I appreciate the opportunity to speak on It's Still the Wild Wild West, Corralling CLABSI Reduction in High Acuity ICUs. I have no financial relationships with corporations. I am a subject matter expert on CAUTI CLABSIs, working in cohorts over the last 10 years, reducing CAUTI CLABSIs in low-performing ICUs in conjunction with the American Hospital Association, AHRQ, and SCCM. Our objectives today are to reinforce guidelines and processes for preventing central line infections in the post-pandemic world, identify barriers that predispose patients to central line infections, and to re-establish the path to improve CLABSI rates in your high-acuity ICU. Remember, we can still maintain patient safety while being focused on processes, even when we are faced with limited resources. Even specialty ICUs are not immune to system shocks. These are such things as staffing or resource limitations, the higher and changing acuity of patients, such as during a pandemic, and multiple other reasons. Surgical ICUs and trauma ICUs have seen more femoral lines placed, longer line use per patient, worse conditions of patients on admission, and the staffing challenges due to overflow ICUs. There have been several cardiac ICUs that have seen cardiac arrest and failure increases, inotropic support use, vasopressor increased use, and increased mechanical circulatory support. Also, dressing disruptions due to the skin issues and edema of patients have also increased. It is important to understand that there are independent risk factors for CLABSIs. Listed in bold are the areas we, as intensivists and providers, may have input to affect change in the ICU. There's certain listed items that we cannot affect, such as body mass index, the prematurity of any gestational age, the patients being neutropenic on arrival. But in bold, things we might affect change, prolonged duration of a catheter itself, heavy microbial colonization at the insertion site or at the catheter hub, multilumen catheter use and concurrent catheters in the same patient. There are independent risk factor of reduced nurse to patient ratio in the ICU, the use of prolonged parenteral nutrition, as well as substandard catheter care, such as excessive manipulation of the catheters itself. Much of the discussion today really should focus on ways to disrupt the life cycle of the vascular catheter. I have organized the discussion of interventions and challenges really based upon four ways to address vascular catheter use. Most important is step zero. Don't put one in unless it is essential. Step one, always use aseptic technique, full sterility, and it's good to have two-person evaluation of the technique to identify any breaks in sterility. Step two, maintenance and proper care of a catheter. And step three, prompt removal of a catheter when it is not needed. Don't be complacent. And this is where multi-professional rounds on a twice daily basis can help identify catheters that are not needed. I am certain many of you have heard of the MAGIC Guidelines, the Michigan Appropriateness Guide for Intravenous Catheters. It's a wonderful tool to be able to help determine, as it says here, the right catheter for the right amount of time with the right infusate. Following the evidence-based and newly updated MAGIC Guidelines could significantly improve your CLABSI rates in your ICU. For peripherally compatible solutions, it defines which catheters should be used for estimated length of time. Ultrasound-guided peripheral intravenous catheters are much better than just plain peripheral intravenous catheters if needed for between 6 to 14 days. A central line is the preferred access in critically ill patients for hemodynamic monitoring. A midline catheter is much preferred to a PICC line if the duration is less than or equal to 14 days. And PICC lines are preferred to tunnel catheters if a line is needed for between 15 and 30 days. For peripherally incompatible infusate solutions and for critical care patients, we should use non-tunneled catheters for periods of less than 14 days. Central lines for hemodynamic monitoring if used for 6 to 14 days. PICC lines are appropriate for all proposed durations of infusion. Remember that some solutions require dedicated lumens, such as TPN, and that PICC lines are rated as appropriate for all timelines if using solutions that are peripherally incompatible. But remember, they can get infected just like any central line without processes in place, and they tend to be treated differently perceptually by a lot of providers. When processes fail and collapses increase, remember to go back to the essential basics. These are specific interventions that will make a difference in reestablishing the culture of safety in your high-acuity ICUs. Tier 1 categories, such as standardizing supplies, procedures, and processes, complete these interventions along with the education and audits for compliance before moving to the Tier 2 interventions. Tier 2 interventions are behavioral, to develop the mindfulness and sustain the gains in the fight to reduce infections. These include real-time data