Slide 1: Hello and welcome. Thank you for joining us. In this presentation, we are reviewing the NHSN criteria for central line associated bloodstream infections.
Slide 2: The National Healthcare Safety Network (NHSN) is an electronic, integrated surveillance system used to collect comprehensive data about hospital acquired infections. The data then enables healthcare facilities to effectively identify problem areas and to focus efforts on process improvement and prevention. To ensure accurate and meaningful data, NHSN requires facilities to report events based on specific, clearly defined criteria. This presentation will provide definitions related to CLABSI criteria and reporting and will provide examples for application in adult acute care settings. This learning module is approximately 15 minutes in length and can be viewed as needed. As NHSN reporting is extensive, be sure to click on and review provided links and resources for more in-depth and nuanced definitions and application of criteria.
Slide 3: After viewing this learning module, the learner will be able to identify CLABSI events per NHSN definitions and will understand reporting requirements. Please note, this presentation will address CLABSI events in the adult population. For secondary bloodstream infections and CLABSI in neonates, please refer to the NHSN Patient Safety Component Manual as well as the NHSN website.
Slide 4: The first two documents linked on this slide cover all of what we are reviewing today. If possible, it would be beneficial to your learning and comprehension to have these two documents open and available as you continue this module. You may pause the recording and select those links from the handout provided with this video. The third document is the comprehensive NHSN organism list for reference when investigating a possible hospital acquired infection. Please note, this list is not exhaustive. For guidance and clarification regarding an organism not on the list, contact NHSN directly. Be sure to download and save all documents for future use.
Slide 5: The next two slides will review infection definitions that apply to CLABSI as well as other hospital acquired conditions. These definitions can be found in the comprehensive document the “NHSN general key terms and definitions” on the link provided. We will put these concepts into practice through case studies later in this presentation. So again, if possible, it would be beneficial to your learning and comprehension to have this document open and available as we move through the module. Let’s quickly review the definitions on this slide:
Healthcare-associated infection (HAI): The criterion occurs on or after the third calendar day of admission to an inpatient location.
Present on admission (POA): This criterion occurs during the admission time period, which includes the day of admission to an inpatient location, two calendar days before admission and one calendar day after admission.
Infection window period (IWP): This window is the seven days during which all site-specific infection criteria must be met. It includes the collection date of the first positive diagnostic test, three calendar days before and three calendar days after collection.
Date of event (DOE): This is the date the first element used to meet criteria occurs for the first time within the seven-day infection window period
Location of attribution (LOA): This is the inpatient location where the patient was assigned on the date of event (DOE).
Transfer rule: If the date of event is on the date of transfer or discharge, or the next calendar day, the infection is attributed to the transferring location.
Slide 6: Repeat infection timeframe (or RIT): This is the 14-day timeframe during which no new infection of the same type is reported. This is applied only to a single admission.
Device days: A count of the number of patients with a specific device in a specific inpatient care location during a defined time period.
Patient Days: A count of the number of patients in a specific patient care location during a defined time period.
Calendar Day: Defined as midnight (00:00) to 11:59pm.
Settings: Surveillance occurs in any inpatient location where denominator data can be collected. This includes:
- Intensive care units
- Specialty care areas
- Step-down units
- Medical/surgical units and
- Inpatient rehabilitation units
One thing to note about surveillance settings -- if an observation patient is admitted to an inpatient location, the patient must be included in surveillance and included in patient and device day counts as the patient is being housed, monitored, and cared for in an inpatient location and therefore is at risk for acquisition of an infection.
Slide 7: Let’s review the background on CLABSI. Both, the CDC and CMS continue a sustained push to eliminate central line infections. Their work and advocacy, coupled with the immense efforts and dedication of healthcare organizations and care providers, have resulted in a 46% reduction in CLABSIs over the past 15 years. However, it is estimated that over 30,000 CLABSIs continue to occur in acute care facilities across the U.S. each year. CLABSIs are associated with poor patient outcomes such as increased length of stay and a mortality rate of 12 – 25%. It is also estimated that a single CLABSI costs around $70,000, which is absorbed by the healthcare facility.
Slide 8: More definitions! The next three slides will review definitions specific to CLABSI before we get into reporting requirements and work through examples. If needed, refer to slides six and seven for common infection definitions or the NHSN General Key Terms document as we move through this section. The accompanying resource on this slide is Chapter 4 of the NHSN patient safety component manual. For accurate and meaningful reporting and data, it is important to understand these definitions and follow strict adherence to definitions and reporting instructions. A primary bloodstream infection, or BSI, is a laboratory-confirmed bloodstream infection, or LCBI, that is not secondary to an infection at another body site. A central line-associated bloodstream infection occurs when an eligible BSI organism is identified, and an eligible central line is present on the LCBI day of event or the day before.
