Central Line Related Blood stream Infection (CLR-BSI)

Note: for info about QA Infection Audit see that article.

• July 15.13 - Laura Kolesar will rewrite these criteria here based on discussion and Dr. Kendiss Olafsons input at Task meeting July 11.13. Thank you Laura, Gail and Marie for persuing this.Trish Ostryzniuk 16:01, 2013 July 16 (CDT)

• Centers for Disease Control and Prevention (CDC): January 2013:CDC_CLR_BSI criteria
• A List of common comensals can be found on Regional Server: \\ad.wrha.mb.ca\WRHA\REGIONWRHA\SHARED\ICU_DATA_COLLECTION\documents\List of Common Comensals CDC Jan 2013

Legacy Content

This page is about the pre-ICD10 diagnosis coding schema. See the ICD10 Diagnosis List, or the following for similar diagnoses in ICD10:Iatrogenic, infection, central venous catheter-related bloodstream infection (CVC-BSI, CLI)

Click Expand to show legacy content.

edit dx infobox
Category/Organ System:	Category:Infection (old)
Type:	[[:Category: Medical Problem (old)]][[Category: Medical Problem (old)]]
Main Diagnosis:	Central Line Related Blood stream Infections
Sub Diagnosis:	See: UPL (Universal Pathogen List)
Diagnosis Code:	8600 - Central Line Related Blood stream Infections
Comorbid Diagnosis:	No
Charlson Comorbid coding (pre ICD10):	0
Program:	Critical Care and Medicine
Status:	Currently Collected
Start Date:	Code added Jan 1996

Criteria for ICU associated Central Line Related Blood stream Infections (CLR-BSI)

NOTE: Central Line Infections can be coded in the diagnosis section if the pt already has a line sepsis on arrival to the ICU. The criteria in this section relates to when a pt develops a central line sepsis while in the ICU, in this event the CLI code is put in the complications section and also the tmp study section under QA infection CLI must also be completed with the date. (Note: Basil Evan must be notified of all ICU related CLI's)

• Laboratory confirmed bloodstream infection must meet at least one of the following criteria and have occurred in the ICU or within 48 hours of leaving an ICU: The ICU collectors do not follow patients once they leave the ICU so those who leave and subsequently develop a line infection may be captured by the medicine collectors if it is on a ward in our program.
• ICU associated CLR-BSI is not present on admission to ICU. The patient must have been in the ICU for 48 hours for the CLR-BSI to be considered ICU associated, unless compelling evidence suggests the infection was ICU associated.
• ONE OF THE FOLLOWING 2 CRITERIA MUST BE MET: (FOR BOTH CRITERIA, THE PT MUST HAVE A CENTRAL LINE AND HAVE BEEN IN THE ICU WITH A CENTRAL LINE FOR AT LEAST 48 HOURS).
• CRITERION 1:
• Patient has a recognized pathogen cultured from one or more blood cultures and the organism cultured from blood is not related to an infection at another site.
• CRITERION 2:
• Patient has at least one of the following signs or symptoms:
  • fever (>38 C)
  • chills
  • hypotension
• Note: These 3 symptoms should not have any other recognized cause.

and

• Common skin commensal ( e.g. diphtheriods, Bacillus sp., Propionibacterium sp., coagulase-negative staphylococci, or micrococci) is cultured from two or more blood cultures drawn on separate occasions.

Special considerations for the above criteria

• Criterion elements must occur within a timeframe that does not exceed a gap of one calender day. "Criterion Elements" refer to the fever, and other symptoms of infection and the timing of the first positive culture.
• Separate occasions for the blood cultures can range from 15 minutes apart to within 48 hours of each culture.
• Different ports of the same line is considered 2 sites.
• One blood culture is defined as one site (at least one bottle from a blood draw is reported as having grown at least one organism).
• If the central line tip is positive but the blood cultures are negative then it is not a central line infection. You must have positive blood culture(s) as listed in the above criteria.

