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Hospital Acquired Catheter-Related Hospital Acquired Catheter-Related Bloodstream InfectionsBloodstream Infections
(CR-BSI)(CR-BSI)
MED INF 406 - Decision Support Systems and Health Care
BackgroundBackground
More than 5 million Central vascular catheters used annually in US.
250,000 cases of CVC-associated BSIs occur annually in the US
ICU related CVC-associated BSIs occuring annually in the US: 80,000
Attributable mortality for these BSIs : upto 28,000 deaths
Attributable average cost per infection : $ 56000
Financial Impact!
Annual cost of CVC-associated BSIs – upto $2.3 billion• http://www.firstdonoharm.com/HAC/CRBSI/
DefinitionDefinition
Bacteremia / fungemia in a patient with an intravascular catheter with:
at least one positive blood culture obtained from a peripheral vein
clinical manifestations of infection (i.e., fever, chills, and/or hypotension)
and no apparent source for the bloodstream infection except the catheter.
Bloodstream infections are considered to be associated with a
central line if the line was in use during the 48-hour period before the development of the bloodstream infection.
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Measures/CatheterRelatedBloodstreamInfectionRate.htm
Impact!Impact! Common in healthcare, especially in ICU Morbidity (risk for local and systemic infectious complications) LOS Mortality Cost - in term of morbidity and financial resources
As of Oct, 2008
CMS New Rule – No Pay for Never Events
Cannot Bill Patient for HAIs
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm
Why Address it ?Why Address it ?
EtiologyEtiology
Sources of InfectionSources of Infection
Skin organisms
Environmental contamination
Post-placement subcutaneous tract infection
Intraluminal contamination
Hematogenous seeding
Risk FactorsRisk Factors
The incidence of CRBSI varies considerably by:
type of catheter frequency of catheter manipulation patient-related factors
underlying disease
acuity of illness
.By
Type of Vessel it occupies
-peripheral venous-central venous-arterial
By Catheter
pathway from skin to vessel -tunneled -nontunneled
By the site of insertion •femoral•subclavian•internal jugular•peripheral•peripherally inserted central catheter [PICC
By the intended life span of Catheter
- temp or short-term
-permanent or long-term
or by some special characteristic of the catheter, e.g.:- presence or absence of a cuff- impregnation with heparin• antibiotics or antiseptics• and the number of lumens
By Catheter
Physical Length
- long -short
CLASSIFYING THE
CATHETERS
Peripheral venous catheters• most frequently used devices for vascular access • Low incidence of associated infections
BUT
Higher frequency of such catheters used
SO It adds up! Serious infectious complications produce considerable annual morbidity
Central venous catheters (CVCs)• majority of serious catheter-related infections associated
with CVCs - especially those that are placed in patients in ICUs
Risk FactorsRisk Factors1. Type of Catheter
Risk Factors Risk Factors 2. Setting / frequency of catheter manipulationRisk Factors Risk Factors 2. Setting / frequency of catheter manipulation
• In the ICU setting, the incidence of infection is often higher:• central venous access needed for extended periods of time• Patient colonization with hospital-acquired organisms• Catheter can be manipulated multiple times per day
contamination clinical infection• Catheter insertion in urgent situations with sub-optimal aseptic
precautions
Risk Factors Risk Factors 3. Patient Related Factors
• Diabetic or high blood glucose levels• Immuno-compromised• Cancer patients• Age - elderly
- pediatric population
To improve patient outcome
reduce health-care costs
strategies should be implemented to reduce the incidence of these
infections
The Keystone ICU Project The Keystone ICU Project #:Evidence-based recommendations from CDC for
preventing CR-BSI• A care bundle of best practices in terms of CRBSIs that
individually improve care, but when applied together result in substantially greater improvement. The science supporting the bundle components is sufficiently established to be considered standard of care.
•
(1) Hand Hygiene
(2) Full Barrier Precautions during insertion of CVC
(3) Cleaning the skin with 2% Chlorhexidine
(4) Appropriate site and line selection
(5) Remove Unnecessary Catheters
# Pronovost P, Needham D, Berenholtz S et al. An Intervention to Decrease Catheter Related Bloodstream Infections in the ICU. N Engl J Med 2006;355:2725-32.
