Catheter-Associated Bloodstream Infection Surveillance Variability
Kochurani Thomas
Grand Canyon University
NRS-433V
May 1, 2011

Bloodstream infections are the most common hospital-associated infection (HAI) in intensive care units (ICU) and a significant source of in-hospital deaths, increased length of stay and added medical costs. Both adult and pediatric patients who have catheters inserted into their blood vessels face increased risk of an infection developing along the invasive plastic devices which can become life-threatening as they spread into the bloodstream. According to Centers for Disease Control and Prevention (CDC), an estimated 248,000 blood stream infections are reported per year (CDC, June 2010), and mortality rate of 12%-25 %( CDC, 2011) .This dangerous lethal medical complication can be prevented by proper management of the catheter insertion and strict aseptic technique during care. Even though CDC has recommended standard catheter associated blood stream infections (CA-BSI) prevention strategies, the study shows areas of variability in the surveillance. A central line is an intravascular catheter that terminates at or close to the heart or in one of

the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring.

The Aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal

jugular veins, subclavian veins, external iliac veins, common iliac veins, common femoral veins, and

the umbilical artery/vein in neonates are considered to be the commonly used great vessels for the

purpose of reporting the central line blood stream infection (CLBSI).

Central line plays a crucial role in medical practice, especially in intensive care unit,

during major surgery, resuscitation, reliable hemodynamic monitoring, and vascular access for

dialysis patients. However central lines also endanger the patients for complications like systemic

infections such as CA-BSI, septic thrombophlebitis, endocarditis, and sepsis. According to the

CDC’s National Nosocomial Infections Surveillance System (NNIS), Blood stream infections

are laboratory-confirmed bloodstream infections (LCBI) that are not secondary to an infection at

another body site and the catheter is in situ for more than 48 hours before the identification of a

positive blood culture.

CA-BSI rates are impacted by various factors like, clinical practices on central line insertion and maintenance, patient risk factors, and surveillance method. A very little significance was given for the surveillance method in regard of the CA-BSI rates where as a considerable attention was given to other factors like insertion technique and maintenance. A research study led by Dr.Mathew Neidner, MD, assistant professor of pediatrics and communicable diseases, Mott Children’s Hospital in Ann Arbor, Michigan, brings an eye opening findings on this CA-BSI surveillance practices. The objective of their study was to assess the variability in CA-BSI surveillance practices, management, and attitudes /beliefs in pediatric intensive care units (PICUs) and to verify the correlation between the surveillance variation and CA-BSI rates. The method they used is a survey of six health care professions at multiple institutions, namely, PICU medical directors, PICU nurse managers, PICU clinical intensivists, PICU bedside nurses, infection control personnel and microbiology personnel. The Survey was conducted securely online through The National Association of Children’s Hospitals and Related Institutions (NACHRI) survey center. The primary null hypothesis was absence of variability in the resources, methods, and attitude/beliefs as they relate to the surveillance practices for CA-BSI when comparing institutions. Two secondary null hypotheses were also defined a priori, that there would be no variability between methods and attitudes/beliefs within the institution, and the reported CA-BSI rates and the aggressiveness of surveillance practices. The team received 146 responses from 366 people given surveys, with a response rate of 40% from 16 participated PICUs. All ten (100%) Infection control departments were found to be inconsistent with the CDC definition of central line types, five (50%) calculated line-days inconsistently. Five out of ten (50%) infection control departments polled, submit CA-BSI data to National Healthcare Safety Network (NHSN), and only five (50%) reported using a strict written policy for BSI classification. Similarly, substantial variations were reported by the infection control departments in methods, timing and resources used to screen and adjudicate BSI cases. The study reveals that more than 80% of centers have a formal written policy about collecting the blood culture, and half of the time they are not strictly followed. In blood culturing practices also remarkable interindividual and interinstitutional variation noticed like temperature thresholds, preemptive antipyretics and blood sampling (volume, number, sites, and frequencies).In respect of attitudes /beliefs, 92% of physicians and nurses report patient risk factor as a major contributor, 70% cited CVL maintenance practices and 40% believed that the CVL insertion practices as the main reason for the CA-BSI.When they analyzed with a surveillance aggressiveness score to quantify practices, likely to increase identification of blood stream infection, they noticed a considerable relationship between the CA-BSI rates and the surveillance aggressiveness score (r =0.6, P=.034). The more aggressive surveillance for CA-BSI correlated significantly to higher CA-BSI rates. The study findings demonstrate substantial variability in CA-BSI surveillance on many areas, from the application of diagnostic strategies to interpretation of the CDC definition itself. There is an indisputable opportunity to improve standardized CA-BSI surveillance to augment the validity of this metric for interinstitutional comparisons. The aggressiveness surveillance at the level of nursing practice corresponds with CA-BSI rates, indicating that the harder you look for, the more likely to find them. The author concludes: “improved understanding of this variability and awareness of the potential consequences provides an opportunity and rationale to define CA-BSI surveillance best practices and work toward standardizing them across institutions.”(M F.Niedner,2008). The above study gives an insight into the importance and need for a universal, standardized recommendations for CA-BSI prevention and surveillance.CDC has outlined and recommended CA-BSI bundle which should be re enforced to the health care workers mainly the nurses who plays a vital role in patient care. Annual educational sessions would bring an updated uniformity of the surveillance practices to all health care personnels.Many problems become more manageable when we standardize procedures .Various professional bodies have put forward recommendations for CA-BSI surveillance, but not at the level that will give it real traction. It’s going to take a national entity endorsing standardized surveillance practices to improve the validity of institutional comparisons.

