CLABSIs are “Central Line Associated Blood Stream Infections.” “Central line” catheters are tubes placed in some patients’ large veins (typically in the neck, chest or groin) to give fluids and medicines or to collect blood. While such catheters are lifesaving, they can introduce germs into the bloodstream and lead to bloodstream infections. Such infections can be very serious and even lead to death. Medical researchers developed a “bundle” of best practices and checklist for use during the insertion and maintenance of “central line” catheters that were proven to reduce CLABSIs by up to 70%. Tracking such infections in acute care hospitals is beneficial to encourage the adoption of the “central line bundle” and to evaluate its effect. In Connecticut and across the country, this has led to a substantial decrease in CLABSIs.

The Standardized Infection Ratio (SIR) is the primary measure used to track healthcare associated infections by the Connecticut Department of Public Health. The ratio is the number of actual infections that occur in a given time (called the baseline period) divided by the number predicted. The baseline is 1.0, which means that the number of infections observed is the same as the number predicted. If the SIR is greater than 1.0, it indicates that more HAIs were observed than predicted; conversely, an SIR less than 1.0 indicates that fewer HAIs were observed than predicted. As the aim is to reduce CLABSI, the SIR needs to be below 1 (the lower, the better).

Acute care hospitals in Connecticut and across the country reduced CLABSIs significantly in Intensive care Units (ICUs) which are considered to be high risk setting for these infections since the sickest patients are found in the ICU, many needing central lines. Once progress was achieved in selected ICUs, Connecticut expanded tracking to all ICUs. This led to an apparent increase in the SIR, until progress was achieved in reducing infections in all ICUs. By 2013, Connecticut had achieved the goal of reducing infection by 50% among all ICUs. In 2014, Connecticut and the nation expanded tracking of CLABSIs to include patients housed on acute care hospital wards, not just those in ICUs. There are many patients in ward settings who need “central line” catheters for longer term treatment, and who may be at risk for infections, such as cancer patients.  Keeping central lines free of germs in the ward setting, where patients can walk around, is challenging. The expanded tracking to hospital wards caused an increase in the SIR.

Since 2016, Connecticut has been tracking CLABSIs using the national baseline that was reset in 2015. As expected, this re-baselining increased the SIR close to 1.0 nationally in 2016. The Connecticut statewide SIR has down trended subsequntly, indicating that acute care hospitals' prevention efforts are reducing CLABSIs.

Hospital medical and non-medical staff, especially infection prevention and control staff (infection preventionists and hospital epidemiologists). Connecticut Hospital Association. Qualidigm, the Connecticut CMS Quality Improvement Organization (QIO). The Connecticut Healthcare Associated Infections Advisory Committee. The Connecticut Chapter of the Infectious Diseases Society of America (CIDS). Centers for Disease Control and Prevention, Division of Healthcare Quality and Prevention. National Healthcare Safety Network. Council of State and Territorial Epidemiologists. The Association of Professionals in Infection Control, Inc. The Society for Healthcare Epidemiology in America. Connecticut Department of Public Health.  

To implement the “bundle”, healthcare facilities must track use of the best practices, and ensure that all staff involved in the insertion and maintenance of central lines rigorously adhere to the protocols, despite the many competing priorities they address every day to care for patients. Dr. Peter Provonost and colleagues at Johns Hopkins University developed the “Comprehensive Unit-based Safety Program (CUSP).” This program can be adopted by healthcare facilities to ensure the routine use of the central line bundle and checklist. By doing so, changes in the culture of the organizations, and changes in logistics to support and maintain use of these best practices. The ultimate goal is preventing CLABSIs with the aim of eliminating them. The CUSP programs are developed and delivered in the overall infection control and prevention program of each healthcare facility.  

We will continue to track progress in preventing CLABSIs in acute care hospital ICUs and wards. Making additional progress may be more difficult than in the past, because infections that are easier to prevent have largely been prevented.

Many facilities have adopted the best practices after participating in the CUSP programs. We will continue to monitor the CLABSI SIR to assess the effectiveness of this successful intervention.