A new frontier: Central line-associated bloodstream infection surveillance in home infusion therapy

Implementing and validating a home-infusion central-line-associated bloodstream infection surveillance definition

OBJECTIVE

Central-line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy is necessary to track efforts to reduce infections, but a standardized, validated, and feasible definition is lacking. We tested the validity of a home-infusion CLABSI surveillance definition and the feasibility and acceptability of its implementation.

DESIGN

Mixed-methods study including validation of CLABSI cases and semistructured interviews with staff applying these approaches.

SETTING

This study was conducted in 5 large home-infusion agencies in a CLABSI prevention collaborative across 14 states and the District of Columbia.

PARTICIPANTS

Staff performing home-infusion CLABSI surveillance.

METHODS

From May 2021 to May 2022, agencies implemented a home-infusion CLABSI surveillance definition, using 3 approaches to secondary bloodstream infections (BSIs): National Healthcare Safety Program (NHSN) criteria, modified NHSN criteria (only applying the 4 most common NHSN-defined secondary BSIs), and all home-infusion-onset bacteremia (HiOB). Data on all positive blood cultures were sent to an infection preventionist for validation. Surveillance staff underwent semistructured interviews focused on their perceptions of the definition 1 and 3-4 months after implementation.

RESULTS

Interrater reliability scores overall ranged from κ = 0.65 for the modified NHSN criteria to κ = 0.68 for the NHSN criteria to κ = 0.72 for the HiOB criteria. For the NHSN criteria, the agency-determined rate was 0.21 per 1,000 central-line (CL) days, and the validator-determined rate was 0.20 per 1,000 CL days. Overall, implementing a standardized definition was thought to be a positive change that would be generalizable and feasible though time-consuming and labor intensive.

CONCLUSIONS

The home-infusion CLABSI surveillance definition was valid and feasible to implement.

The need to expand the infection prevention workforce in home infusion therapy

Infection prevention and surveillance training approaches for home infusion therapy have not been well defined. We interviewed home infusion staff who perform surveillance activities about barriers to and facilitators for central line-associated bloodstream infection (CLABSI) surveillance and identified barriers to training in CLABSI surveillance. Our findings show a lack of formal surveillance training for staff. This gap can be addressed by adapting existing training resources to the home infusion setting.

Surveillance and attribution of ambulatory central line-associated bloodstream infections in a pediatric healthcare system

BACKGROUND

Central line-associated bloodstream infections (CLABSI) in ambulatory pediatric populations are difficult to track at an institutional level, especially for complex patients seen by multiple divisions and home health infusion agencies.

METHODS

A multidisciplinary team comprised of key stakeholders from divisions with the most patients discharged with a central line utilized Lean Six Sigma methodology of Define-Measure-Analyze-Design-Verify (DMADV) to create a standardized data collection process for all ambulatory CLABSIs and infection event reviews.

RESULTS

A surveillance workflow was created to track, identify, and confirm ambulatory CLABSIs in all patients with an indwelling central line. Defined surveillance criteria included scope of patients eligible for ambulatory CLABSI surveillance, numerator definitions, and denominator calculations. Additionally, a novel attribution method was created for ambulatory CLABSIs in complex patient populations shared among multiple divisions and home care infusion services.

CONCLUSIONS

This report is a novel institutional approach to accurately surveil, attribute, and calculate ambulatory CLABSI data in a pediatric healthcare system.

Recommendations for change in infection prevention programs and practice

Fifty years of evolution in infection prevention and control programs have involved significant accomplishments related to clinical practices, methodologies, and technology. However, regulatory mandates, and resource and research limitations, coupled with emerging infection threats such as the COVID-19 pandemic, present considerable challenges for infection preventionists. This article provides guidance and recommendations in 14 key areas. These interventions should be considered for implementation by United States health care facilities in the near future.

A task analysis of central line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy

BACKGROUND

Barriers for home infusion therapy central line associated bloodstream infection (CLABSI) surveillance have not been elucidated and are needed to identify how to support home infusion CLABSI surveillance. We aimed to (1) perform a goal-directed task analysis of home infusion CLABSI surveillance, and (2) describe barriers to, facilitators for, and suggested strategies for successful home infusion CLABSI surveillance.

