Preventing Central Line–Associated Bloodstream Infections A Global Challenge, A Global Perspective Preventing Central Line–Associated Bloodstream Infections: A Global Challenge, A Global Perspective The use of central venous catheters (CVCs) is an integral part of modern health care throughout the world, allowing for the administration of intravenous fluids, blood products, medications, and parenteral nutrition, as well as providing access for hemodialysis and hemodynamic monitoring. However, their use is associated with the risk of bloodstream infection caused by microorganisms that colonize the external surface of the device or the fluid pathway when the device is inserted or manipulated after insertion. These serious infections, termed central line–associated bloodstream infections, or CLABSIs, are associated with increased morbidity, mortality, and health care costs. It is now recognized that CLABSIs are largely preventable when evidence- based guidelines are followed for the insertion and maintenance of CVCs. This monograph includes information about the following: • The types of central venous catheters and risk factors for and pathogenesis of CLABSIs • The evidence-based guidelines, position papers, patient safety initiatives, and published literature on CLABSI and its prevention • CLABSI prevention strategies, techniques and technologies, and barriers to best practices • CLABSI surveillance, benchmarking, and public reporting • The economic aspects of CLABSIs and their prevention, including the current approaches to developing a business case for infection prevention resources This monograph was authored by The Joint Commission, Joint Commission Resources, and Joint Commission International. They partnered with infection preven- tion leaders from the following organizations: • Association for Professionals in Infection Control and Epidemiology • Association for Vascular Access • Infectious Diseases Society of America • International Nosocomial Infection Control Consortium • National Institutes of Health • Society for Healthcare Epidemiology of America Additionally, several international and US infection prevention leaders lent their expertise to the writing of this publication and were also instrumental in the development of the monograph. International representatives were from Argentina, Australia, Egypt, Saudi Arabia, Switzerland, and Thailand. This monograph was supported in part by a research grant from Baxter Healthcare Corporation. Preventing Central Line–Associated Bloodstream Infections A Global Challenge, A Global Perspective Project Staff Richard Koss, MA Linda Kusek, MPH, RN, CIC Director Associate Project Director Department of Health Services Research Department of Health Services Research Division of Healthcare Quality Evaluation Division of Healthcare Quality Evaluation The Joint Commission The Joint Commission Jerod Loeb, PhD Barbara M. Soule, RN, MPA, CIC, FSHEA Executive Vice President Practice Leader, Infection Prevention and Control Services Division of Healthcare Quality Evaluation Joint Commission Resources The Joint Commission Joint Commission International Nancy Kupka, PhD, MS, MPH, RN Editorial and Production Support Project Director Lori Meek Schuldt Department of Health Services Research Senior Editor Division of Healthcare Quality Evaluation Department of Publications and Education Resources The Joint Commission Joint Commission Resources Scott Williams, PsyD Christine Wyllie, MA Associate Director Senior Project Manager Division of Healthcare Quality Evaluation Department of Publications and Education Resources The Joint Commission Joint Commission Resources The Joint Commission Mission sions in, this monograph. The inclusion of an organization The mission of The Joint Commission is to continuously name, product, or service in a Joint Commission publica- improve health care for the public, in collaboration with tion should not be construed as an endorsement of such other stakeholders, by evaluating health care organizations organization, product, or service, nor is failure to include an and inspiring them to excel in providing safe and effective organization name, product, or service to be construed as care of the highest quality and value. disapproval. Disclaimer © 2012 The Joint Commission The Joint Commission project staff is solely responsible for the content of this monograph. This monograph is Permission to reproduce this guide for noncommercial, edu- informed by the research conducted by the project staff and cational purposes with displays of attribution is granted. For the recommendations of our technical advisory panel. other requests regarding permission to reprint, please call Published literature as well as information referred by proj- Nancy Kupka at 630-792-5947. ect advisors, reviewers, and collaborating organizations was considered. However, the inclusion of any reference or Printed in the USA 5 4 3 2 1 example should not be construed as an endorsement by The Joint Commission, or by the project technical advisory Suggested Citation: panel or any of its members, of any specific method, prod- The Joint Commission. Preventing Central Line–Associated uct, treatment, practice, program, service, vendor, or Bloodstream Infections: A Global Challenge, a Global resource. We hope this monograph contains useful informa- Perspective. Oak Brook, IL: Joint Commission Resources, tion, but it is not intended to be a comprehensive source for May 2012. http://www.PreventingCLABSIs.pdf. all relevant information. The Joint Commission and its col- laborating organizations are not responsible for any claims For more information about The Joint Commission, please or losses arising from the use of, or from any errors or omis- visit http://www.jointcommission.org. CONTENTS Acknowledgments ..................................................................iv Introduction ............................................................................v Chapter 1: Types of Central Venous Catheters and Risk Factors for and Pathogenesis of CLABSIs........................1 Chapter 2: Background on CLABSIs: Clinical Practice Guidelines, Position Papers, Initiatives on CLABSI Prevention, and Barriers to Best Practices ............................11 Chapter 3: CLABSI Prevention Strategies, Techniques, and Technologies....................................................................39 Chapter 4: CLABSI Patient Safety Initiatives: Factors Contributing to Improvement ..............................................71 Chapter 5: CLABSI Surveillance, Benchmarking, and Public Reporting....................................................................85 Chapter 6: Economic Aspects of CLABSIs and Their Prevention............................................................................103 Appendix A: Evolution of Health Care–Associated Infection Surveillance in the United States, 1958–2011......113 Appendix B: CLABSI Rates per 1,000 Central Line–Days in Limited-Resource Countries (2002–2011) ......................115 Glossary ..............................................................................119 Index ....................................................................................123 iii Preventing Central Line–Associated Bloodstream Infections: A Global Challenge, A Global Perspective Acknowledgments The Joint Commission, Joint Commission Resources, and We are grateful to the members of the Technical Advisory Joint Commission International are sincerely appreciative of Panel (TAP), who provided outstanding advice, active par- all the individuals and organizations that contributed to the ticipation, and feedback throughout the development of the development of this monograph. Project staff would like to monograph. We were privileged to have domestic and inter- gratefully acknowledge the generous contributions of several nationally recognized experts on the TAP who not only are groups and persons. committed to reducing the risks associated with the use of central venous catheters but also were a pleasure to work We wish to thank our collaborating organizations for their with. We also thank the many reviewers who contributed partnership throughout this project. Specifically, we thank their knowledge and expertise to this publication. the Association for Professionals in Infection Control and Epidemiology (APIC), the Association for Vascular Access Last, but certainly not least, we are grateful to Baxter (AVA), the Infectious Diseases Society of America (IDSA), Healthcare Corporation for supporting the development of the International Nosocomial Infection Control Consortium the monograph with a research grant. Although Baxter had (INICC), the National Institutes of Health (NIH), and no involvement in the design, writing, or evaluation of the the Society for Healthcare Epidemiology of America monograph, we truly appreciate Baxter’s important role in (SHEA). making this publication possible. Technical Advisory Panel Anucha Apisarnthanarak, MD Leonard Mermel, DO, ScM, AM (Hon), FSHEA, FIDSA, FACP Associate Professor, Thammasat University Hospital, Thailand Professor of Medicine, Warren Alpert Medical School of Brown University International Representative, Thailand Medical Director, Department of Epidemiology and Infection Control, Rhode Island Hospital Hanan Balkhy, MD, MMed, FAAP, CIC Representative, Society for Healthcare Epidemiology of America and the Director, WHO Collaborating Centre and Infectious Diseases Society of America, USA GCC Centre for Infection Control Associate Professor and Executive