QA Infection CLI

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Projects
Active?: legacy
Program: CC
Requestor: Critical Care QI Team
Collection start: 2009-08-22
Collection end: 2018-12-31
  • Anyone who has this problem and is discharged PRIOR to Jan 1.19, code in TMP
  • Anyone who has this problem and is discharged AFTER Dec 31.18, code using ICD10

The Critical Care QI Team is monitoring Central Line Infections in the ICUs. This project is in collaboration with CCVMS which is a cross Canada ICU collaborative project.

Data Collection Instructions

For all ICU patients:

If a patient
  • develops a Complication of Central Line Infection while in your unit
  • the CLR-BSI is newly acquired on your unit and not already reported at different unit
  • there is a positive culture (no positive culture, don't code)
then
  • Project: QAInf
  • Item: Central Line Infection
  • date_var: date (no time) positive blood culture was sent to micro lab.

Don't use TMP as notes

Please do not enter this TMP until you have actually confirmed a DX of CLI exists. Use the Notes field on you laptop as a reminder if needed.

Patient from other ICU with Central Line and possibly CLI

If Patient already has a CLR-BSI present on admission to your unit:

  • in the admitting diagnosis field, enter Central Line Infection.
  • do not enter into Tmp project.
  • if the patient is from another ICU in the city, email the collector at that site to check if CLR_BSI was captured as a complication at that site.

Reporting

Sampling /Denominator

The denominator used to calculate CLBSI rate are the total patient days with central lines in the Central Line Tracking project before 2013 and the Central Venous Catheter at 2300 (TISS Item) from 2013 to present.

for which ICU do we report the CLI?

If the QA Infection CLI entry indicates a lab within 48 hours of arriving at a second (or more) ICU, it is reported for the previous ICU. If the sample is more than 48 hours after admission, or within 48 hours of discharge from an ICU to a ward, we report it for that ICU

  • Reported in Director/Manager quarterly reports.
  • separate report to Infection Control (Myrna Dyck), STB and Oaks.
    • August 2018 stopped sending separate report for CLI and VAP for Myra Dyck, infection control.

Cross checks

See QA Infection

Data Integrity Checks (SMW)

 AppStatus
Query s tmp apostrophe in commentCCMDB.mdbimplemented
Query s tmp QAInf dx no tmpCCMDB.mdbretired
Query s tmp QAInf basicCCMDB.mdbretired
Query s tmp QAInf LT 48 hrs after admitCCMDB.mdbretired
Query s tmp QAInf tmp no dxCCMDB.mdbretired
Query NDC CLI AcqDX but NoCLI DateinTMPV2Centralized data front end.accdbimplemented
Query NDC CLI No AcqDX but CLI DateinTMPV2Centralized data front end.accdbimplemented
Query NDC CLI unacceptable dateCentralized data front end.accdbretired

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