metrics and reporting, multi-professional rounding, doing root cause analyses of any CLABSI failures, and this engages staff and continues to effect change. Now let's talk about some of the clinical challenges that we all face in dealing with CLABSIs in our high-acuity ICUs. These include certain processes, CHG bathing, and dressing disruption. A big cause of contamination and central line infections are dressing disruptions. In this study of over 1,400 patients, there were almost 300 colonized catheters, 29 major catheter infections, and 23 identified absolute CLABSIs. What is noted is out of over 11,000 dressing changes, 67% of them were performed before the planned due date. This was due to dressing disruptions and the need to put on a new dressing. A big cause of central line infections are dressing disruptions that go unrecognized or ignored. We must have a secure dressing around our central lines. In this publication, they showed that dressing cost inversely was related to increased rate of disruption of the dressing. The number of dressing disruptions increased the risk of colonization of the skin around the catheter at the time of removal. The risk of infection increased threefold after the second dressing disruption, and the risk of infection increased tenfold when the final dressing was disrupted independently of any other risk factors for infection. How do we maintain dressing integrity around our central lines? There have been multiple studies evaluating types of dressings to maintain adherence, especially in patients with sweaty skin and multiple access points. Over time, these lines and the skin will build up colonization, increasing the infection risk without a process in place to document a safe line dressing. In this study, two medical units in two separate hospitals evaluated transparent dressings with the use of a liquid gum mastic adhesive on improving the dressing integrity without increasing any of the medical adhesive related skin injuries. They had existing dressing with education. They updated the dressing with education on the 3M IV-Advanced. They used Sorbivue Shield with gum mastic, and then the 3M 1683 IV-Advanced dressing with gum mastic. They looked at baseline, pre-implementation, and post-implementation percentages of the four different dressing protocols. As you can see, the overall dressing integrity of the new protocol showed that the 3M securement dressing, along with the mastisol adhesive, improved the dressing integrity and showed no exposed insertion sites over the time of the study. Using this protocol of mastisol adhesive with the central line dressing, over time, they're seeing the same results. It has now become a standard of practice. Recently, a meta-analysis was published examining the impact of chlorhexidine gluconate bathing on CLABSIs. This included a total of 26 studies. In this analysis, they evaluated five measures of fidelity within the studies, examining adherence, exposure or dose, quality of delivery, patient responsiveness, and program differentiation. As you can see, out of all the studies, 12% had all 5, 12% had 4, 15% had 3, 27% had 2, and 35% had 1. Bias was considered quite low in the study. The data showed significant differences in CLABSI rates with CHG bathing. The overall reduction in the incidence rate was 40%. This study looked at the differential effects of antisepsis skin cleansing methods. It was a prospective, randomized, two-center study that was also blinded. It was to determine whether three different CHG skin cleansing methods yielded similar residual CHG concentrations and bacterial densities on the skin. They used method A, which was a 2% CHG cloth, method B, which was a 4% liquid placed onto a non-medicated cloth, and method C, which was a 4% CHG liquid on a cotton washcloth. They looked at CHG concentrations, measured immediately after bathing, as well as six hours after. The concentration of CHG was astronomically higher with method A, so the 2% impregnated cloth proved to be much superior. Every location where our ICU patients either started or while they are in our ICUs, the patients will have road trips. All the areas that they go to need to have the same standards and similar processes as you do in your ICU. If a line is placed in the emergency department, it needs to be sterile, and if not, identified for early removal or replacement with a new line. In the operating room, CRNAs and anesthesiologists need to scrub the hub and not mix solutions in dedicated ports or lumens of the central line. Also in the operating room, having a final timeout as a checklist to discuss items such as catheters that are placed in the operating room for potential monitoring or for needed temporary infusates. These checklists really will discuss whether a catheter should be removed prior to leaving the operating room, and if not, document if it was placed sterile and or emergently so they can be removed in less than 24 hours. When a patient comes back from the OR to the ICU, we have what's called a post-op stop, where everything is communicated from the procedure, such as catheter