CRBSI: Measurement, cost and impact on patient safety. Jane Hodson Lead IV Practitioner Guys and St Thomas NHS Foundation Trust

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1 CRBSI: Measurement, cost and impact on patient safety Jane Hodson Lead IV Practitioner Guys and St Thomas NHS Foundation Trust

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3 Catheter Related Blood Stream Infection (CRBSI) Clinical definition used for the diagnosis and treatment of infection that requires definitive laboratory evidence that the central venous catheter is the source of an individual patient's blood stream infection

4 Definition used at GSTT to confirm CRBSI Growth of an indistinguishable organism (same species and antibiotic resistance pattern) from at least one peripherally drawn blood culture and the tip of the removed catheter, OR Growth of an indistinguishable organism from at least one peripheral and one centrally drawn blood culture, where the central culture was detected in the automated blood culture machine > 2 hours before the peripheral culture (differential time to positivity or DPT)

5 When to Suspect CRBSI Diagnosis should be considered in all patients developing fever and/or sepsis in the presence of an intravascular catheter Frequently occurs without clinical evidence of inflammation at the catheter exit site Fever and/or sepsis in the presence of significant erythema or purulence at the exit site Development of fever and/or rigours after accessing the intravascular catheter

6 Do We Measure? Number of central line-associated blood stream infections (BSIs) identified for the patient care unit(s) under surveillance Number of central line days for the patient care unit(s) under surveillance X1000 MRSA MSSA Ward/clinical area dependant Learning from our mistakes

7 CQC inspection Continue to improve governance and assurance systems and reduce the backlog of complaints and investigations into serious incidents

8 Cost An excessive attributable cost which is the incremental cost directly related to infection Found to vary from $3700 to $39000/episode ( 2500 to 26000) Increased length of stay Additional medications

9 National Safety Standards for Invasive Procedures (NatSIPPS ) Checklist approach is not fully effective in protecting patients from adverse incidents Checklist must be conducted by teams of healthcare professionals that have: Trained together Received appropriate education in human factors that underpin safe team work Safety is not just about checklists, team work or human factors It is about checklists AND teamwork AND human factors and many other things besides

10 "No One Goes to Work to Make a Mistake" (NatSSIPS) Situation Awareness Decision Making Teamwork Leadership Coping with stress

11 Strategies to Prevent Central Line Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update (Marschall et.al) Make the problem real Identify a patient who has suffered harm as a result of developing a CLABSI Share the story

12 Glen s Story YouTube Viewable at Source Glen's Story How hospital associated infections can impact on a person's life and family, Copyright 2011 Victorian Infection Control Professionals Association (VICPA) For further information, contact Glenys Harrington, VICPA Video Project Team Coordinator, infexion@oz .com.au

13 Case Study: MSSA Bacteraemia 19 year old living at home Complex medical history Spina bifida repaired at 3 months, Arnold Chiary malformation, VP Shunt, neuropathic bladder and bowel History of long standing nausea and vomiting resulting in decreased oral intake Admitted to local hospital for OGD - oesophageal web at upper oesophageal sphincter, diffuse oesophagitis Transferred to tertiary centre for Oesophageal dilatation

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15 Admitted To Tertiary Centre Baseline Observations: T = 36.1 HR = 88 RR =18 BP = 95/62 BP post OD = 70/40 Persistent Vomiting with poor intake of fluids Barium Swallow followed by NG Insertion Persistent abdominal pain, vomiting and refusing anti-emetics Difficult Access Failed cannulation by the Anaesthetist Day 10 PICC Inserted Day 12 FY2 Review Obs: T 35.9 / HR 85 / RR 18 / BP 73/48 Hr fluid challenge and response No bloods done since day 4 repeated K mmols..40 mmols KCL Mg 0.48Mg.Infusion given WCC 3.1 K+ 2.1 PO CRP 26 Worsening Nausea and Vomiting

16 Trouble Brewing Day 17 documented in notes remain unable to flush one lumen of PICC off ward celebrating birthday with family Return to ward 20:00hrs HR = 96 / RR = 16 / BP = 65/41 Par score 4 Fluid challenge administered Day 18 Obs: HR = 88 / RR = 16 / BP = 74/47 K+ 1.9 Fluid challenge and electrolyte replacement Transfer to HDU Day 19 WCC = 7.3 CRP = 173 Plan of Action: Blood cultures Unblock PICC Hold Antibiotic Day 20 PICC line re-wired WBC = 8.2 / CRP = 197 Day 21 Call from Micro +MSSA Step down as electrolytes stable

17 What Went Wrong? Baseline Observations on Ward: T = 35 HR = 120 BP = 65/40 Par score 6 Drowsy but arousable Start Flucloxacillin Day 22 HR = 120 / BP = 50/22 cuff to large Micro opinion on antibiotics Drowsy on exam,? Line infection Re-culture, continue with antibiotics Day 23 Early hours of the morning HR = 126 RR = 27 BP = 62/24 Par score 9 Mother concerned about deterioration, and? Seizure activity Mid morning peri arrest Transferred to ITU Day 24 R.I.P

18 What did go wrong? Team work / Leadership No single person had oversight of this case Vital information was not shared between teams Situation Awareness / Decision making Goal posts moved Each individual involved only had a view of a single interaction, procedure, ward round or shift Stress reduction Complex patient

19 My Story

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