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What’s New in the
Patient Safety World
May 2021
CLABSI’s Up in the
COVID-19 Era
Several studies have found an increase in CLABSI’s (Central Line-Associated Bloodstream Infections) during the COVID-19 pandemic. Patel et al. (Patel 2021) used data reported to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN) in almost 3000 acute care hospitals. They compared standard infection ratios of CLABSI’s from April, May and June of 2019 to the same period of 2020. They found the rate of CLABSI’s increased from 0.68 in 2019 to 0.87 in 2020, an increase of 28%. Critical care units experienced the highest increase at 39% (from 0.75 to 1.04), followed by ward locations at 13%.
Fakih et al. (Fakih 2021) also used NHSN data to do a retrospective evaluation of CLABSI and CAUTI outcomes in 78 hospitals from a single healthcare system over 2 periods: before the COVID-19 pandemic (March 2019–February 2020; 12 months) and during the COVID-19 pandemic (March–August 2020; 6 months). CLABSI rates increased by 51.0% during the pandemic period from 0.56 to 0.85 per 1,000 line days and by 62.9% from 1.00 to 1.64 per 10,000 patient days. Hospitals with monthly COVID-19 patients representing >10% of admissions had a National Health Safety Network (NHSN) device standardized infection ratio for CLABSI that was 2.38 times higher than hospitals with <5% prevalence during the pandemic period. In contrast, no significant changes were identified for CAUTI’s (0.86 vs 0.77 per 1,000 catheter days).
A number of factors have been hypothesized as contributors to this increase in CLABSI rates. The frequency of contact with patients may have changed during the pandemic in attempt to reduce healthcare worker exposure to patients and to preserve personal protective equipment. Patients admitted during the pandemic were more likely to require critical care support and to need it for a longer period of time, potentially putting them at greater risk for CLABSI. The proportion of COVID-19 patients with CLABSI events was 5 times greater than for non–COVID-19 patients during the pandemic period. The average time from COVID-19 diagnosis to developing CLABSI was ∼18 days, indicating that the CLABSI events occurred in COVID-19 patients with prolonged hospitalization.
Qualitative feedback from their infection prevention teams reported changes to routine CLABSI prevention practices in ICUs, such as less universal decolonization (eg, mupirocin administration and chlorhexidine bathing), alterations in line care due to intravenous pumps placed in hallways (eg, extension tubing used and less bedside checks on lines), line and dressing integrity gaps related to prone positioning of patients, opportunities in scrub-the-hub compliance, and increases in line draws for blood cultures.
In addition, staffing changes responding to increased patient volume on the units, such as the help of traveling clinicians not as familiar with standard unit prevention practices, may have contributed.
They also noted that “line rounds”, which had been a routine practice prior to the COVID-19 pandemic, often stopped during the COVID-19 pandemic period due to competing priorities. Those rounds had helped ensure proper device selection, utilization, and bedside practices were being followed.
Line rounds are
something we advocate be performed on a daily basis to
reduce CLABSI’s (we also advocate “Foley rounds” daily to reduce CAUTI’s).
During those rounds we consider the continued “appropriateness” of such
devices.
The above studies do not separate CLABSI’s due to traditional central lines vs. peripherally inserted central lines (PICC’s). An important milestone in reducing CLABSI’s was publication of the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) (Chopra 2015), which provides evidence-based criteria for multiple types of vascular access devices but especially focused on peripherally inserted central catheter (PICC) use. Chopra and colleagues recently looked at whether implementing MAGIC reduces complications (Chopra 2021). They used data from 52 Michigan hospitals. During the preintervention period, the mean frequency of appropriate PICC use was 31.9% and the mean frequency of complications was 14.7%. Following the intervention, PICC appropriateness increased to 49.0% while complications decreased to 10.7%. Compared with patients with inappropriate PICC placement, appropriate PICC use was associated with a significantly lower odds of complications (OR 0.29), including a decrease in CLABSI’s (OR 0.61). There were also decreases in occlusion (OR 0.25) and VTE (OR 0.40).
Some of our other columns on IV access, central venous catheters and PICC lines:
January 21, 2014 “The PICC Myth”
December 2014 “Surprise Central Lines”
July 2015 “Reducing Central Venous Catheter Use”
October 2015 “Michigan Appropriateness Guide for
Intravenous Catheters”
March 27, 2018 “PICC
Use Persists”
February 26, 2019 “Vascular
Access Device Dislodgements”
July 16, 2019 “Avoiding PICC’s in CKD”
March 2, 2021 “Barriers to Timely Catheter
Removal”
References:
Patel P, Weiner-Lastinger L, Dudeck M, et a;. Impact of COVID-19 Pandemic on Central Line-Associated Bloodstream Infections During the Early Months of 2020, National Healthcare Safety Network. Infection Control & Hospital Epidemiology 2021; 1-8 Published online by Cambridge University Press: 15 March 2021
Fakih MG, Bufalino A, Sturm L, et al. Coronavirus disease 2019 (COVID-19) pandemic, central-line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI): The urgent need to refocus on hardwiring prevention efforts. Infect Control Hosp Epidemiol 2021; Published online 2021 Feb 19
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8007950/
Chopra V, Flanders SA, Saint S, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results from a Multispecialty Panel Using the RAND/UCLA Appropriateness Method. Ann Intern Med 2015; 163(6_Supplement): S1-S40
https://www.acpjournals.org/doi/10.7326/M15-0744?articleid=2436759&atab=7
Chopra V, O'Malley M, Horowitz J, et al. Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals. BMJ Quality & Safety 2021; Published Online First: 29 March 2021
https://qualitysafety.bmj.com/content/early/2021/03/28/bmjqs-2021-013015
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