METHODS

We conducted semi-structured interviews with team members involved in CLABSI surveillance at 5 large home infusion agencies to explore work systems used by members of the agency for home infusion CLABSI surveillance. We analyzed the transcribed interviews qualitatively for themes.

RESULTS

Twenty-one interviews revealed 8 steps for performing CLABSI surveillance in home infusion therapy. Major barriers identified included the need for training of the surveillance staff, lack of a standardized definition, inadequate information technology support, struggles communicating with hospitals, inadequate time, and insufficient clinician engagement and leadership support.

DISCUSSION

Staff performing home infusion CLABSI surveillance need health system resources, particularly leadership and front-line engagement, access to data, information technology support, training, dedicated time, and reports to perform tasks.

CONCLUSIONS

Building home infusion CLABSI surveillance programs will require support from home infusion leadership.

Exploring infection prevention practices in home-based nursing care: A qualitative observational study

BACKGROUND

Home-based nursing care continues to expand, delivering care to increasingly older clients with multiple, chronic and complex conditions that require the use of additional and more numerous invasive medical devices. Therefore, the prevention of infections poses a challenge for nurses, professional caregivers and clients.

OBJECTIVE

This article explores infection prevention practices and related behavioural factors in both nurses and clients to identify barriers and facilitators of infection prevention practices in home-based nursing care.

DESIGN

A qualitative, exploratory design.

SETTING

Four healthcare organisations providing home-based nursing care in the Netherlands.

METHODS

Participant observations were used as the main source of data collection complemented with focus group discussions and semi-structured interviews.

PARTICIPANTS

Participant observations: 16 nurses, three professional caregivers and 80 clients. Semi-structured interviews: 11 clients. Focus group discussions: 15 nurses and four professional caregivers.

RESULTS

A total of 87 unique care delivery situations were observed for 55 h, complemented with three focus group discussions and 11 individual semi-structured client interviews. Infection prevention practices in home-based nursing care appeared to be challenged by 1. The specific context or environment in which the care occurred, which is more autonomous, less structured, less controlled and less predictable than other care settings; 2. Suboptimal and considerable variation in professional performance concerning the application of hand hygiene and the proper use of personal protective equipment such as face masks, barrier gowns and disposable gloves; 3. Extensive use in and outside the client's surroundings of communication devices that are irregularly cleaned and tend to interrupt nursing procedures; and 4. Inadequate organisational support in the implementation and evaluation of new information or policy changes and fragmentation, variation and conflicting information regarding professional guidelines and protocols.

CONCLUSIONS

From a first-hand observational viewpoint, this study showed that the daily practice of infection prevention in home-based nursing care appears to be suboptimal. Furthermore, this research revealed considerable variation in the work environment, the application of hand hygiene, the proper use of personal protective equipment, the handling of communication devices and organisational policies, procedures and support. Finally, the study identified a number of important barriers and facilitators of infection prevention practices in the work environment, professional and team performance, clients and organisations.

Vascular Access Device Care and Management: A Comprehensive Organizational Approach

The Infusion Nurses Society asserts that a comprehensive organizational approach to vascular access device (VAD) care and management is imperative to ensure safe and efficacious patient care. It is essential that each organization (1) develops policies and procedures to align VAD care and management with recognized standards of practice; (2) integrates unique aspects of organization-selected VAD care products into policies and procedures and establishes expectations for adherence to these organizational directives; (3) develops a framework for gathering and analyzing clinical data related to patient outcomes for VAD care and management; (4) utilizes quality outcome data to facilitate evidence-based best practices within the organization; and (5) evaluates and facilitates educational programming to validate clinician competency.

Is a 20 gauge fenestrated intravenous catheter non-inferior to a 18 gauge standard catheter for apheresis procedures? A pilot study

BACKGROUND

Peripheral venous access has been promoted as the safest, quickest, and most easily achievable route for performing apheresis procedures by the American Society for Apheresis' Choosing Wisely campaign. The current literature regarding catheter size and selection for both draw and return access is limited. Furthermore, the Infusion Nurses Society recommends using the smallest gauge catheter possible for the prescribed therapy in order to limit vein trauma and phlebitis. Since there is a lack of evidence to guide selection of catheter size for return access during therapeutic apheresis procedures (TAPs) for patients with chronic conditions, this pilot study seeks to compare the performance of a 20-gauge fenestrated (20G) catheter to a standard 18-gauge (18G) intravenous catheter.

