Focusing on central line-associated bloodstream infections

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CDC releases CLABSI guidelines

A look at how new guidelines affect infection control in hospitals

In April, the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection ­Control Practices Advisory Committee released a new set of guidelines to eliminate central line-associated bloodstream infections (­CLABSI). The guidelines, titled Guidelines for the Prevention of Intravascular Catheter-Related Infections, replace the 2002 edition and are available on the CDC website (

"I think infection preventionists and other ­patient safety professionals always welcome new ­guidelines based on evidence to guide patient practice," says Libby Chinnes, RN, BSN, CIC, consultant with IC ­Solutions, Inc., in Mount Pleasant, SC. "The evidence is constantly changing and our practice needs to change with it for improved care."

Chinnes is also happy to see that the new guidelines rely on using bundles. She says the guidelines are much clearer and easier to understand than the previous edition.

The guidelines were developed by a working group led by clinical scientists from the National Institutes of Health's Critical Care Medicine Department (CCMD), along with 14 other professional organizations.

Naomi O'Grady, MD, a senior staff physician at CCMD at the National Institutes of Health in Bethesda, MD, is the lead author of the new guidelines. "There's been a lot of new data coming out since 2002, either ­reinforcing recommendations that were made previously, leading to higher levels of evidence, or new data coming out that allows us to change ­certain recommendations," says O'Grady. "For ­example, this guideline recommends anything greater than 0.5% chlorhexidine rather than what we said previously, which was a minimum of 2%."


Setting and maintenance matter

The guidelines reflect the idea that hospitals need to move past insertion techniques and an ICU focus.

"We know that catheter care and maintenance has a big impact on infections if they're not maintained ­correctly outside of the ICU setting," O'Grady says. "­Although we have made a big impact in the ICU setting, I think there is still a lot of work to be done in the general medical wards and in the outpatient setting where patients often have permanent catheters for things like cancer chemotherapy and other long-term needs for IV access."

A significant change in the guidelines is the focus on catheter maintenance, says O'Grady.

"I think that the 2002 guidelines put a lot of ­emphasis on insertion techniques and infections that occurred close to the time of insertion, especially with central lines that were place in the ICU," O'Grady says. "So the idea was clearly an emphasis on reducing the number of early infections that we saw at the time of insertion."

Since then, however, insertion techniques have ­improved tremendously, providing more opportunities to reduce infections through maintenance of the central line.


Focus on bundles

More emphasis was also placed on the bundled ­approach and the use of central line kits that force practitioners to use the appropriate materials.

"Often we hear that there are barriers out there to adhering to some of these recommendations, and that's where the bundled strategy comes in, making it easy for people to do the right thing and difficult for them to do the wrong thing," O'Grady says.



Lastly, the updated guidelines further emphasize the need for initial staff education, with ­reeducation as needed. Reeducation also needs to be at the point of care in order to fix any potential missteps.

"We know that simple didactic sessions rarely have impact in changing provider behavior," says O'Grady. "Education and training really needs to be done at the bedside in a one-on-one situation or a small ­seminar where there is active learning rather than passive learning going on." She recommends following the "triple A's" when implementing these updated guidelines:

  • Awareness of best practices
  • Agreement with those new guidelines in your specific facilities
  • Adherence to appropriate policies and ­guidelines, along with finding and eliminating barriers to adherence


O'Grady reminds healthcare providers that, ultimately, the guidelines provide simple, low-cost strategies.

"Although there are a lot of novice technologies out there, such as antibiotic-impregnated catheters and chlorhexidine-impregnated sponge dressings that might be a little more expensive than standard [equipment], we also know that you can accomplish the ­elimination of CLABSIs for a period of time without using novel ­technologies," she says.

"You can use simple strategies and still achieve the same goal," she adds.


Working toward zero

A long-standing question among infection control and patient safety professionals has been whether hospitals can truly rid themselves of these infections for good. "The goal is to eliminate CLABSIs. Attention to detail is critical for achieving that goal. You can use simple strategies and be very attentive to the care and maintenance of the catheters and remain infection-free," says O'Grady.

However, there are some inevitable factors, such as human error or a patient being more susceptible to infection or already colonized, that will ­result in infection regardless of efforts. O'Grady says that although infections can be greatly reduced, and some hospitals have shown 0% infection for a period of time, researchers are unsure how long such a rate can be achieved.

"While every single CLABSI may not be avoidable, there is definitely a shift in viewing CLABSIs in general as preventable infections," says Chinnes.

Focusing on central line-associated bloodstream infections

  • Starting in 2011, hospitals must track and report central line-associated bloodstream infections (CLABSI) in ICUs to receive an annual 2% Medicare payment increase
  • As part of its Action Plan to Prevent HAIs, the U.S. ­Department of Health and Human Services has a ­national goal of reducing CLABSIs by 50% by 2013
  • CLABSIs are reported to the public through the CMS Hospital Compare website
  • The Joint Commission's National Patient Safety Goal NPSG.07.04.01 requires hospitals to use proven guidelines to prevent CLABSIs
  • Vascular catheter-associated bloodstream infections are included in CMS' no-pay events
  • Central line-associated bloodstream infectionrate for ICU and high-risk nursery patients is a National Quality Forum-endorsed measure