Central line-associated bloodstream infections DQ

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Central line-associated bloodstream infections DQ

Central line-associated bloodstream infections DQ

Introduction

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Central line-associated bloodstream infections (CLABSI) are the third most frequent cause of healthcare-associated infec- tion (HAI; The Joint Commission, 2012). Mortality rates from CLABSI are 12% to 25% and significantly increase cost and hospital length of stay (Centers for Disease Control and Prevention [CDC], 2011). Nurses are on the frontline of CLABSI prevention, contributing to the 58% decrease in CLABSI rates that has occurred between 2001 and 2009 (CDC, 2016). Despite their involvement in the process, they may not understand the implications that mandatory public reporting or current pay-for-performance programs may have on their hospital system. Statistics are readily available online for consumers to review how local hospitals compare with one another in terms of HAI rates and other critical factors that determine hospital quality. Favorable performance in these metrics attracts patients, influences accreditation boards, and may lead to salary bonuses. Mandatory public reporting of CLABSI and other HAI began in 2003 and has increased incrementally over time in terms of participation and what is required to be reported—37 states currently require reporting, while the rest are incentivized to do so (Herzig, Reagan, Pogorzelska-Maziarz, Srinath, & Stone, 2015; Stone et al., 2015). Hospitals are now facing extrinsic pressures to keep their CLABSI rates low; otherwise, they may experience a 1% reduction in Medicare reimbursement.

Pressure on hospital systems may enhance CLABSI safety and prevention efforts. Attempts at improving healthcare out- comes and cost are deeply interrelated, and this review of lit- erature aims to summarize current knowledge regarding how extrinsic factors have affected rates of CLABSI.

Current State of CLABSI Prevention

Best evidence-based practice is a driver to intrinsically changing individual nurse behavior and individual hospital standards extrinsically influence nursing practice to achieve lower CLABSI rates. One of the most researched aspects of CLABSIs is testing various prevention methods. Study of best practices is important to review because the purpose of mandatory reporting, pay-for-performance, and the Affordable Care Act (ACA) are all designed at incentivizing hospitals toward implementing best practices and punishing those who fail to do so. CLABSI-prevention research has been pivotal in the gradual decline of CLABSIs and develop- ment of best practices implemented over the past decade,

677747 SGOXXX10.1177/2158244016677747SAGE OpenWoodward and Umberger research-article2016

1The University of Tennessee, Knoxville, USA

Corresponding Author: Benjamin Woodward, College of Nursing, The University of Tennessee, Knoxville, 1200 Volunteer Blvd., Knoxville, TN 37996, USA. Email: bwoodwa4@vols.utk.edu

Review of Best Practices for CLABSI Prevention and the Impact of Recent Legislation on CLABSI Reporting Central line-associated bloodstream infections DQ

Benjamin Woodward1 and Reba Umberger1

Abstract Central line-associated bloodstream infections (CLABSI) are a very common source of healthcare-associated infection (HAI). Incidence of CLABSI has been significantly reduced through the efforts of nurses, healthcare providers, and infection preventionists. Extrinsic factors such as recently enacted legislation and mandatory reporting have not been closely examined in relation to changes in rates of HAI. The following review will examine evidence-based practices related to CLABSI and how they are reported, as well as how the Affordable Care Act, mandatory reporting, and pay-for-performance programs have affected these best practices related to CLABSI prevention. There is a disconnect in the methods and guidelines for reporting CLABSI between these programs, specifically among local monitoring agencies and the various federal oversight organizations. Future research will focus on addressing the gap in what defines a CLABSI and whether or not these programs to incentivize hospital to reduce CLABSI rates are effective.

