Getting to ZeroStrategies to Reduce Central Line Associated

Bloodstream Infections (CLABs)

Brian S. Koll, MD, FACPMedical Director, Infection Prevention

Chief, EpidemiologyBeth Israel Medical Center, New York, NY

Beth Israel Medical Center2004

• Petrie Division• Kings Highway Division

• 94 ICU beds– 3,000 discharges

• 824 non-ICU beds– 43,000 discharges

• > 3,000 central lines placed annually

BIMC USA

Patients in ICU with Central Line

40% 48%

CLABs Rate per 1,000 line days

4.5 5.3

CLABs Rate per 100 patients

2% 4%

Increase LOS 5 d 14 d

Used BI BSI information and discharge information from 2004

Costs Incurred Care of Patients with CLABs

Annual Incremental

Costs

Incremental Cost Per

CLAB PatientCLAB

PatientsDischarges

Per Year

94 ICU Beds $960,000$40,000243,000

$1,510,000Total Incremental CLAB Costs

824 Non-ICU Beds

$550,000$25,0002243,000

Leadership

• Administrative• Clinical• Physician and Nursing

Champions

American Journal of Infection Control2008;36:232-40

• Everyone has the ability, permission and responsibility to “stop the line” to prevent risk to patients (and staff)

• All are empowered to identify and change (or eliminate) risky processes, no matter when, where or who is involved and always without fear of retaliation

• There is participatory management at every level of the organization with both top-down and bottom-up communication

• Integrity and trust are woven into the fabric of the organizational culture

• Everyone is engaged in the prevention system, and there is reciprocal responsibility

Inter-disciplinary Team Members

Physicians• Chief Executive Officer• Chief Medical Officer• Administrative Intern• Associate Chairman, Department of

Medicine• Director

– ICU, MICU, SICU– Emergency Room– Medical Residency Programs

• Intensivist• Critical Care Fellow• Residents and Interns• Medical Student

Infection Control• Hospital Epidemiologist• Manager• Practitioner

Patient Care Services• Vice President• Director• Nurse Manager

– ICU, MICU, SICU• Nurse Education Manager• New Nurses• Nursing Student

Other• Director

– Materials Management– Housekeeping– Respiratory Therapy– Quality Improvement

• Pharmacist• Pharmacy Intern• Radiology• Transport Services

Multi-disciplinary CLABs TeamPrinciples

• It is not good enough that our infection rates are below national benchmarks.

• CLABs are preventable, they are not an inevitable consequence of sophisticated, complex care that we provide to our severely ill patients.

• CLABs can be eliminated by determination as opposed to additional resources.

BETH ISRAEL MEDICAL CENTER VASCULAR ACCESS PROCEDURE NOTE

Date: _________________ Time Out at _______ AM/PM Verified Correct (all must be verified): Patient Procedure Site/Side Position Supplies Equipment _________________________ RN/MD ________________________RN/MD Central vein: R L Pulmonary artery: R L Transvenous pacemaker R L subclavian internal jugular femoral (if femoral, reason for choice) ________________________________________________________________ Arterial: R L radial femoral other_______________ Indication(s): _________________________________________________________ Consent in chart Operator(s): _______________________________________ Central Line Check List : 1- all equipments at bedside 8- Time-out 2- Wash hands 9- Mask 3- Chlor- prep 10- procedure with sterile technique 4- Gown 11- Bio-Patch 5- Gloves 12- Dressing with date 6- Cap 13- Dispose sharps 7- Drape 14- wash hands Anesthesia: _________________________________________________________ Technique: _________________________________________________________ Comments: ________________________________________________________ Complications: ______________________________________________________ __________________________________________________________________ Signature/Title Time:_______

8

Strategies to Reduce Central Line Associated Bloodstream Infections (CLABs)

Beth Israel Medical CenterCLABs Prevention ICUs

CLABs Rates

0

1

2

3

4

5

2004 2005 2006 2007

Rate

Rate per 1,000 Line Days Rate per 100 Patients

0102030405060708090

100

Rate (% )

Aug Oct Dec Feb Apr Jun Aug

Time

Bundle Compliance

Beth Israel Medical CenterCLABs Prevention

UnitLongest Duration of Days Without

CLAB

CCU 644

ICU 601

ED 547

SICU 483

PICU 396

non-ICU 345

MICU 344

CSICU 300

HAI Rates

0

1

2

3

4

5

6

7

8

Pre-Bundle Post-Bundle

Rat

eCLAB VAP MRSA CDI

CLABs Collaborative Infection Results

11

Reporting Period

CL

AB

s R

ate

pe

r 1

,00

0 L

ine

Da

ys

CLABs Prevention ICUs

12