APSIC guide for prevention of Central Line Associated Bloodstream Infections (CLABSI)

This document is an executive summary of the APSIC Guide for Prevention of Central Line Associated Bloodstream Infections (CLABSI). It describes key evidence-based care components of the Central Line Insertion and Maintenance Bundles and its implementation using the quality improvement methodology, namely the Plan-Do-Study-Act (PDSA) methodology involving multidisciplinary process and stakeholders. Monitoring of improvement over time with timely feedback to stakeholders is a key component to ensure the success of implementing best practices. A surveillance program is recommended to monitor outcomes and adherence to evidence-based central line insertion and maintenance practices (compliance rate) and identify quality improvement opportunities and strategically targeting interventions for the reduction of CLABSI.


Background
Central line-associated bloodstream infections, or CLAB-SIs, are associated with increased morbidity, mortality, and health care costs [1]. It is now recognized that CLAB-SIs are largely preventable when evidence based guidelines are followed for the insertion and maintenance of Central Venous Catheters (CVC) [2]. The intent of this document is to highlight practical recommendations in a concise format designed to assist healthcare settings in the Asia Pacific region in implementing CLABSI prevention efforts. This document is a summary of the CLABSI prevention guidelines developed by the Asia Pacific Society of Infection Control (APSIC).
The term "central line" used in the guidelines is defined as an intravascular access device or catheter that terminates at or close to the heart or in one of the great vessels. The following are considered great vessels for the purpose of defining a central line; pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins, common iliac veins or femoral veins. A hollow introducer is considered a central line if the tip is situated in a great vessel. The line may be used for infusion, or hemodynamic monitoring. Examples include a central venous catheter for infusion, pulmonary artery (PA) catheter, sheath/introducer for a PA catheter, dialysis or hemofiltration catheter in a great vessel and a peripherally inserted central catheter (PICC). A central line may be inserted centrally or peripherally (PICC) in a patient. Neither the location of the insertion site nor the type of device determines whether a line qualifies as a central line.

Workgroup Composition
APSIC convened Infection Prevention and Control experts from the Asia Pacific region to develop the APSIC Guide for Prevention of Central Line Associated Bloodstream Infections (CLABSI). The members of this workgroup comprising key opinion leaders from the Asia Pacific region are the authors of this paper.

Literature Review and Analysis
For the APSIC guideline, the workgroup reviewed previously published guidelines and recommendations relevant to each section and performed computerized literature searches using PubMed on keywords including CLABSI, CA-BSI, CR-BSI, Asia Pacific and guideline.

Process
The workgroup met face to face on two occasions in addition to email correspondence to complete the development of the guideline. Discussion was also focused on how best to integrate the evidence in the Asia Pacific setting. Criteria for grading the strength of recommendations and quality of evidence are described in Table 1. Systematic review of existing guidelines was undertaken in addition to review of studies from the Asia Pacific region [3][4][5][6][7][8][9][10][11][12][13][14]. Optimal site selection [15][16][17][18] The catheter insertion site affects the risk for catheterrelated infection and phlebitis. The risk for catheter infection in part can be related to the risk for thrombophlebitis and the density of local skin flora. Femoral catheters are associated with a higher risk of infection and deep venous thrombosis, than internal jugular or subclavian catheters and should also be avoided, where possible. A subclavian site is preferred in adult patients and factors such as potential for mechanical complications and risk for subclavian vein stenosis, should be considered when determining the catheter insertion site. Hand hygiene [19,20] Hand hygiene before catheter insertion or maintenance, combined with proper aseptic technique during catheter manipulation and care, provides protection against infection.

1.
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 Alcohol-based chlorhexidine skin preparation [21,22] While alcohol-based chlorhexidine has become a standard antiseptic for skin preparation for the insertion of both central and peripheral venous catheters, alternatives may need to be used where there is a contraindication.

Maximum barrier precautions [23]
These refer to the wearing a sterile gown, sterile gloves, mask and a cap along with the use of a full body sterile drape to cover the patient (similar to the sterile drapes used in the operating room) during the insertion of central venous catheters. Disinfection of hubs and changing the access lumens/devices The hubs on CVCs are a common source of bacterial colonization and serve as immediate portal of entry of microorganisms to the intraluminal surface of the catheter. These colonizers from the catheter hub and lumen can be dispersed into the bloodstream resulting in CLABSI. The disinfection of catheter hub surface is therefore, critical every time before they are accessed.