Slide 9: A central line is defined as an intravascular catheter that terminates at or close to the heart or in one of the great vessels, and is used for infusion, blood withdrawal, or hemodynamic monitoring. Peripherally inserted central catheters, otherwise known as PICC lines that meet criteria are also included. Once a line is determined to be a central line it is considered a central line until it is removed, or the patient is discharged. The table on this slide identifies the great vessels used for NHSN CLABSI reporting. An infusion is the administration of any solution through the lumen of a catheter into a blood vessel. This includes continuous infusions, intermediate infusions, IV antimicrobial administration, blood transfusions, or hemodialysis treatments. Access is defined by the performance of one or more of the following activities: line placement, use for infusion or blood draw, or use for hemodynamic monitoring.
Slide 10: Eligible central line: Lines are eligible for CLABSI events and remain eligible for CLABSI events until the day after removal from the body or patient discharge, whichever comes first, if the patient below criteria are met:
1. The CL has been in place for more than two consecutive calendar days (which is on or after CL day 3)
2. And, it must be following the first access of the central line, in an inpatient location, during the current admission.
There are three types of central lines identified by NHSN for reporting purposes – permanent lines, temporary lines, and umbilical catheters, which are only used in neonates. For this presentation, we will address the two types used in adult patient populations -- permanent and temporary lines. Permanent central lines are tunneled catheters, including tunneled dialysis catheters and implanted catheters, such as ports. A temporary central line is a non-tunneled, non-implanted catheter, such as peripherally inserted central catheter or PICC line. Central line days are the number of days a central line is accessed to determine if a laboratory confirmed bloodstream infection is a CLABSI. For eligible bloodstream infection organisms, please refer to the NHSN organism list. As a reminder, this list is not exhaustive and some eligible pathogens as well as some exclusion pathogens may not be on the list. For guidance and clarification regarding an organism not on the list, contact NHSN directly.
Slide 11: This table defines the CLABSI criteria for a laboratory-confirmed bloodstream infection, or LCBI 1, along with clarifying notes, which can be found in chapter 4 of the NHSN patient safety component manual. We will only be addressing LCBIs in this presentation. Mucosal barrier injury, or MBI, can occur during periods of prolonged neutropenia in patients receiving cytotoxic chemotherapy for hematologic malignancies. This can lead to an LCBI, as well as subsequent complications, including sepsis, organ failure, and possible death. MBIs should be assessed in oncology patient populations. A LCBI is defined as a recognized bacterial or fungal infection identified from one or more specimens obtained by a culture OR identified to the genus or species level by non-culture based microbiologic testing methods AND the organism identified in the blood is not related to an infection at another site. You will want to review this criteria and accompanying notes in depth so keeping this table readily accessible is highly suggested.
Slide 12: This table defines the CLABSI criteria for LCBI 2. Again, this table can be found in chapter 4 and should be kept readily available. LCBI 2 is met if the following three criteria are met:
- The patient has at least ONE of these signs or symptoms: fever (greater than 100.4 Fahrenheit), chills, or hypotension AND
- The organism identified in blood is not related to an infection at another site AND
- The organism is a common skin commensal which is identified by a culture from two or more blood specimens collected on separate occasions.
Common skin commensals are bacteria that live and thrive on the skin, but do not cause harm. However, scratching, picking, and improper care and maintenance of central lines can cause these skin bacteria to contaminate a line and cause blood stream infections.
Slide 13: Now we will discuss reporting CLABSI events. Events should be reported to NHSN at a minimum of every quarter for the prior three months surveillance periods. If no CLABSIs are identified during the surveillance periods, the “report no events” box must be checked. If CLABSIs are identified, the numerator reported will be the actual number of events confirmed during the surveillance period. Included on this slide is an investigative tool to help identify CLABSIs as well as the instructions for tool completion.
Slide 14: The denominator consists of two data points – device days and patient days. Device days are the count of central lines in a specific inpatient location that is collected at the same time each day. The central line is included in the count the first day it is present, regardless of access. Patient days is the number of patients on a specific inpatient location, collected daily at the same time each day. Each of these data points should be collected separately for each inpatient location surveilled. Daily counts are summed and only the total for the month should be reported to NHSN. Included on this slide is a denominator tracking form. If your organization is pulling counts electronically, you first must validate the electronic method against the manual method. This is done by collecting three months of concurrent data using both methods. The electronically calculated data must be within 5% (+/-) of the manually collected data.
Slide 15: On this slide you will find a CLABSI determination algorithm developed by the University of California San Francisco Department of Epidemiology and Infection Prevention. The link on this slide in your handout will take you to the website for the algorithm. This algorithm may be helpful for your staff when determining if a bloodstream infection meets the criteria for a CLABSI.
Slide 16: This slide contains the steps for investigating a possible CLABSI. This is pulled directly from the NHSN training. We will use these steps as we work through examples on the following slides.
