CLABSI/CRBSI PREVENTION BUNDLE CARE FOR NURSES

1. 1

2. Introduction
Modern healthcare employs many types of invasive devices
and procedures to treat patients and to help them recover.
Infections can be associated with the devices used in
medical procedures, such as catheters or ventilators.
These healthcare-associated infections (HAIs) include
 Central line-associated bloodstream infections(CLABSI)
 Catheter-associated urinary tract infections(CAUTI)
 Ventilator-associated pneumonia(VAP)
 Surgical site infections.(SSI)
-CDC
2

3. Conti…
 Central venous catheterization placement was first
described in 1929,and rapidly developed as an
important experimental instrument for studying
cardiac Physiology as well as indispensable clinical
tool in the treatment process.
-Joshua Koilikof
3

4. Central Lines
 A central venous catheter (CVC), also known as
a central line, central venous line, or central
venous access catheter, is a catheter placed into a
large vein. It is a form of venous access.
4

5. Medical uses
 Difficult peripheral venous access – central venous catheters may be placed when
it is difficult to gain or maintain venous access peripherally (e.g. obesity, scarred
veins from prior cannulations, agitated patient).
 Delivery of certain medications or fluids – medications such
as vasopressors (e.g., norepinephrine, vasopressin, phenylephrine etc.),
chemotherapeutic agents, or hypertonic solutions are damaging to peripheral
veins and often require placement of a central line. Additionally, catheters with
multiple lumens can facilitate the delivery of several parenteral medications
simultaneously.
 Prolonged intravenous therapies – parenteral medications that must be delivered
for extended periods of time (more than a few days) such as long-term parenteral
nutrition, or intravenous antibiotics are administered through a central line.
 Specialized treatment – interventions such as hemodialysis, plasmapheresis,
transvenous cardiac pacing, and invasive hemodynamic monitoring
(e.g. pulmonary artery catheterization) require central venous access.
5

6. Types of central lines
 Peripherally inserted central catheter (PICC). This
line is placed in a large vein in the upper arm, or
near the bend of the elbow.
 Subclavian line. This line is placed into the vein
that runs behind the collarbone.
 Internal jugular line. ...
 Femoral line.
 Umbilical line(Neonates)
6

7. Types of Central Lines reporting
purposes
1.Permanent central line: Includes:
a) Tunneled catheters, including tunneled dialysis
catheters
b) Implanted catheters (including ports)
2. Temporary central line: A non-tunneled, non-implanted
catheter
3. Umbilical catheter: A vascular catheter inserted
through the umbilical artery or vein in a neonate. All
umbilical catheters are central lines.
7

8. Devices Not Considered CLs
 Arterial catheters
 Arteriovenous fistula
 Arteriovenous graft
 Atrial catheters (also known as transthoracic intra-cardiac
catheters, those catheters inserted directly into the right or
left atrium via the heart wall)
 Extracorporeal life support (ECMO)
 Hemodialysis reliable outflow (HERO) dialysis catheter
 Intra-aortic balloon pump (IABP) devices
 Peripheral IV or Midlines
 Ventricular Assist Device (VAD)
8

9. Difference between CLABSI/CRBSI
CRBSI is a clinical definition, used when diagnosing and treating patients, that
requires specific laboratory testing that more thoroughly identifies the catheter as the
source of the BSI. It is not typically used for surveillance purposes.
A CLABSI is a primary BSI in a patient that had a central line within the 48-hour
period before the development of the BSI and is not bloodstream related to an
infection at another site.
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10. Epidemiology
 CLABSIs lead to prolonged hospital stays and
increase health care costs and mortality
 International Nosocomial Infection Control
Consortium (INICC) surveillance data from
January 2010 through December 2015
(703 intensive care units in 50 countries) reported a
CLABSI rate of 4.1 per 1000 central line days.
10

11. Etiology
 Based on the National Healthcare Safety Network (NHSN) the order of selected pathogens
associated with causing CLABSI are as follows.
Gram-positive organisms
 Coagulase negative staphylococci, 34.1%
 Enterococci, 16%
 Staphylococcus aureus 9.9% are the most common
Gram negatives
 Klebsiella, 5.8%;
 Enterobacter, 3.9%;
 Pseudomonas, 3.1%;
 E.coli, 2.7%;
 Acinetobacter, 2.2%),
 Candida species (11.8%),
 and others (10.5%).
**Approximately 40%–80% of CRBSIs are caused by gram-positive organisms
**20%–30% of infections CRBSIs are caused by gram-negative organisms
11

12. Organism Criteria
Organism(s) cultured from blood must be one of the following
with no other organisms isolated

Bacteroides spp.

