Pathogen Analysis of Central-Line Associated Bloodstream (CLAB) Infections-Life Beyond Rates

Background: Efforts to reduce the incidence of CLAB infections began in the W.PA area in 2001.  By the time the state began mandated public reporting of all healthcare associated infections in 2004, CLAB rates had already been reduced by 63% in the region. In 2002, UPMC-Presbyterian, a 766 bed university hospital with 158 ICU beds and a case mix index of 2.29 began an initiative focusing on insertion practices that resulted in a 71.4% decrease in the ICU CLAB rate to 1.2/1000 CL days within the year. UPMC has an extensive internal quality program and since 2005 has participated in a similar program with Highmark QualityBLUE (QB) that incentivizes hospitals that reach goals. Participation in CLAB initiatives requires extensive data collection of both process and outcome measures. Through FY08, house wide CLAB rates remained low with an aggregate rate ≤ 0.7/1000 CL days.  Decreases in CLAB rates over the past 4 years were attributed to reduction of infections from skin flora, evidence that our bundle approach to CL insertion was effective.  Clinicians document insertion processes electronically and compliance has been near 100% and for >5 years.  However; over the past year the rate began to increase. While rates are still well belo5/08. Despite a 15 second scrub the hub initiative, rates are increasing and pathogen predominance has changed.

Objective: Pathogens were stratified by organism type to evaluate potential causes which could result in an increasing infection trend.  

Methods: Primary bloodstream (BSI) data was pulled from NHSN from 1/06 through 9/09.  Of the 326 BSIs recorded, 86.5% were considered CLABs.  Pathogens were stratified into 6 categories: Coag negative Staph (CNS), Staph aureus, yeast, enterococci, enteric Gram negative rods (GNRs) and non-fermenters.  Data was organized by event date and pathogen group. Unit specific CLAB rates were calculated monthly.

Results: With 9 months of data available for CY09, the CLAB rate in our 8 ICU types is 0.715/1000 CL days and the house wide rate is 0.78/1000 CL days.  Pathogen analysis between 2006 and 2009 identified a 47.7% increase in frequency of GNRs and a 36.1% decrease in CNS. Other organisms were not significantly different.

Conclusions:     

·         Infection rates do not provide sufficient data to identify process improvement opportunities. 

·         Had we not experienced this increase in GNR CLABs, our overall CLAB rate would have likely decreased even further.

·         Attention has focused on the care of the mechanical value. Culturing of blood drawn through the catheter is planned.

·         With public reporting mandates in PA since 2004, detailed analysis required for our internal quality group and our QB program necessitated a more intense review of data for process improvement.