Cutting bloodstream infection rates

26 March 2012
Counties Manukau DHB is proving it is possible to achieve a major reduction in rates of central line-associated bacteraemia, better known as CLAB.

As part of its internal Aiming for Zero Patient Harm campaign, the DHB began taking steps to reduce the incidence of CLAB in its Critical Care Complex (CCC) – incorporating ICU and HDU - in late 2008.

Improvements soon followed, with 14 cases in Middlemore Hospital’s CCC in 2008 falling to just four cases throughout 2009.

The reduction was all the more significant considering the CCC expanded from six beds to 18 within that period and that Middlemore also operates the region’s specialist burns unit. Burns patients are known to be particularly vulnerable to infection.

“We have shown that CLAB rates can be reduced. It can be done,” said Catherine Hocking RN, Counties Manukau DHB Quality Coordinator.

Counties Manukau DHB’s success forms a template for the other Northern DHBs under the First, Do No Harm patient safety campaign, which aims to reduce CLAB rates across the region by 40 per cent.

The DHB, via its Ko Awatea Centre for Health Services Innovation, has also entered into a partnership with the Health Quality and Safety Commission to develop a national CLAB reduction programme, starting with ICUs.

The imperative to reduce CLAB rates is driven primarily by the shared regional desire to reduce preventable harm to patients.

But a study by researchers at Auckland City Hospital in the mid-2000s also confirmed the high cost of these events to the health system. It concluded that each case of healthcare-associated bloodstream infection added $20,000 to the cost of care and an extra 9.7 days to average length of stay.

The improvement experience at Middlemore Hospital saw the CCC CLAB rate fall from 6.7 cases per 1000 line days to as low as 0.9 cases per 1000 line days.

“We tried to take a systems approach so it was easier to follow than not. People were skeptical but were willing to give it a go.

“There was a feeling that ‘other places have CLABs, too’ and that they are inevitable to some degree when you are dealing with burns patients, as we do.

“We also had variations in practice … not everyone wore a hat or used a full-body sterile drape. It was down to clinician choice but we standardised this.

“We went two months without a CLAB, then had one in March ‘09 and then four months without one again. There was clear proof the approach we were taking was having an impact.”

The start-up was not without its challenges. The roll-out began with an ‘insertion bundle checklist’ for staff and a trolley equipped with all the sterile supplies they would need when performing a line insertion.

This proved fallible, however, as compliance issues resulted when items ran out and weren’t always replaced. Variability of practice was also an issue.

The DHB worked around this by developing its own CLAB insertion pack for staff in partnership with one of its major medical suppliers.

This user-friendly, self-contained kit comes wrapped in plastic, with equipment positioned in the sequential order required by staff to minimise the risk of infection during insertion.

Finally, a ‘maintenance bundle’ and checklist was developed to further reduce the risk of infection in patients with central lines. It challenges whether the line is still needed and sets clear daily line care requirements.

Soon after the introduction of the maintenance bundle, Middlemore CCC went 194 days without a CLAB case as compliance peaked.

The only blip on the graph came last year when a ‘cluster’ of cases occurred that were unusual in terms of recent performance. On review, it was found that the blip was attributable to a drop-off in compliance with the insertion and maintenance bundles.

“It really showed us that there is a need for vigilance and sticking to the system.”