Electronic Documentation of Central Line-days; Validation is Essential

Background:   Beginning January 2011, hospitals will report central line-associated bloodstream infections (CLABSI) to the National Healthcare Safety Network [NHSN] per Center for Medicare and Medicaid Services (CMS) payment rules.  The NHSN definition for CLABSI uses central line-days as the denominator.  Manual collection of line-days outside the intensive care unit (ICU) is resource intensive and NHSN allows for use of electronic data sources if line-days are within 5% of manual count. However, NHSN has no validation component at the facility level.  

Objective: To design and validate an accurate process to electronically “count” line-days outside the ICU at 2 university hospitals with a total of 1000 beds and to assess the impact of this intervention on CLABSI rates.

Methods:   An electronic query was created to capture patient and line information along with a process for tracking, reporting and correcting errors in documentation to improve the validity of the electronic data.  The interventions included: an electronic error tracking tool, re-education of 98% of the nursing staff, re-design of the documentation interface, audit and feedback of errors in real time, and a dedicated central line champion.  After an initial stage of manual validation, an electronic documentation error tracking tool was developed to flag common errors leading to incorrect line-day counts, used daily by a trained nurse covering two hospitals.  Ongoing education focused on units with a high documentation error rate and errors were corrected in real time.    After validation of electronic data capture, CLABSI rates were calculated using both patient-days and electronic line-days for two selected wards over 8 months.

Results:   At baseline, there were 3454 errors/month in 5576 line-days for an error rate of 0.6 /line-days.  Post-intervention, there were 343 errors/month in 5061 line-days for an overall rate of 0.07/line-days and has remained stable 19 months post-intervention (figure).     

At baseline, a mean of 121 patients/day had ≥1 errors (81% involved a missing line type or insertion date), which decreased to 12 patients/day 13 months post-intervention. 

There were 7 CLABSIs in Ward A and 6 CLABSIs in Ward B in the study period. Using patient days as a denominator, Ward A had a higher CLABSI rate compared to Ward B (1.4 vs. 1.2 per 1000 patient-days).  However, using line-days as the denominator, Ward A had a lower CLABSI rate than Ward B (3.2 vs. 4.8 per 1000 line-days).

Conclusions:   Without intensive validation efforts, electronic line-day counts had a very high error rate. Using an existing electronic data source, combined with stepwise interventions yielded a highly accurate and reliable dataflow.  These findings raise concern that non-validated data could adversely impact the quality of NHSN denominator line-day data.

Our pilot comparing CLABSI rates in 2 wards had discordant results depending on choice of denominator (line-days vs. patient-days).