What is the impact of a CLAB?
A CLAB is a serious infection. It makes vulnerable patients sicker, prolonging their length of hospital stay by five to seven days, and is associated with an increase in mortality of between 10 to 50%. Each CLAB is estimated to cost at least $20,000.
CLABs are largely preventable by using standardised, evidence-based processes of care (‘bundles of care’) when inserting and maintaining central lines.
Target CLAB Zero: a national collaborative
In October 2011 we joined a national collaborative programme called Target CLAB Zero. Led by Counties Manukau DHB in partnership with the Health Quality and Safety Commission, Target CLAB Zero has enabled all DHBs to work together and put in place a standardised CLAB measurement system.
Participation in the programme requires the bundles of care to be used in a hospital’s intensive care unit (ICU) and one other area.
The aim of Target CLAB Zero is to reduce the rate of CLAB towards zero (<1 CLAB per 1000 line days) by April 2013.
What are we trying to achieve?
Reduce the rate of CLAB in Waitemata District Health Board towards zero (<1 CLAB per 1000 line days). We will do this by using standardised processes (bundles of care) when inserting and maintaining central lines in our ICU.
The Insertion Bundle of Care
When inserting a central line the inserting clinician must:
- perform Hand Hygiene
- prepare the site of insertion using chlorhexidine and alcohol
- use maximum barrier precautions (hat, mask, gown and gloves for the inserter, and full body drape for the patient)
- maintain a sterile technique
An assistant uses an Insertion Checklist to check with the inserting line clinician that each parts of the bundle are completed.
The Maintenance Bundle of Care
- Daily review and prompt removal of unnecessary lines.
- Cleaning the injection ports (entry points) on central lines with clorhexidine and alcohol.
- Using a dedicated port for intravenous nutrition.
A Maintenance Checklist is completed by nursing staff each shift.
CLAB Insertion checklist
CLAB Maintenance Checklist
Compliance is measured and tracked by auditing the completed insertion and maintenance bundle checklists weekly.
What have we done?
A dedicated central line insertion pack
Our ICU team together with our Infection, Prevention and Control team have worked hard to implement the Target CLAB Zero programme in our ICU. Some of the keys to their success are:
- using a dedicated central line insertion pack and trolley
- establishing a robust measurement approach
- having a dedicated staff nurse responsible for data collection
- providing rapid feedback to staff through weekly audits
- making results visible with "CLAB FREE Days" and compliance graphs displayed on a quality board
- getting the support of the organisation from the "board to the ward"
How do we track our progress?
We use four measures to track how well we are doing:
- Percentage compliance with the insertion bundle
- Percentage compliance with the maintenance bundle
- Rate of CLAB per 1,000 line days
- Days since the last CLAB (CLAB free days)
- All parts of the insertion and maintenance bundles need to be completed to achieve compliance
- Line days are calculated using the number of patients in an ICU with a central line and the number of days the lines were in place (number of central lines x number of days). This allows adjustment for larger ICUs that have more patients and, therefore, a greater number of central lines, so that rates of CLAB can be compared between ICUs. The rate of CLAB per 1,000 line days = total number of CLAB x 1000 ÷ number of line days
How are we doing?
Compliance with the insertion and maintenance bundles has ranged between 75-100%. The national target (Quality and Safety Marker) is ‘use of the insertion and maintenance bundle >90% of the time’. We have achieved better than the target for each quarter from April 2012 – March 2013:
- Quarter 1: 95%
- Quarter 2: 95%
- Quarter 3: 95%
- Quarter 4: 91%
Our CLAB rate is tracking to zero. We have reduced the incidence of CLAB from 1.25 CLAB per 1,000 line days in January 2012 to 0.83 in June 2013.
Promoting CLAB FREE days on our ICU
National CLAB rates
Nationally, the rate of CLAB has decreased from 3.32 CLAB to under 1.0 CLAB per 1,000 line days between April 2012 and March 2013. If the baseline rate of 3.232 had not changed, 100 CLABs would be expected. In fact, there were 15. At a cost of $20,000 per CLAB, this represents avoided cost of nearly $2 million.
Where to from here?
We are spreading the success of Target CLAB Zero from our ICU to other hospital areas where central lines are used.
- We launched the insertion bundle in our renal department in December 2011.
- We launched the insertion bundle with our anaesthetic team in the operating theatres in May 2012.
- We began rolling out the maintenance checklist in our wards in July 2012 .