Improving central venous catheter insertion documentation to facilitate electronic surveillance of bundle compliance

Background: Use of the central line bundle has demonstrated sustained reductions in central line-associated bloodstream infections (CLA-BSI).  Although most hospitals track CLA-BSI, manual compliance tracking of the bundle is time-consuming and often not done.

Objective: To develop an electronic surveillance system to monitor the insertion of central venous catheters (CVC) and the associated documentation of bundle compliance.

Methods: A central line insertion checklist was implemented in August 2008 as a powernote within the electronic medical record (EMR) containing all the bundle elements in discrete data fields which then could be electronically queried.  In January 2009, the insertion checklist was incorporated into a general “Time-Out” powernote consisting of a pre-procedure verification check list as well as all the individual bundle elements in an effort to standardize the time-out documentation for all invasive procedures.  As part of the team review of the checklist, nursing documents the time-out note within the EMR allowing identification of the specific note and subsequent data extraction.  Electronic surveillance was compared to manual review of documentation through sample audits, followed by review of all CVC placed in the intensive care units from October 2009 to April 2010.

Results:  Initial compliance with bundle documentation using the central line insertion checklist was 20% in October 2008 and 50% compliance in December 2008.  With the incorporation of the insertion checklist and bundle elements into the “Time Out” note used for documentation, feedback to the individual units and nursing staff through an automated daily central line list, and monthly intensive reviews of every CLA-BSI, compliance with documentation of the bundle elements continued to increase towards 90% (Fig 1) during the study period.

Conclusions: We developed an electronic surveillance system combined with modification of the EMR and documentation practices to allow automated tracking of the central line bundle documentation with the insertion of CVCs.  Despite significant improvements in documented use of the central line bundle, our CLA-BSI rate remained unchanged suggesting further training and education on proper line maintenance is required for those catheters medically required for prolonged periods of time.