Standardize administration sets change
Administration sets are used for transfer of fluids, medicines and nutrition to patient's body. Prolonged use of these sets increases the risk of infection. Therefore, routine change of the administration systems (primary and secondary sets and add-on devices) is recommended. Recommendations for implementation [36][37][38][39][40] A key success factor to the implementation of the central line insertion and maintenance bundles is the adoption of the model of improvement approach involving multidisciplinary process stakeholders. The Plan-Do-Study-Act (PDSA) methodology to conduct small-scale tests of change in the ICU i.e. planning a test, trying it, observing the results, and acting on what is learned; is the scientific approach adopted in the implementation.
1. Implementation of the use of the CLABSI insertion and maintenance bundles is best done using a quality improvement approach with a multidisciplinary team.

Build teams which include all staff involved in CVC
insertion and maintenance including local champions. 3. Enhanced communication to share data and take action 4. Hospital leadership and policymakers are to continue providing support to build a culture of zero tolerance. 5. Lines of accountability need to be established to link everyone in a hospital -from the board to frontline staff -so that everyone has a shared understanding of the organizations goals, knows their role in meeting them, and receives feedback (e.g. dashboards) on how they are performing.
6. There should be an ongoing focus on skill development and competency assessment across the organization. 7. Education and training programs should be assessed for their content, relevance and impact on work performance. 8. Although adherence to evidence-based practices reduces inconsistencies in practice and can significantly improve the overall quality of care, healthcare organizations often find it difficult to implement best practices. Thus, identifying and removing barriers to adherence to these practices is essential to a successful implementation of best practices in the era of patient safety.

C. Additional measures to reduce CLABSI [41-77]
The rationale for the use of chlorhexidine antiseptic bathing in place of soap and water bathing relates to the patient's resident skin flora that can enter the bloodstream at the CVC insertion site or the extraluminal surface of the catheter. Reducing skin contaminants with chlorhexidine bathing can further reduce the risk of CLABSI.
Similarly, a chlorhexidine-impregnated dressing is now recommended by the Centers for Disease Control and Prevention (grade IB) when basic prevention measures are ineffective to decrease CLABSIs.
Additional measures to reduce infection include: 1. Chlorhexidine bathing in addition to maximal barrier precautions and maintenance bundle prevention measures. (IIB) 2. If the CLABSI rate is not decreasing despite successful adherence to maintenance bundle Have both the operator and assistant practised maximal sterile barrier precautions (wearing a sterile gown, sterile gloves, and cap and using a full body drape for patient)?

Yes No
Signature of person in-charge:

Surveillance
Surveillance for outcomes (CLABSI infection rates) is a primary outcome. Several centers have found it useful to monitor adherence to evidence-based central line insertion and maintenance practices (insertion bundle compliance rates) as a method for identifying quality improvement opportunities and strategically targeting interventions for the reduction of CLABSI.
1. The CLABSI rate are calculated per 1000 central line days 2. The Central line insertion bundle compliance rate is calculated as a percentage of central line insertions per month (%) [this is computed using data collected from checklist in Table 2] The Central line maintenance bundle compliance rate is calculated as a percentage of central line insertions per month (%) [This is computed using data collected from checklist in Table 3]. Improvement takes place over time. Determining if improvement has really occurred and if it is a lasting effect requires observing rates of infection over time. Run charts can be used to monitor these changes. Run charts are graphs of data over time and are one of the single most important tools in performance improvement.
Feedback the data is best done in a timely manner to relevant clinical groups so that targeted CLABSI prevention and control measures can be introduced and reported on.

Conclusion
There are few reports on the CLABSI rates in hospitals at Asia Pacific region. A recent systematic review revealed a pooled incidence density of 4 · 7 per 1000 catheter-days (95 % CI: 2 · 9-6 · 5; I2 = 83 · 8; χ 2 n = 30 · 9, p < 0 · 001) from 6 published studies [78]. Most ICUs in developed countries now report CLABSI rates which are zero or close to zero. CLABSI is one of the most common and yet preventable healthcare associated infections. We recommend hospitals in the Asia Pacific region that have yet to achieve zero CLABSI rates continue surveillance of CLABSIs and implement Central Line Insertion and Maintenance Bundles using quality improvement approaches to improve practices as described in the APSIC Guide For Prevention Of Central Line Associated Bloodstream Infections (CLABSI).
Competing interests AA was supported by the National Research University Project of the Thailand Office of Higher Education Commission. The authors declare that they have no competing interests.
Authors' contributions LML drafted the manuscript and AA did the initial editing before revised manuscript was seen by other authors for further comments. All authors read and approved the final manuscript.