Candida spp.

Clostridium spp.

Enterobacteriaceae

Enterococcus spp.

Fusobacterium spp.

Peptostreptococcus spp.

Prevotella spp.

Veilonella spp.

Viridans group streptococci
12

13. Host Factors
Host factors that increase the risk of CLABSI are
 Chronic illnesses (hemodialysis, malignancy,
gastrointestinal tract disorders, pulmonary
hypertension)
 Immune-suppressed states (organ transplant, diabetes
mellitus)
 Malnutrition
 Total Parenteral Nutrition
 Extremes of age
 Loss of skin integrity (Burns)
 Prolonged hospitalization before line insertion.
13

14. Conti..
 The femoral central venous catheters are associated
with the highest risk of CLABSI followed by the
internal jugular, and subclavian catheters.
Further
 the catheter type
 conditions of insertion (emergent versus elective)
 use of full barrier precautions versus limited) catheter
care
 skill of the operator also influence the risk of CLABSI
14

15. Modifiable Risks
 Many CLABSI risk factors can be reduced by careful and consistent use of targeted
prevention practices.
Situation High Risk Low Risk
Insertion Circumstances Emergency Elective
Skill of inserter Novice Specialized
Insertion site Femoral Vein Subclavian Vein
Skin antisepsis 70% alcohol; 10% Povidone-iodine 2% chlorhexidine
Catheter lumens Multi-lumen Single lumen
Duration of catheter use Longer duration Shorter duration
Barrier precautions Submaximal Maximal
15

16. Routes of entry of Microbes
16

17. Pathogenesis of CLABSI
Based on route of entry of bacteria:
 Extra -luminal:Pathogens migrate along external
surface of catheter from skin entry site Often occurs
within 7 days of insertion.
 Intra -luminal: Hub contamination, migration
along internal surface of catheter More commonly
occurs >7 days, intraluminal colonization.
 Secondary BSI: Bacteria from another source in
the body infects the blood.
 Infusate Contamination:Introduction of pathogens
from fluids infused through the catheter system.
17

18. Examples of counting CL days
Eligible Central Line:
 A CL that has been in place for more than two consecutive calendar days (on or
after CL day 3), following the first access of the central line, in an inpatient
location, during the current admission. Such 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.
Oct 30 Oct 31 Nov 1 Nov 2 Nov 3 Nov 4 Nov 5
Patient A CL
Day 3
CL
Day 4
CL
removed
CL
Day 5
CL
Replaced
CL Day 6
CL
Day 7
CL
Day 8
No
Central
Line
Patient B CL
Day 3
CL
Day 4
CL
removed
CL
Day 5
No CL CL
Replaced
CL
Day 1
CL
Day 2
CL Day 3
18

19.  Patient has a central line inserted on June 1. On June 3, the central
line is removed and on June 4 the patient has a positive blood
culture with S. aureus
This is a CLABSI because the central line was in place for >2
calendar days (June 1, 2, and 3), and was in place the day before the
date of event (June 4).
Jun 1 Jun 2 Jun 3 Jun 4
CL 1 CL 2 CL 3 No CL CLABSI
CL Removed Culture
positive
19

20. EXAMPLES
 A central line is placed in the facility on May 30th. On June 3, the
central line is removed and on June 5 patient spikes a fever of
38.3°C. Two blood culture sets collected on June 6 are positive for
S. epidermidis.
May be a healthcare-associated bloodstream infection but it is not a
CLABSI because the Date of Event (June 5) did not occur on the
day the central line was discontinued (June 3) or the next day (June
4).
May 30 may31 Jun 1 Jun 2 Jun 3 Jun 4 Jun 5 Jun 6
CL1 CL2 CL3 CL 4 CL 5 No CL No CL No CL
CL Removed Fever Spike Blood Culture
positive
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21. Definitions Specific to BSI / CLABSI
Surveillance:
 Primary bloodstream infection (BSI):
A Laboratory Confirmed Bloodstream Infection (LCBI) that is
not secondary to an infection at another body site
 Secondary BSI:
A BSI that is thought to be seeded from a site-specific
infection at another body site.
21