Decision Tree: Decision Tree: Appropriate Site and Line Appropriate Site and Line
Selection Selection
Does patient have peripheral access? YesNo
Patient will need one of the following:Vesicant medicationVasopressorTPNFuild bolus
Patient needs hemodynamic monitoringYesNo
Anticipate IV therapy greater than 5 daysYesNo
Workflow engine Alert to clinicianWorkflow engine Alert to clinician
Central line AlertPatient does not meet criteria:
No peripheral accessIV vesicantHemodynamic monitoringIV therapy greater than 5 days
Decrease the risk of a hospital acquired central line infection by PLACING A PERIPHERAL LINE
Populates database with patient names
who had the alert associated with
them
Daily Documentation To Justify Daily Documentation To Justify Keeping A Central LineKeeping A Central Line
High volume IVFHi volume bloodMultiple dripsTPNLimited accessLong term accessHemodynamic monitoringVasopressor/vesicant meds
Populates database to track reasons for keeping central lines etc.
Workflow engine Alert to clinicianWorkflow engine Alert to clinician
Central line Dwelling Time AlertDwelling time of central line catheter is greater than 5 days
Decrease the risk of a hospital acquired central line infection
consider discontinuation of Central line
Populates database with patient names
who had the alert associated with
them
Outcome and Process MeasuresOutcome and Process Measures
• Outcome measures– CRBSI/1000 central line days– Average length of central catheter dwelling
time
• Process measures– Justification of central line– # of alerts rendered and response to them
Average Central Line DaysAverage Central Line Days
.
CDSS Design CDSS Design
Guided by the AMIA Roadmap for National Action on CDS vision:
“optimal, usable and effective clinical decision support is widely available to providers, patients, and individuals where and when they need it to make health care decisions.”
AMIA RoadMap PillarsAMIA RoadMap Pillars
1. Best Knowledge Available when Needed
2. High Adoption and Effective Use
3. Continuous Improvement of Knowledge and CDS Methods
CDSS FrameworkCDSS Framework
Service-oriented Architecture (SOA):• An SOA infrastructure allows different
applications to exchange data with one another as they participate in business processes.
• Core business capabilities are encapsulated within independent software services, and these services are leveraged by various front-end applications to fulfill business requirements.
CDSS ArchitectureCDSS Architecture
DemographicsAllergiesClinical
DocumentationPhysician
DocumentationOrders
Laboratory ResultsRadiology Reports
Clinical Information System (CIS)
Data Repository
CIS Action Broker
HL7 message
Web Service`
ClinicianReference Database(s)
KeystoneKnowledge Module
SOAP
XML
XML
XML
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90
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Surveillance Reports -Performance Measures
How did we do ?How did we do ?
• Design – Provides a good foundation to build additional
CDSS– Reusable, separates knowledge from code– Based on standards
• Information availability– Data repository provides robust reporting
capabilities – Ability to monitor clinician responses to alert
against patient outcomes
What are the Limitations?What are the Limitations?
• Design requires technical resources
• Clinician workflow is critical– Be reasonablereasonable in expectation of CDSS use
SummarySummary
• Information is powerful!Information is powerful! Use it to influence clinician practice to positively impact patient outcomes
• Performance measures should be monitored to reflect effectiveness
• CDSS Design must be re-usablere-usable and based on standards
• Must lay foundation for additional CDSS
Resources Resources 1. CDC Guidelines
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm
2. Clinical study - An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU http://content.nejm.org/cgi/reprint/355/26/2725.pdf
3. Clinical study -Prevention of Intravascular Catheter–Related Infections. Leonard A. Mermel, DO, ScM, AM(Hon)
http://www.annals.org/cgi/reprint/132/5/391.pdf
4. http://www.journals.uchicago.edu/doi/pdf/10.1086/377265?cookieSet=1
5. A Roadmap for National Action on Clinical Decision Support. Osheroff, MD, Teich, MD, PhD, Middleton, MD, Steen, MA, Wright, Detmer, MD, MA
6. Proposal for Fulfilling Strategic Objectives of the U.S Roadmap for National Action on Decision Support through a Service-oriented Architecture Leveraging HL7 Services – Kawamota, PhD, Lobach, MD, PhD, MS
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