References

Matthew F. Neidner, 2008, the harder you look, the more you find: catheter –associated bloodstream infection surveillance variability. Retrieved from American Journal of Infection Control - October 2010 (Vol. 38, Issue 8, Pages 585-595, DOI: 10.1016/j.ajic.2010.04.211)

Riley, M. Mei-Sheng, 2008, A Lurking Danger: A 'Bundle' of Safety Measures Available to Fight Central Line Infections, Retrieved from http://nursingspectrum.netstation.us/ce476.pdf

Centers for disease control and prevention, vital signs: central line –associated blood stream Infections --- United States, 2001, 2008, and 2009, accessed from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6008a4.htm?s_cid=mm6008a4_
Elsevier (2010, September 24). Study of bloodstream infections reveals inconsistent surveillance methods, reporting among hospitals. ScienceDaily. Retrieved May 1, 2011, from http://www.sciencedaily.com/releases/2010/09/100924084604.htm

Resource 2:
Nursing Research Study Contributions Grading Rubric

Nursing Research Study Contributions (Due Module 2)
| |1. Unsatisfactory |2. Less than |3. Satisfactory |4. Good |5. Excellent |Total |
| | |Satisfactory | | | | |
|Summarization |5 points |6 points |7 points |8 points |10 points |10 |
|addresses the |Summary lacks any |Summary is insufficiently|Summary is |Summary is clear, |Summary is | |
|article’s problem |discernible overall |developed and/or vague: |appropriate. |forecasting development of|comprehensive; makes | |
|statement (why this |purpose or organizing |Purpose is not clear. | |paper. It is descriptive |the purpose of the | |
|issued is being |claim. | | |and reflective of the |paper clear. | |
|studied). | | | |arguments and appropriate | | |
| | | | |to the purpose. | | |
|Addresses methods and |5 points |6 points |7 points |8 points |10 points |10 |
|research design |Does not mention the |Incorrectly identifies |Provides the research|Provides the methods |Provides the methods | |
|utilized in the study.|methods and research |the methods and research |design utilized in |utilized in the article |and research design | |
| |design discussed in the |design discussed in the |the article | |utilized in the | |
| |article. |article. | | |article | |
|Explains the ways in |7 points |9 Points |11 Points |13 Points |15 Points |15 |
|which the research |Explanation does not |Sufficient justification |Evidence is orderly, |Evidence is strong, |Clear and convincing | |
|findings might |justify that the |of claims is lacking. |but may have a few |showing logical |evidence presents a | |
|contribute to nursing |findings contribute to |Explanation lacks |inconsistencies. |progressions that the |persuasive claim in a| |
|practice. |nursing practice. |consistent unity. There |Explains logically, |findings contribute to |unique and compelling| |
| |Evidence is in part or |are obvious flaws in the |but not thoroughly |nursing practice. |manner ,explaining | |
| |wholly incoherent. |logic. |enough to support | |that the study’s | |
| | | |that the findings | |findings contribute | |
| | | |contribute to nursing| |to nursing practice. | |
| | | |practice. | | | |
|Explains the ways in |7 points |9 Points |11 Points |13 Points |15 Points |15 |
|which the research |Explanation does not |Sufficient justification |Evidence is orderly, |Evidence is strong, |Clear and convincing | |
|findings contribute to|justify that the |of claims is lacking. |but may have a few |showing logical |evidence presents a | |
|patient outcomes. |findings contribute to |Explanation lacks |inconsistencies. |progressions that the |persuasive claim in a| |
| |patient outcomes. |consistent unity. There |Explains logically, |findings contribute to |unique and compelling| |
| |Evidence is in part or |are obvious flaws in the |but not thoroughly |patient outcomes. |manner, explaining | |
| |wholly incoherent. |logic. |enough to support | |that the study’s | |
| | | |that the findings | |findings contribute | |