Related temporary study collection instructions

• See Qa_inf#B._Central_Line_Infection

Definition of Terms

CL means Central Line

A CL is a vascular access catheter that passes through or has a tip ending at or close to the heart or in one of the great vessels.

Great vessels include:

• aorta
• pulmonary artery
• superior vena cava
• inferior vena cava
• brachiocephalic vein
• internal jugular vein
• subclavian vein
• external iliac vein
• commom femoral vein

Central Lines include:

• subclavian vein catheter
• internal jugular vein catheter
• PICC (Peripherally Inserted Central Catheter)
• Swan-Ganz (pulmonary artery) catheter (TISS item # T12. See: TISS Cardiovascular)
• Brovic
• Groshong
• Hickman
• Dialysis catheter (TISS item # T53, T54, T55. See: TISS Genitourinary)
• introducer for temporary pacing wire

Not counted as Central Lines:

• arterial catheters inserted into an artery
• ECMO
• IABP
• VAD
• IMPELLA

Common skin commensal

• Common skin commensal means microorganisms that are commonly found on the skin and often indicate contamination of the blood culture media rather than identification of a pathogenic organism when identified in blood culture tests. These include coagulase negative staphylococci, proprionbacterium species, corynebacterium species, diphtheroids, bacillus species and mirococcus species.
  • A List of common comensals can be found on Regional Server located: \\ad.wrha.mb.ca\WRHA\REGIONWRHA\SHARED\ICU_DATA_COLLECTION\List of Common Comensals CDC Jan 2013

How do we count?

a.) Count the number of patients with a central line in place at the time of the count.Template:Discussion Statistician using TISS28 item #46, count at 2300 hrs? --Trish Ostryzniuk 19:26, 2013 May 14 (EDT)

b.) A patient with two or more central lines in place at the time of the count is counted as one patient with a central line on that day.

c.) Count the total number of patients who are in the ICU each day at the time of the line counts. Statistician using Registry Data to obtain admit date and time closet to 2300 hrs?--Trish Ostryzniuk 19:26, 2013 May 14 (EDT)

Julie reports line count for central line infection rates in quarterly and annual reports and for CCVSM. Since TISS28 will be collected and entered for entire LOS, Julie will utilize TISS28 & Registry Data for counts starting January, 1, 2013. Julie will need to post more information in regards how data is used. Trish Ostryzniuk 19:11, 2013 May 14 (EDT)

Central Line Count Start Dates

Hosp	Central Line_start date	Unit
HSC	Sept 1.07	MICU/CCU
	Sept 1.07	SICU
	Sept 1.07	IICU
STB	Jan 1.06	MICU/SICU
	Not included	CCU
	Not included	CICU
GRA	Feb 1.08	MICU
VIC	Feb 25.08	MICU
OAK	Feb 19.08	MICU
CON	Feb 4.08	MICU

TOstryzniuk 20:17, 22 January 2009 (CST)