22. CLABSI Clinical Definition
CLABSI occurs when these three criteria exist:
Clinical signs of infection
 e.g., fever, rigors, altered mental status, hypotension
No alternate source of bloodstream infection
Positive blood culture from a peripheral vein with any one of the
following:
 Catheter tip/segment culture that matches organism grown from
blood
 At least threefold higher number of organisms grown from the
catheter versus the peripheral blood culture on simultaneously drawn
cultures
22

23. LCBI Hierarchy -Types of LCBIs
LCBI
LCBI 1 LCBI 2 LCBI 3
MBI-LCBI 1 MBI-LCBI 2 MBI-LCBI 3
23

24. LCBI 1
 Patient of any age has a recognized bacterial or fungal
pathogen, not included on the NHSN common
commensal list:
 Identified from one or more blood specimens obtained
by a culture OR
 AND
 Organism(s) identified in blood is not related to an
infection at another site
 NHSN COMMENSAL.xlsx
24

25. LCBI 2
 Patient of any age has at least one of the following
signs or symptoms:
 fever (>38.0oC), chills, or hypotension
AND
 Organism(s) identified in blood is not related to an
infection at another site
AND
 The same NHSN common commensal is identified by
a culture from two or more blood specimens collected
on separate occasions (see Blood Specimen
Collection).
25

26. LCBI 3
 Patient ≤ 1 year of age has at least one of the following
signs or symptoms:
 fever (>38.0oC), hypothermia (<36.0oC), apnea, or
bradycardia
 AND
 Organism(s) identified in blood is not related to an
infection at another site
 AND
 The same NHSN common commensal is identified by
a culture from two or more blood specimens collected
on separate occasions (see Blood Specimen
Collection).
26

27. Mucosal Barrier Injury Laboratory-Confirmed
Bloodstream Infection (MBI-LCBI)
MBI.xlsx
27

28. Contin….
 Patient meets at least one of the following:
 1. Is an allogeneic hematopoietic stem cell transplant recipient
within the past year with one of the following documented during
same hospitalization as positive blood specimen:
 a. Grade III or IV gastrointestinal graft versus host disease [GI
GVHD]
 b. ≥1-liter diarrhea in a 24-hour period (or ≥20 mL/kg in a 24-hour
period for patients <18 years of age) with onset on or within the 7
calendar days before the date the positive blood specimen was
collected.
 2. Is neutropenic, defined as at least two separate days with ANC†
and/or WBC values <500 cells/mm3 collected within a 7-day time
period which includes the collection date of the positive blood
specimen, the 3 calendar days before and the 3 calendar days after
28

29. Strategies for Prevention of Catheter-Related
Infections in Adult and Pediatric Patients
1. Education, Training and Staffing
2. Selection of Catheters and Sites
3. Central Venous Catheters Recommendations
4. Hand Hygiene and Aseptic Technique
5. Maximal Sterile Barrier Precautions
6. Skin Preparation
7. Catheter Site Dressing Regimens
8. Administration set change
9. Flushing CVC (INS)
10. Systemic Antibiotic Prophylaxis
11. Anticoagulants
12. Replacement of CVCs, Including PICCs and Hemodialysis Catheters
13. Needleless Intravascular Catheter Systems
14. Performance Improvement
15. 15.Central line-associated bloodstream infection care bundles
29

30. 1.Education, Training and Staffing
 Educate healthcare personnel regarding the indications for
intravascular catheter use, proper procedures for the insertion and
maintenance of intravascular catheters, and appropriate infection
control measures to prevent intravascular catheter-related infections
 Periodically assess knowledge of and adherence to guidelines for all
personnel involved in the insertion and maintenance of
intravascular catheters
 Designate only trained personnel who demonstrate competence for
the insertion and maintenance of peripheral and central
intravascular catheters.
 Ensure appropriate nursing staff levels in ICUs. Observational
studies suggest that a higher proportion of “pool nurses” or an
elevated patient–to-nurse ratio is associated with CRBSI in ICUs
where nurses are managing patients with CVCs.
30

31. 2.Selection of Catheters and Sites
Midline Catheter Recommendations
 In adults, use an upper-extremity site for catheter
insertion..
 In pediatric patients, the upper or lower extremities
or the scalp (in neonates or young infants) can be
used as the catheter insertion site
31