Keywords CLABSI, ACA, pay-for-performance, prevention, legislation, reporting

mailto:bwoodwa4@vols.utk.edu
http://crossmark.crossref.org/dialog/?doi=10.1177%2F2158244016677747&domain=pdf&date_stamp=2016-11-01
2 SAGE Open

including studies focusing strictly on strict hand hygiene (Johnson et al., 2014), CLABSI-prevention bundles includ- ing interventions to increase hand hygiene compliance (Berenholtz et al., 2014; Guerin, Wagner, Rains, & Bessesen, 2010; Theodoro et al., 2015), antimicrobial catheters (Rutkoff, 2014), and chlorhexidine baths (Dixon & Carver, 2010; Scheithauer et al., 2014). Hospital culture is an extrin- sic motivator that plays a large role in the effectiveness of adopting these best practices (Fan et al., 2016). Intrinsic motivation, the degree to which individual healthcare pro- viders drive toward and implement best practices, is difficult to cultivate but can be aided by champions of a particular healthcare improvement process who have stronger profes- sional relationships with bedside nurses and physicians (Damschroder et al., 2009). If healthcare providers are unwilling to alter their practice, little change is likely to occur, and those attempting to improve hospital CLABSI rates should consider these intrinsic and extrinsic factors as equally important to establishing hospital protocols in line with best practice guidelines.

Although the reduction in CLABSI rates is an excellent trend, recent research indicates that rates can still be signifi- cantly reduced across the United States by applying a simple bundled approach. The bundle includes efforts to ensure best practices are being implemented, to improve safety culture and teamwork, and to provide feedback to leaders in quality improvement (Berenholtz et al., 2014; Guerin et al., 2010). There has been a vast amount of research devoted to discov- ering best practices related to CLABSI prevention, but this review will focus on the less-studied extrinsic factors related to CLABSI prevention.

Regulatory Bodies and Their Roles in Mandatory Reporting

The following three sections will cover the current process of reporting CLABSIs. This information is important for nurses to understand because it will help them to understand why CLABSI has become such a large focus in hospitals. There are several regulatory bodies that determine whether a CLABSI is present, how they are coded for medical billing, and methods of reporting CLABSI to state and federal data- bases. The CDC and the National Healthcare Safety Network (NHSN) have guidelines for laboratory-confirmed blood- stream infection (LCBI), which determines whether or not a bloodstream infection is the result of a central line. Once a CLABSI has been identified, the CMS utilize the International Classification of Diseases (ICD) selected by providers to code the CLABSI for billing. The majority of states also require hospitals to report their CLABSIs to the NHSN through providers coding with ICD and/or infection preven- tionists following LCBI guidelines. In states where this is not mandated, healthcare providers are incentivized to provide their ICD codes to payers such as CMS and private insurance companies. Each of these links in the chain of mandatory

reporting is vital to ensuring accurate CLABSI identification at the levels of the patient, hospital, state, and nation.

Identifying Patients With CLABSI

According to further CDC guidelines, LCBIs are divided into LCBI 1, LCBI 2, and LCBI 3 (LCBI 3 will not be defined or used due to its sole use in patients < 1 year of age, which is not the focus of this review). An LCBI 1 is defined as a patient with a recognized pathogen cultured from one or more blood cultures, and this cultured bacteria is not related to an infection at any other site. This confirms that the blood- stream infection is not related to another source of infection and is therefore determined to be caused by the central line. LCBI 2 requires that the patient have either fever (>38°C), chills, or hypotension, alongside positive blood lab results (cultures) that are not related to infection at another site. Finally, bacteria must be cultured from two or more blood tests drawn within a 24-hr period. LCBI 2 allows for diagno- sis of a CLABSI when blood cultures reveal a microorgan- ism that is not strictly pathogenic in nature (CDC, 2016). Recent changes occurred in 2015, with the CDC and NHSN (Patient Safety Manual, 2015) adding an extra table in their guidelines, which was “added to highlight site specific crite- ria that require blood cultures in order to meet a secondary BSI” (p. 1). Central line-associated bloodstream infections DQ