Frequently asked questions

1. If a patient in an ICU has a temporary or tunneled hemodialysis catheter, is that device counted as a central line in the central line days?
   • If a line meets the defintion of what is a central line, then it should be counted. The only exception to this would be an implanted device that is not used. In this situation, the line would only be counted beginning on the first day that it is accessed (e.g., physician orders that the port-a-cath be flushed). Then it would be counted every day there after.
2. Do central lines include the following: implantable-ports, non tunneled TLC, Swan Ganz catheter, tunneld-Borviac, Groshong, Quinton, Hickman, ASHE catheter, PICC lines? If yes would they be counted in the central line days for that unit?
   • Yes to all of the above if they meet the definition. Central lines are not defined by the type of device.
3. Is a dialysis catheter considered a central line since it isn't used for infusion?
   • A dialysis catheter is considered a central line if it meets the definition of a central line. It is used for infusion of the patient's own blood.
4. Are permanent shunts and balloon pumps considered central lines?
   • Yes if they meet the definition of a central line. Central lines are not defined by type of device.
5. If a patient is admitted to the ICU with a central line in place, is it counted in the central line days
   • Yes
6. Clarify the last sentence of the definition for CLR-BSI that reads, "If the time interval was longer than 48 hours, there must be compelling evidence that the infection was related to the vascular acess device."
   • This means only that if the time interval between the removal of the line and the onset of bloodstream infection (BSI) is greater than 48 hours, the BSI should not be considered central line-associated unless there is evidence that is was related to this device.
7. What if: a patient had a central line inserted in the ICU; 6 days later the patient has a positive blood culture; and the patient meets the definition for laboratory confirmed bloodstream infection. Would this patient be counted as a Central Line Related blood stream Infection (CLR-BSI)?
   • If the line was not discontinued, it would be counted as a CLR-BSI. If the line were to be discontinued on day 4 or earlier, it would not be counted as a CLR-BSI.
8. How do you determine which unit to "credit with a bloodstream infection? E.G., on May 2nd the patient is in the medical ICU; on May 3 the patient is transferred to the coronary care unit; symptoms develop on May 4th. Which unit is "credited"?
   • The patient is followed for 48 hours AFTER TRANSFER to another unit. If a BSI develps within that 48 hour period, the original unit is "credited" with the infection.
9. what should be done if a device-day is not counted?
   • Days should not be skipped. If days are not recorded (say on weekends),then the staff charts should be reviewed and staff interviewed to determine what the counts were at the appropriate time period.
10. A patient with a dialysis catheter is in one the ICU's under surveillance for CLR-BSI. If this patient's dialysis catheter is only accessed in the dialysis center, are the central line days for this patient counted in the ICU's central line count days? #*No. In this instance, the central line days would not be counted in the ICU central line day count.
11. A patient with dialysis catheter is in one of the ICU's under surveillance for CLR-BSI. Someone from the dialysis center comes to the ICU to perform the dialysis. Will the central line days for this patient be counted in the ICU's central line day count?
    • Yes. In this instance, the central line days would be counted in the ICU's central line day count.

Background

The Case for Preventing Central Venous Catheter related Bloodstream Infections

• Central Venous Catheters (CVCs) are being used increasingly in the inpatient and outpatient setting to provide long-term venous access. CVCs disrupt the integrity of the skin, making infection with bacteria and/or fungi possible. Infection may spread to the bloodstream and hemodynamic changes and organ dysfunction (severe sepsis) may ensue, possibly leading to death. Approximately 90% of the catheter-related bloodstream infections (CR-BSIs) occur with CVC.
• Forty-eight percent of intensive care unit (ICU) patients in the U.S. have central venous catheters, accounting for 15 million central-venous-catheter-days per year in U.S.-based ICUs. Studies of catheter-related bloodstream infections that control for the underlying severity of illness suggest that mortality attributable to these infections is between 4% and 20%. Thus, it is estimated that 500 to 4000 U.S. patients die annually due to bloodstream infections.
• In addition, nosocomial bloodstream infections prolong hospitalization by a mean of 7 days.Attributable cost per bloodstream infection is estimated to be between US $3,700 and $29,000. There are no equivalent Canadian figures for burden of illness. (as per literature).

Purpose

• To identify the incidence of Central Venous Line Related Infections within the WRHA ICU's.
• The monitoring of the incidence over time will identify the magnitude of the problem within a specific area or unit and will enable comparisons between selected ICU's across Canada (Canadian Collaborative - Safer Health Care Now).
• This should lead to the review of practices occuring at the time of insertion as well as the care processes relating to the maintenance of the catheter dressings.

Goal

• Eliminate this preventable patient harm.

LEGACY TISS76 items that refer to central line

No all central line are collected on TISS only these:

• T12 - TISS Cardiovascular
• T43 - TISS Gastrointestinal
• T53, T54, T55 - TISS Genitourinary
• T71 - TISS Meds IVs

Legacy Line Count Form used by ICUs in Region

Stopped May 6.13