32. 3.Central Venous Catheters Recommendations
 Avoid using the femoral vein for central venous access in
adult patients
 Use a subclavian site, rather than a jugular or a femoral site,
in adult patients to minimize infection risk for nontunneled
CVC placement
 Avoid the subclavian site in hemodialysis patients and
patients with advanced kidney disease, to avoid subclavian
vein stenosis
 Use a fistula or graft in patients with chronic renal failure
instead of a CVC for permanent access for dialysis
 Use a CVC with the minimum number of ports or lumens
essential for the management of the patient
 Promptly remove any intravascular catheter that is no longer
essential
32

33. 4.Hand Hygiene and Aseptic
Technique
 Perform hand hygiene procedures, either by washing hands with
conventional soap and water or with alcohol-based hand rubs
(ABHR). Hand hygiene should be performed before and after
palpating catheter insertion sites as well as before and after
inserting, replacing, accessing, repairing, or dressing an
intravascular catheter. Palpation of the insertion site should not be
performed after the application of antiseptic, unless aseptic
technique is maintained
 Maintain aseptic technique for the insertion and care of
intravascular catheters
 Wear clean gloves, rather than sterile gloves, for the insertion of
peripheral intravascular catheters, if the access site is not touched
after the application of skin antiseptics.
 Sterile gloves should be worn for the insertion of arterial, central,
and midline catheters
33

34. 5.Maximal Sterile Barrier Precautions
 Use maximal sterile barrier precautions, including
the use of a cap, mask, sterile gown, sterile gloves,
and a sterile full body drape, for the insertion of
CVCs, PICCs, or guidewire exchange.
34

35. 6.Skin Preparation
Prepare skin with 2% chlorhexidine in 70% alcohol using swabs and a
friction scrub for at least 30 seconds s. Do not wipe or blow dry and allow
to dry completely before skin puncture:
30 s for a dry site.
2 min for a moist site (especially femoral).
35

36. 7.Catheter Site Dressing Regimens
 Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the
catheter site
 Replace catheter site dressing if the dressing becomes damp, loosened, or visibly
soiled
 Do not use topical antibiotic ointment or creams on insertion sites, except for
dialysis catheters, because of their potential to promote fungal infections and
antimicrobial resistance
 Do not submerge the catheter or catheter site in water. Showering should be
permitted if precautions can be taken to reduce the likelihood of introducing
organisms into the catheter (e.g., if the catheter and connecting device are protected
with an impermeable cover during the shower
 Replace dressings used on short-term CVC sites every 2 days for gauze dressings.
 Replace dressings used on short-term CVC sites at least every 7 days for
transparent dressings, except in those pediatric patients in which the risk for
dislodging the catheter may outweigh the benefit of changing the dressing
36

37. 8.Administration set change
REPLACEMENT OFADMINISTRATION SETS:
 1.In patients not receiving blood, blood products or fat emulsions, replace
adminisration sets that are continuously used, including secondary sets
and add-on devices, no more frequently than at 96-hour intervals.
 2. Change intermittent administration set every 24 hours. When an
intermittent infusion is repeatedly disconnected and reconnected for the
infusion , there is increased risk of infection rate.
 3.Replace tubing used to administer blood ,blood products , or fat
emulsions(those combined with amino acids and glucose in a 3-in 1
admixture or infused separately) within 24 hours of initiating the infusion.
 5. Replace tubing used to administer propofol infusions every 6 or 12
hours or When the vial is changed , per the manufacturer recommendation.
 6. No recommendations can be made regarding the length of time a needle
used to access implanted ports can remain in place.
37

38. Given by CDC
Primary continuous Every 96 hours
Secondary Every 96 hours
Primary intermittent Every 24 hours
Secondary intermittent Every 24 hours
TPN Every 24 hours
Lipid emulsion every 24 hours
Blood /blood components after each unit of administration
Propofol infusions Every 6 or 12 hours
38

39. 9.Flushing policy- (INS,Standard 40,
Flushing & Locking, S77).
1.Flush all VADs with preservative-free 0.9% sodium
chloride.
2. Use only preservative-free solutions for flushing all
VADs in neonates to prevent toxicity.
3. Do not use sterile water for flushing VADs.
39

