A Preliminary Description of Adherence to Central Line Insertion Practices Reported through the National Healthcare Safety Network

Background:

Central line-associated bloodstream infections (CLABSI) increase morbidity, mortality, and costs for hospitalized patients.  Successful prevention efforts have focused on adherence to a set (i.e., “bundle”) of central line insertion practices (CLIP).  In 2008, healthcare facilities began reporting CLIP adherence to the National Healthcare Safety Network (NHSN).

Objective:

1) Describe the volume and types of locations reporting CLIP data; 2) Assess overall adherence to the NHSN-defined CLIP bundle and 3) Identify specific elements of the CLIP bundle contributing to non-adherence.

Methods:

Adherence to the NHSN CLIP bundle was observed and documented at participating NHSN facilities for four mandatory components: hand hygiene prior to insertion, appropriate skin antisepsis, dry antiseptic before skin puncture, and maximal barrier precautions (cap, sterile gown, gloves, and inserter mask and a full drape for the patient). Adherence was documented by a third-party observer during insertion or by the inserter after insertion. Differences in adherence by location type, insertion site, observer type and reason for insertion were assessed with chi-Square statistics. For the subset of insertions in which the inserter did not adhere to the CLIP bundle, the percentages of each omitted bundle component were assessed. 

Results:

Between 3/1/08 and 9/30/09, 72,216 CLIP records were reported from 744 unique locations within 343 facilities. The table below displays the locations and circumstances in which insertion practices were documented, accompanied by overall and stratified adherence rates. Adherence was lowest for emergency room and operating room locations, subclavian and femoral insertion sites, and insertions observed by a third-party. Most insertions took place in intensive care units and at upper extremity insertion sites.  Of the 6356 insertions that did not adhere to the CLIP bundle, 16% did not perform hand hygiene, 20% did not use appropriate skin antiseptic, 21% did not let the antiseptic dry, and 60% did not adhere to maximal barrier precautions; of the barrier precautions, the cap was the most often omitted barrier (63%), followed by the full patient drape (34%). 

Conclusions:

In this first description of NHSN CLIP data, adherence rates were high but suboptimal. Facilities that use CLIP data to facilitate quality improvement by identifying specific gaps in adherence should recognize that, while locations with the lowest adherence rates should be targeted, locations with higher adherence rates also perform more insertions so small adherence increases may result in the greatest number of proper insertions.  Our analysis suggests that future validation of NHSN CLIP data include an assessment of the discrepancy between inserter and observer adherence and documentation of specific situations presenting barriers to adherence in various settings.