Assessing Application of the National Healthcare Safety Network (NHSN) Central Line-Associated Bloodstream Infection (CLABSI) Surveillance Definition Across Pediatric Sites

Background: The NHSN CLABSI definition is used widely to track the effectiveness of interventions to prevent CLABSIs and for public reporting of CLABSI rates.

Objective:   To assess accuracy of application of the NHSN CLABSI definition in Pediatric Intensive Care Units (PICUs) and pediatric Hematology/Oncology Units (H/O) participating in the National Association of Children's Hospitals and Related Institutions (NACHRI) Quality Transformation Collaborative to reduce CLABSIs; to identify sources of variability in the application of this definition.

Methods: We administered an online survey containing 18 standardized case-scenarios to participating units.  Each scenario provided information about a positive blood culture in a PICU or H/O patient with additional information that assessed the application of a specific aspect of the NHSN definition.  Respondents were asked “Is this a CLABSI?” and provided a yes/no answer.  Respondents were instructed to be persons who routinely adjudicated CLABSI events and were allowed to collaborate on a response.  The survey was completed by NHSN staff whose answers were the gold-standard comparator.

Results:   58 (89%) of 65 participating institutions representing 29 states responded to the survey; 87 individuals participated in submitting 60 responses from units in these institutions (34 PICU¸9 H/O, 17 PICU & H/O).  These individuals included 54 (62%) infection control professionals, 7 (8%) hospital epidemiologists, 7 (8%) infectious diseases physicians, 13 (15%) critical care or oncology physicians and nurses, and 6 (7%) other.  Compared to NHSN staff answers, the mean (standard error, SE) percent of correct answers was 78% (1.8%) for all unit responses, 77% (2.5%) for PICU responses, 70% (5.8%) for H/O responses, and 83% (1.9%) for PICU & H/O responses.  While the mean [SE] percent of correct answers did not differ for scenarios based on NHSN criterion 1 (known pathogen; 78% [1.7%]) vs. criterion 2 (skin contaminant, > 1 year of age; 76% [2.5%]) vs. criterion 3 (skin contaminant, ≤ 1 year of age; 81% [3.8%]), it was lower for scenarios requiring respondents to (Figure): 1. determine if a CLABSI was present or incubating on admission (64% [4.6%]); 2. distinguish a primary vs. a secondary bacteremia (65% [2.5%]).

Conclusions: The accuracy of the application of the NHSN CLABSI definition to standardized case scenarios in this pediatric collaborative was suboptimal, in large part due to errors in determining if a CLABSI was present or incubating on admission and distinguishing a primary vs. secondary bacteremia.  Efforts are needed to optimize the application of this definition, particularly in high-risk populations such as H/O patients who have multiple sources of bacteremia, to better track the effects of interventions to prevent CLABSIs and improve the accuracy of public reporting of CLABSI rates.