40. 10.Systemic Antibiotic Prophylaxis
 1. Do not administer systemic antimicrobial
prophylaxis routinely before insertion or during use
of an intravascular catheter to prevent catheter
colonization or CRBSI.
40

41. 11.Anticoagulants
 Do not routinely use anticoagulant therapy to
reduce the risk of catheter-related infection in
general patient populations.
41

42. 12.Replacement of CVCs, Including
PICCs and Hemodialysis Catheters
1. Do not routinely replace CVCs, PICCs,
hemodialysis catheters, or pulmonary artery catheters
to prevent catheter-related infections.
2. Do not remove CVCs or PICCs on the basis of
fever alone. Use clinical judgment regarding the
appropriateness of removing the catheter if infection
is evidenced elsewhere or if a noninfectious cause of
fever is suspected.
42

43. 13. Needleless Intravascular Catheter
Systems
1. Change the needleless components at least as frequently as the administration set.
There is no benefit to changing these more frequently than every 72 hours.
2. Ensure that all components of the system are compatible to minimize leaks and
breaks in the system
3. Minimize contamination risk by scrubbing the access port with an appropriate
antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol) and
accessing the port only with sterile devices
4. Use a needleless system to access IV tubing.
43

44. 14. Performance Improvement
 Use hospital-specific or collaborative-based
performance improvement initiatives in which
multifaceted strategies are "bundled" together to
improve compliance with evidence-based
recommended practices.
44

45. 15.Central line-associated bloodstream
infection care bundles
Central line insertion bundle
 Hand hygiene
 Wash hands or use an alcohol-based, waterless hand cleaner when caring for central lines:
 Before and after palpating the catheter insertion site.
 Before and after inserting, replacing, adjusting or dressing the site.
 During palpation of the insertion site and after application of antiseptic and only if full asepsis is
maintained.
 Complete maximal barrier
 The operator inserting the central venous catheter should adhere to strict aseptic techniques
and wear sterile gloves, gown, surgical cap and surgical mask.
 Chlorhexidine 2% skin antisepsis
 Prepare skin with 2% chlorhexidine in 70% alcohol using swabs and a friction scrub for at
least 30 seconds s. Do not wipe or blow dry and allow to dry completely before skin
puncture:
 30 s for a dry site.
 2 min for a moist site (especially femoral).
45

46. Conti…
Central line maintenance bundle
 Hand hygiene
 Practice hand hygiene at five moments33:
 Before touching a patient.
 Before clean/aseptic procedures.
 After body-fluid exposure/risk.
 After touching a patient.
 After touching patient surroundings.
Aseptic technique for accessing and changing needleless connectors
 Scrub the access port or hub immediately prior to each use with an appropriate antiseptic.
Standardised tubing change
 Intravenous medication administration tubing should be changed as per the recommendation
in the local organisations policy.
Daily review of catheter necessity
 Daily review of line necessity during rounds so that the necessity of the lines can be
determined and unnecessary lines removed.
46

47. Surveillance
1.The CLABSI rate are calculated per 1000 central
line days
CLABSI
rate
As per
CDC/NHSN
definition
Number of CLABSI in a
month
______________________
No.of Central line days in
that month
X 1000
/ 1000
Central
Line days
Monthly
47

48. Central line insertion bundle: cornerstone of
CLABSI
48

49. Maintenance of CVC
49

50. 50

51. 51

52. 52

53. Conclusion
Successful implementation of evidence-based interventions can lead to
dramatic and sustained reductions of CLABSIs in hospital ICUs
 Clinician education
 Skill Competency Of Clinician Who performs CVC need to assessed
privileging of Clinicians
 Designated Physician and Nursing Team Leader
 Central-line cart in each ICU
 Insertion Checklist with BUNDLE care
 Nurse empowerment to stop procedure if best practices are not followed
 Empowering Infection control Nurses/Link Nurses on capturing HAI
 Adherence to best clinical practices
 To frontline staff, feedback provided regarding rates of CLABSI
53

54. Take home message
 Wash Hands.
 Use Aseptic Precautions.
 Follow BUNDLE care Approach.
54

55. References
 CDC (Central Disease Control and Prevention)
 AHRQ (Agency for Healthcare Research and Quality)
 AIIMS, New Delhi
 Joint Commission
 NHSN (National Healthcare Safety Network)
 INS (Infusion Nurses Society)
 NABH 5th Edition
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