use and removal timeframes. What about the referring hospitals? Do you trust their sterility processes and lines? If a patient is transferred to your ICU and a line was placed at the outside hospital, should it be removed or changed when they get to your ICU? These things need to be considered. If an emergency central line was placed, having a process for EMR documentation and or a checklist item on a multi-professional rounding list helps to identify that infected line or non-sterile line, and that line can be removed or a new line placed within less than 24 hours. All lines placed without proper sterilization and, you know, the ones that are halfway done sterile should be considered dirty lines and need to be removed or replaced within 24 hours. We all have this type of patient, you know, the one, the one in extremis or the one with challenging comorbidities, such as obesity, minimal access targets, severe diabetes, other reasons for severe high risk of infections. We can't just give up and say, oh, well, they'll get an infection, nothing to do. These are the times to really double down and tightly focus on the processes that could prevent infection and salvage the situation. These listed areas can help in extreme conditions and prevent collapses. These are such as placing an IO or using an external jugular or other access points that aren't central lines, use of ultrasound guided peripheral IV, focus processes for extending the use time of any central line that you have. You can have a line maintenance team in the ICU for crisis situations that round multiple times a day to try to salvage the line access that you have. Really extreme observance on insertion and maintenance and sterility. Always have a plan B for the what ifs. You know, the what ifs of a line being removed or being pulled out always usually happen at resource limited times. Only use essentially the solutions and products in the line that need to be used and don't cross contaminate the lumens. And this is the type of patient that antibiotic impregnated central lines may be of benefit. I've included this study to show the future of technology and possibly preventing central line infections. This study aimed to have a prediction model to identify patients who could develop a central line infection in the next 24 hours. They collected variables potentially related to infection identification and all the patients admitted to a cardiac intensive care unit. This was done in between January 2010 and August 2020, excluding the diagnosis of endocarditis. They basically created models predicting whether a patient could develop a CLABSI in the ensuing 24 hours. And they found that a machine learning tool could be used to accurately predict up to 25% of patients with impending CLABSIs. Once validated, it may allow for earlier treatment and at least infection prevention. I included this to show that everyone is really looking for technology to solve problems. But when we are dealing with our complex high acuity ICUs and patients, this is where processes going back to the basics and making sure we have a culture of patient safety really help reduce the infection rates in these high acuity ICUs. As the MAGIC guidelines suggest, midline catheters can prevent central line infections. The demand is increasing globally because they are less expensive and usually more available than standard central lines and people are using them more to prevent infections. In resource limited times due to the global demand, there have been supply chain reductions in availability, so plan accordingly. Many of our ICUs in the post-pandemic world are now considered high acuity with challenging infection rates, so you are not alone. Processes fail without maintaining a culture of safety. Remember that education and re-education with onboarding expectations and standardization help us reduce infections. Simple to implement educational programs have been associated with marked reductions in the rate of CLABSI training as well as reduction in those infections. Care processes need to be refreshed regularly and supported with feedback on performance to be effective. CHC baths and attention to dressing integrity is absolutely essential. In extremist patient situations, constant focus on the details and consider using antibiotic coated catheters and processes to maintain the lines that you have are also essential. The MAGIC criteria, utilizing an algorithm for the right catheter, right length of time and the right infusate have been shown to reduce infections. Standardizing sterility processes at all sites outside the ICU, especially when our patients go on road trips, and to evaluate the catheters per every shift in the ICU also help reduce CLABSIs. Everyone is looking for the magic bullet in technology to reduce infections in our ICU, but in the end, the real solution is with proven basics and improving the ICU culture. Thank you for listening to this session and for attending Congress 2023.

central line-associated bloodstream infections

CLABSIs

high-acuity ICUs

infection prevention

catheter care practices