was  developed  by  Dr. Peter Pronovost, in 2001. This checklist reduces infections when inserting a central venous catheter (CVC) \cite{00025}.

The Performance Gap

Each  year  in  the  United  States  there  are  more  than  700,000  healthcare-associated  infections  (HAIs)  resulting  in 75,000 deaths and $28-$45 billion in extra health care costs \cite{Klevens_2007},\cite{00026}.
Central  line-associated  bloodstream  infections  (CLABSIs)  are  amongst  the  most  commonly  occurring  HAIs  and have  a  mortality  rate  of  12-25%  (3).  An  estimated  41,000  patients in  US  hospitals  acquire  central  line-associated infections each  year \cite{21460264}.  Heavy  bacterial colonization at the insertion site, catheter placement in the  arm or leg rather than  the  chest,  catheterization  longer  than  3  days,  and  insertion  with  less  stringent  barrier  precautions  all significantly  increase  the  risk  of  catheter-related infection \cite{Mermel_1991}.  While  intensive  care  unit  (ICU)  patients  are  at  the highest  risk  for  CLABSIs,  central  venous  catheters  are  becoming  increasingly  utilized  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 \cite{Vonberg_2006}.  While  central  line  use  is  increasing  outside  the  ICU,  since  2008  CMS  has implemented a policy  of reduced reimbursement for reasonably preventable hospital-acquired conditions, including CLABSI. This policy  change can represent a significant financial burden to the hospital because increased hospital costs due to CLABSI can be as much as $23,000 per case \cite{00026}.
CLABSI  and  other  HAIs,  however,  are  largely  preventable.  Interventions  focusing  on  reducing  CLABSIs  in particular resulted in reductions ranging from 38 to 71%.3 Pronovost et al.  for example, observed a 66% decrease in CLABSIs after implementing a multi-component intervention in the ICUs  of 67 Michigan hospitals \cite{Pronovost_2006}. In a separate study  conducted  in  32  hospitals  in  Pennsylvania,  CLABSIs  decreased  by  68%,  following  targeted  interventions between  April  2001  and  March  2005 \cite{00027}.  Other  studies  have  shown  similar  reductions  in  CLABSI,  saving  lives  and dramatically reducing costs \cite{Rosenthal_2012},\cite{Hong_2013},\cite{Gozu_2011}.
A  variety  of  guidelines  and recommendations have  been  identified  to  prevent  CLABSIs  including  those  published by  The  Healthcare  Infection  Control  Practices  Advisory Committee, \cite{21511081}.  The  Institute  for  Healthcare  Improvement (IHI)\cite{00028} and the Agency for Healthcare Research and Quality (AHRQ) \cite{00029}.
Important  shared  components  of  these  recommendations  include:  implementing  a  method  to  detect  the  true incidence of CLABSI, including information technology to collect and calculate catheter days; providing adequate infrastructure  for  the  intervention  including  an  adequately  staffed  infection  prevention  and  control  program  and adequate  laboratory  support  for  timely  processing  of  samples;  implementing  a  catheter  insertion  checklist; monitoring  the  continued  need  for  intravascular  access  on  a  daily  basis;  and measuring  unit-  specific  incidence  of CLABSI as part of performance evaluations.
It is estimated that the use of process change and technology to reduce CLABSI can save up to $2.7 billion per year while significantly improving quality and safety \cite{00026}. Closing the performance gap will require hospitals and healthcare systems  to  commit  to  action in the  form  of  specific leadership,  practice,  and  technology  plans,  examples  of  which are  delineated  below  for  utilization  or  reference.  This  is  provided  to  assist  hospitals  in  prioritizing  their  efforts  at designing and implementing evidence-based bundles for CLABSI reduction.

Leadership Plan

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  increase  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 (Appendix A).

In addition to the change management model leaders should:

Practice Plan

Use of current evidence-based guidelines and/or implementation aids regarding the prevention of CLABSIs:

Insertion

Prepare insertion site

Maintenance

Standardized Access Procedure 17

In the Neonatal ICU:\cite{Miller_2010},\cite{Wheeler_2011},\cite{Milstone_2013},\cite{00030}

Education

  • Ultrasound guided cannulation
  • Maintaining sterile technique – immediate feedback