Central Line Related Blood stream Infection (CLR-BSI)

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

• will need to break up this page into sections. too long. Suggestion welcomedTOstryzniuk 20:18, 22 January 2009 (CST)

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

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

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 the ICU:

• 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.

• 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
  • Signs of infection of catheter insertion site/tunnel

AND

• Common skin commensal (contaminant, e.g. diphtheriods, Bacillus sp., Propionibacterium sp., coagulase-negative staphylococci, or micrococci) is cultured from at least one of the following:
  • two or more blood cultures drawn on separate occasions.
  • at least one blood culture from a patient with an intravascular line.

AND

• physician institutes appropriate antimicrobial therapy.

Not a CLR-BSI

• if "tip" of central line is culture positive, but blood culture is negative, this is not a CLR-BSI. Must have a positive blood culture as indicated by criteria 1 or 2 above.

Collection Instructions

• GO TO: QAInfection (QAInf)

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
• Brovic
• Groshong
• Hickman
• Dialysis catheter
• introducer for temporary pacing wire

Not counted as Central Lines:

• arterial catheters inserted into an artery
• pacemaker wire-permanent

BSI means blood stream infection

The Definition of bloodstream infections established here are not to be construed as technical medical definitions of BSI, but only as a definition necessary to establish a reporting requirement.

Criteria for Blood stream Infection (BSI):

• At least one of the following:

A. at least one blood culture result includes a pathogenic organism OR

B. at least two blood cultures results from specimens obtained at different times or from specimens drawn at different phlebotomy sites, e.g., left arm and right arm, within a 2 day period include the same type of common skin commensal organism. OR

C. at least one blood culture result includes a common skin commensal organism

• AND
  • antibiotic treatment effective against that organism was started on the day that the culture was collected and was continued for greater than 3 days.

Discussion

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.

Central Line Days (CLD's)

• information is collected by the CRN at each of the ICU's in the city.
• form is faxed to our office once per week.
• Data processing manually enters counts into an ACCESS database.
  • NAME: CentralLineswithETtube.mdb
  • LOCATION: share point on X drive in the admin folder under special projects.
• used by statistician in conjunction with DX code 86 to report the number of central line related blood stream infections. This is submit to CCVSM (Critical Care Vital Signs Monitoring)-which is a cross Canada ICU collaborative.

• How do we count?

a.) Count the number of patients with a central line in place at the time of the count.

b.) Perform count at the same time each day, within 1 hour before or after the target time, during the reporting period.

c.) 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.

d.) Count the total number of patients who are in the ICU each day at the time of the line counts.'

e.) Every monday, a copy of the counts from the previous week (Monday to Sunday), will be faxed to the following number: 787-2823 Attention Pagasa Torres/Julie Mojica.

f.) A copy of the line count form will be kept on file by the unit manager at each site.

Line Count Form used by ICU's

• Form is completed daily by CRN (charge nurse) or manager and FAXED to the Database Research office once per week (every Monday with previous weeks data).
• Data Processor makes a phone call to specific contact people in each ICU every week if the form is not submitted by Wednesday each week.
• Data Processor manually enters values from this form into an Access database on our office share drive X.
  • NAME: CentralLineswithETtube.mdb
  • LOCATION: X:\CCMDB_Special_Projects\Central_Line_Infections_ETube\DATA_ENTRY_LineCounts_ETube\CentralLineswithETtube.mdb

• • The same form is used by ICU charge nurses for the QA ETT unschedule extubations project and for counting the number of Central lines for the QA Central Line Related Blood stream Infection project. Also see QAInf ITEM B above.

• • HSC Form
  • HSC-IICU Form
  • All other ICU's form

• each site has a agreed on a different target time each day that would work in their unit.

TOstryzniuk 18:10, 8 October 2008 (CDT)

Central Line Count Start Dates

Hosp	Central Line_start date	Unit
HSC	Sept 1.07	MICU/CCU
	Sept 1.07	SICU
STB	Jan 1.06	MICU/SICU
	Jan 1.06	CCU
	Jan 15.07	CICU
GRA	Feb 1.08	MICU
VIC	Feb 25.08	MICU
OAK	Feb 25.08	MICU
CON	Feb 13.08	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 is "appropriate" antimicrobial therapy"? *This is not defined. If an antibiotic is appropriate for the microoganism identified, for example, not resistant or used for that microorganism, then it is appropriate.
10. 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.
11. 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.
12. 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.

Discussion

• need to attach or link the rest of the teaching package for this project. Rest meaning items below and research iformation.TOstryzniuk 18:48, 2 July 2008 (CDT)

• Sample of LINE COUNT FORM needs to be uploaded here.
  • If you have one I can upload it. Do you want a sample, though, or the actual template/form?Ttenbergen 23:32, 7 October 2008 (CDT)