| | | |contribute to patient| |to patient outcomes. | |
| | | |outcomes. | | | |
|Describes the ethical |7 points |9 Points |11 Points |13 Points |15 Points |15 |
|considerations |Description does not |Description |Description |Description partially |Description is | |
|associated with the |present the ethical |insufficiently presents |marginally presents |presents the ethical |comprehensive; | |
|conduct of nursing |considerations |the ethical |the ethical |considerations associated |clearly presents the | |
|research. |associated with the |considerations associated|considerations |with the conduct of |ethical | |
| |conduct of nursing |with the conduct of |associated with the |nursing research. |considerations | |
| |research. |nursing research. |conduct of nursing | |associated with the | |
| | | |research. | |conduct of nursing | |
| | | | | |research. | |
|Conclusion |7 points |9 Points |11 Points | |15 Points |15 |
| |Conclusion does not |Conclusion supports |Conclusion is weak, | |Conclusion includes | |
| |support the review of |articles as reviewed but |with one suggestion | |suggestions for | |
| |the articles. |lacks suggestions for |for future research. | |future research that | |
| | |future research. | | |are logical and | |
| | | | | |concrete. | |
| | | | | | | |
| | | | | | |80/80 |
| | | | | | | |
|Format and Style | | | | | | |
|15% | | | | | | |
|Mechanics of Writing |1 Point |2 Points |3 Points |4 Points |5 Points |5 |
|(includes spelling, |Surface errors are |Frequent and repetitive |Some mechanical |Prose is largely free of |Writer is clearly in | |
|punctuation, and |pervasive enough that |mechanical errors that |errors or typos are |mechanical errors, |control of standard, | |
|grammar) |they impede |distract the reader. |present, but are not |although a few may be |written American | |
| |communication of | |overly distracting to|present. |English. | |
| |meaning. | |the reader. | | | |
|Language Use |1 Point |2 Points |3 Points |4 Points |5 Points |5 |
|and Audience Awareness|Inappropriate word |Some distracting and/or |Sentence structure is|The writer is clearly |The writer uses a | |
|(includes sentence |choice and/or sentence |inconsistencies in |correct and |aware of audience; uses a |variety of sentence | |
|construction, word |construction, lack of |language choice |occasionally varies. |variety of sentence |constructions, | |
|choice, etc.) |variety in language use.|(register), sentence |Language is |structures and appropriate|figures of speech, | |
| |Writer appears to be |structure, and/or word |appropriate to the |vocabulary for the target |and word choice in | |
| |unaware of audience. Use|choice are present. |targeted audience for|audience; and uses figures|unique and creative | |
| |of “primer prose” |Sentence structure may be|the most part. |of speech to communicate |ways that are | |
| |indicates writer either |occasionally ineffective | |clearly. |appropriate to | |
| |does not apply figures |or inappropriate. The | | |purpose, discipline, | |
| |of speech or uses them |writer exhibits some lack| | |and scope. | |
| |inappropriately. |of control in using | | | | |
| | |figures of speech | | | | |
| | |appropriately. | | | | |
| | | | | | |15/15 |
|APA Format | | | | | | |
|5% | | | | | | |
|Title page |0 Points | |0.5 Points |0.75 Point |1 Point |1 |
| |No title page. | |Title page is |Title page has minor |Title page is | |
| | | |incomplete or |errors. |complete. | |
| | | |inaccurate. | | | |
|Articles attached |0 Points | | | |1 Point |0 |
| |Article not attached to | | | |Article is attached | |
| |presentation. | | | |to presentation. | |
|Page constraint |0.5 Points | |0.75 Points | |1 Point |1 |
| |Information presented | |Information presented| |Information is | |
| |does not meet minimum | |exceeds page or word | |presented within page| |
| |assigned length. | |limit. | |constraints. | |
| | | | | | |4/5 |
|TOTAL | | | | | |99/100 |

© 2008. Grand Canyon University. All Rights Reserved.