Culturing bacteria from blood samples taken from patients who are suspected to have a CLABSI is a pivotal piece in diagnosing the infection, as outlined in LCBIs 1 and 2. If there are multiple central lines in place, they should be cul- tured at the same time, and oftentimes, the suspected catheter is removed to do so. Evidence-based practice calls for all short-term catheters such as peripherally inserted catheters (not peripherally inserted central catheters [PICC]), midline catheters, and non-tunneled central venous catheters (CVCs) to be removed, while long-term catheters such as PICCs and tunneled CVCs should be removed in the event of severe sepsis, thrombophlebitis, pulmonary embolism, and instances of bloodstream infection, which do not resolve within 72 hr following appropriate antibiotic therapy (Han, Liang, & Marschall, 2010). If removal of the line for culturing is not recommended, then the possibility of infection from any other sites must be ruled out (CDC, 2016). Culturing allows providers to know exactly what type of microorganism that they are trying to treat/eradicate, which allows for directed antibiotic therapy. In practice, it is illogical and dangerous to wait for culture results, and providers usually begin immedi- ate treatment.

Catheter tips should not be routinely cultured unless there is a clinical indication that a CLABSI may be present (CDC, 2015c). Complexity can make this extremely difficult because patients may have several potential sources of infec- tion. Current recommendations are to rely on clinical judg- ment when determining whether to remove a line and culture it; use of culturing methods that preserve the integrity of the

Woodward and Umberger 3

central line is recommended to prevent unnecessary expense and time by providers and the laboratory personnel (CDC, 2015a; Raad, Hanna, & Maki, 2007).

Medical Billing for CLABSI

Currently, the ICD Version 10 coding is the most used system of reporting medical diagnoses and procedures in the United States (CMS, 2015b). This classification system replaced ICD-9 starting on October 1, 2015 (World Health Organization, 2015). In this system, a specific numerical code is assigned to an individual diagnosis or medical procedure to facilitate eas- ier reporting to surveillance system and insurance agencies. According to CMS (2015), hospitals are now required under the ACA to report their ICD findings and actions (including CLABSIs and HAIs) within this system to be eligible for full reimbursement. In short, if these codes are not reported, then Medicare or Medicaid will not pay for aspects of the bill. Hospitals with higher rates of CLABSIs will have their federal reimbursement rates cut, with the hope being that hospitals will take more measures and precautions to receive more of this money. Now that hospitals and healthcare providers are beginning to adapt and accept these measures as the norm, research is necessary to assess whether or not these goals have been met. Nursing research is beginning to fill this gap, con- cluding that increased communication between health depart- ments and agencies such as CMS is occurring, but uniform definition of HAIs is still lacking between them (Stone et al., 2015). A great deal more study is needed to evaluate the suc- cess of these incentivizing or penalizing measures including perspectives on specific mandates. Central line-associated bloodstream infections DQ

Reporting CLABSI at the National and State Levels

As dictated by The Joint Commission on Accredidation of Healthcare Organizations (JCAHO), hereinafter referred to as The Joint Commission, CLABSIs are to be reported to the NHSN. Although not all states have legislated this mandate, there are incentives to report CLABSI in all states (The Joint Commission, 2012). For states that do not mandate report- ing, there are still systems in place to transfer ICD codes to the CMS or private insurer to receive reimbursement. These systems are specific to each state that does not have manda- tory reporting guidelines (Beck & Margolin, 2007). CLABSIs that are present on admission (POA), such as from contami- nation from a long-term central line, do not need to be reported to the NHSN. A CLABSI is considered POA if it occurs within two calendar days of admission (CDC, 2016). The hospital’s infection prevention (IP) team is the primary avenue of reporting as it collects data on infection rates throughout its healthcare facility. In general, if a CLABSI is suspected, an IP expert first examines the Electronic Medical Record (EMR) for cultures and evidence to determine whether the infection originated in a site other than a central

line. IPs consult with the nurse managers, team leaders, bed- side nurses, and providers to glean pertinent information related to the patient’s condition. For example, in patients who have a history of known intravenous (IV) drug use, some CLABSI cases have been linked to IV drug abuse in the hospital (Sammons, 2015). Ultimately, IP must prove that another site is responsible for the infection, or it must be con- sidered a CLABSI and reported (CDC, 2016). The NHSN tracks HAIs in the United States.

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