METHODS

This non-inferiority pilot study randomized 26 subjects during 74 TAPs to either 20G fenestrated catheter or 18G standard catheter.

RESULTS

There were no statistically significant differences for variables associated with the efficiency of the TAPs comparing 20G to 18G catheter for inlet rate (P = .8666), return pressure (P = .9427), blood processed (P = .4318), or total procedure time (P = .3184).

CONCLUSION

The results from this pilot study suggest that 20G fenestrated catheter is non-inferior to 18G standard catheters. Additional studies with increased power are warranted to confirm these findings.

Reaching consensus on a home infusion central line-associated bloodstream infection surveillance definition via a modified Delphi approach

BACKGROUND

A consensus on a central line-associated bloodstream infection (CLABSI) surveillance definition in home infusion is needed to standardize measurement and benchmark CLABSI to provide data to drive improvement initiatives METHODS: Experts across fields including home infusion therapy, infectious diseases, and healthcare epidemiology convened to perform a 3-step modified Delphi approach to obtain input and achieve consensus on a candidate home infusion CLABSI definition.

RESULTS

The numerator criterion was identified by participants as involving one of the 2 following: (1) recognized pathogen isolated from blood culture and pathogen is not related to infection at another site, or (2) one of the following signs or symptoms: fever of 38°C (100.4°F), chills, or hypotension (systolic blood pressure ≤90 mm Hg), and one of the 2 following: (A) common skin contaminant isolated from 2 blood cultures drawn on separate occasions and organism is not related to infection at another site, or (B) common skin contaminant isolated from blood culture from patient with intravascular access device and provider institutes appropriate antimicrobial therapy. The criteria for a denominator included days from the day of admission with a central venous catheter to day of removal of central venous catheter. In addition, 11 inclusion criteria and 4 exclusion criteria were included.

DISCUSSION

Home infusion therapy and healthcare epidemiology experts developed candidate criteria for a home infusion CLABSI surveillance definition.

CONCLUSIONS

Home care and home infusion agencies can use this definition to monitor their own CLABSI rates and implement preventative strategies.

Surveillance of home health central venous catheter care outcomes: Challenges and future directions

BACKGROUND

Limited data are available regarding central venous catheter (CVC)-related complications that occur in home care. A practical out-of-hospital surveillance mechanism is needed.

METHODS

Home health/infusion agencies in 4 states submitted monthly data from January 2011 through March 2015. Data were collected by patient age and included number of patients on service with a CVC, device days, central line-associated bloodstream infection (CLABSI), CVC-occlusions, doses of fibrinolytics administered, and number of patients receiving fibrinolytics.

RESULTS

Ten agencies from 4 states contributed data across the study period. A total of 913 occlusions and 73 CLABSIs occurred during the 51-month surveillance period. The CLABSI rates per 1,000 device days per year across the study surveillance period ranged from 0-0.40 for pediatric and from 0-0.37 for adult patients, whereas occlusion rates per 1,000 device days ranged from 0.26-1.59 for pediatric and from 2.59-33.29 for adult patients. Doses of fibrinolytic agents administered per 1,000 device days ranged from 0.26-1.80 in pediatric and 3.53-33.85 in adult patients.

CONCLUSIONS

Opportunities exist to further expand efforts to quantify the presence of CVCs in home settings to enable improvements with measuring and tracking patient outcomes as they relate to CVC care. Exploration of continued sustainability of surveillance and data validation are warranted to optimize home health/infusion care practices and outcomes.

Compliance with evidence-based guidelines for the prevention of central line-associated bloodstream infections in a Belgian home care setting: An observational study

This study assessed the compliance of Belgian home care nurses with good practice recommendations to prevent central line-associated bloodstream infections. The compliance to 3 care bundles was 0% (0 out of 7), 13.3% (2 out of 15), and 22.2% (2 out of 9), respectively. This finding is important given the increasing number of home care patients with an intravascular catheter and underscores the need for quality improvement strategies to prevent central line-associated bloodstream infections in home care.