Slide 17: Let’s work through example one. The patient was admitted to hospital unit A on December 1st with pneumonia. On hospital day three, December 3rd, a central line was placed for IV antibiotic administration. On central line day 7, December 9th, the blood cultures collected were positive for a NHSN recognized pathogen. So, for step 1: Consider the organism and determine the date of event. The blood culture collected on December 9th was positive for a NHSN recognized pathogen, making December 9th the date of event.
For Step 2: we determine the infection window period. The date of event is December 9th, making the infection window period December 6th – December 12th. In Step 3: We determine the element(s) that were present during the infection window period. The element(s) present during the infection window period are the NHSN-recognized bacterial pathogen(s) that were identified in the positive blood culture.
For Step 4: We determine if the infection was present on admission or hospital acquired. The central line was placed on hospital day 3, December 3, outside the present on admission time frame of November 29th – December 2nd, and the blood cultures were collected on hospital day 9, making this a hospital acquired infection.
In Step 5: If the infection is determined to be a hospital acquired infection, we determine the device associated and the location of attribution. In this case, the patient has no other indwelling device and the patient has been located on hospital unit A for the entirety of their admission, making hospital unit A the location of attribution.
In Step 6: We determine the repeat infection timeframe. Remember - this is the 14-day period where no new infection of the same type is to be reported. The date of event is December 9th, making the repeat infection timeframe December 9th – December 22nd. Then, in Step 7: We determine if another site-specific source of infection is present. Again, the patient does not have any other indwelling device and no other site of infection has been identified.
For Step 8: If the infection is not secondary, we determine if the Laboratory-Confirmed Bloodstream Infection is a LCBI 1, LCBI 2, or LCBI 3 based on the organism and patient’s symptoms if required. For this example, LCBI 1 criteria is met – the patient has an NHSN recognized pathogen identified by blood culture and no other site-specific source of infection is present.
Slide 18: Now let’s work through example two. The patient was admitted to hospital unit B on September 7th with sepsis. The patient’s implanted port is accessed on hospital day one for administration of IV fluids and IV vasopressors. On hospital day nine and ten, September 15th and 16th, fevers of 101.3 Fahrenheit and 102 Fahrenheit are documented. A port dressing change is documented on hospital day seven, September 13th. Blood cultures are drawn on hospital day 10, September 16th and day 11, September 17th. The patient was transferred to hospital unit C on hospital day 10, September 16th prior to the collection of the second blood cultures collected on day 11, September 17th. Both cultures are positive for an NHSN recognized common skin commensal. Remember, common skin commensals are bacteria that live on the skin. Improper care and maintenance of central lines can lead to contamination of lines and blood.
In Step 1: We consider the organism and determine the date of the event. Blood cultures collected on September 16th and September 17th were both positive for the same NHSN recognized common skin commensal. A fever was first documented on hospital day nine, September 15th making the date of event September 15th. In Step 2: We determine the infection window period: The first positive diagnostic test, was first culture collected on September 16, making the infection window period September 13th – September 19th.
In Step 3: We determine the elements present in the infection window period. The elements present are the documented fever and the NHSN recognized common skin commensal identified by two separate blood cultures. We then move to Step 4: where we determine if the infection was present on admission or hospital acquired: The date of event, which is the date of the first positive diagnostic test on hospital day nine, September 15, falls outside of the present on admission timeframe of September 5th – September 8th. This makes this event a hospital acquired infection.
For Step 5: If the infection is hospital acquired, we determine the device associated and location of attribution. The patient has no other indwelling device. On the date of event, the patient was located on hospital unit B. Additionally, the transfer rule applies here as date of event was one calendar day before patient was transferred to hospital unit C.
In Step 6: We determine the repeat infection timeframe. The date of event is September 15th, making the repeat infection timeframe September 15th – September 28th; no new infection of the same type identified will be reported during this timeframe.
In Step 7: We determine if another site-specific source of infection is present. Again, the patient does not have any other indwelling device and no other site of infection has been identified. Finally, in Step 8: If the infection is not secondary, we determine LCBI 1, LCBI 2, or LBCI 3 based on the organism and patient’s symptoms if required. For this patient, LCBI 2 criteria is met – the patient has documented fever, a NHSN recognized common skin commensal is identified by two separate blood cultures and no other site-specific source of infection is present.
Slide 19: Explore these additional resources for further and more in-depth instruction on NHSN CLABSI criteria and reporting.
Slide 20: So, what do you do with your data? Although NHSN requires organizations to submit data quarterly, getting into the consistent habit of internally tracking and reviewing data monthly allows organizations to promptly identify, drill down, and respond to areas for improvement. Additionally, routine analyzing and interpreting of data helps support an organization’s ability to make meaningful operational decisions to improve patient care and outcomes. And be sure to share organizational and department progress and celebrate the wins!
Slide 21: Thank you for viewing this video. Remember, you can contact NHSN anytime with questions and for clarifications at email@example.com. Additionally, you can review this video as often as you wish. Let’s get to work!