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MOH Information Paper: 2012/2
CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION (CLABSI) IN
INTENSIVE CARE UNITS
By Goh Helen1
ABSTRACT
This paper compares the Central Line-Associated Bloodstream Infection (CLABSI)
rates in the various intensive care units (ICUs) of public acute-care hospitals with
international benchmarks during 2004-2010.
INTRODUCTION
Critically ill patients require a wide range of therapeutic and diagnostic services to
meet their needs. As a result, devices such as central lines, ventilators and
indwelling urinary catheters are frequently used in critical care settings. Although
meant to be life-saving, these devices also expose the patient to an increased risk of
device-associated infections.
This paper presents the progress made thus far by our local public hospitals in
improving our CLABSI rates as compared with the published rates of the US
National Healthcare Safety Network (NHSN). The NHSN is a benchmarking
database based on the cumulative incidence of nosocomial infections among
participating US hospitals reported since 2005. The NHSN is under the auspices of
the US Centers for Disease Control and Prevention (CDC).
Definitions:
Bloodstream infections may occur in patients from various sources. A bloodstream
infection that develops in a patient as a result of the insertion of a central line is
termed a CLABSI.
The rate of CLABSIs in our public sector ICUs is obtained and calculated using the
standardized data definition and collection methodology of the NHSN.
Central Line-Associated BSI Rate:
1
Number of CLABSI X 1000
Number of central line-days
Goh Helen, Manager (Patient Safety), Standards & Quality Improvement Division
To improve comparability of our results with NHSN results, we have stratified the
comparison by type of ICUs, i.e. Coronary Care Unit (CCU), Medical ICU (MICU),
and Surgical ICU (SICU).
OUTCOMES
The incidence rates of CLABSIs for the local public hospitals for the years 20042010 were compared against the NHSN pooled mean rate reported for the following
ICUs: (1) CCU, (2) MICU, and (3) SICU.
1. Coronary Care Unit
During the SARS crisis period, some of our public hospitals were unable to submit
reports to MOH. When data submission resumed following SARs, the initial low
denominator in 2004 resulted in a relatively high rate of 2.0 per thousand patients.
This figure was, nevertheless, lower than the US NNIS figure (The NNIS was the
predecessor of the NHSN benchmarking database).
Since 2005 the CLABSI rates reported by the reporting hospitals’ CCUs have been
consistently lower than the pooled mean rates of the NHSN. Although the NHSN
rates showed a decrease over the years, our CLABSI rates have remained at less
than 1.0 per thousand central line days (Chart 1).
Chart 1 Central Line-Associated BSIs per 1000 central line-days in CCU (Years 2004
– 2010)
4
3.5
3.5
NHSN
succeeded
NNIS in
2005
Per Thousand Central-line Days
3.5
2.80
3
2.80
2.5
2.10
2
2.00
2
1.70
1.5
0.76
1
0.78
0.68
0.53
0.5
0
0
2008
2009
0
2004
2005
Singapore (Public Hosp-CCU)
2006
2007
NNIS Pooled Mean
NHSN Pooled Mean
2010
2. Medical Intensive Care Unit
The CLABSI rates for MICUs have also been consistently lower than the pooled
mean rates of the NHSN. The spike in 2006 was attributed to the small denominator
reported by hospitals for that year. And following the increase in incidence in 2009,
a quality improvement project was conducted, which resulted in improvement to 0.58
in 2010 (Chart 2).
Chart 2 Central Line-Associated BSIs per 1000 central line-days in MICU (Years
2004 – 2010)
4
3.5
3.5
Per Thousand Central-line Days
3.5
NHSN
succeeded
NNIS in
2005
2.9
3
2.90
2.60
2.40
2.5
2.20
1.89
1.79
2
1.5
0.97
0.95
1
0.71
0.67
2007
2008
0.58
0.5
0
2004
2005
2006
Singapore (Public Hosp -MICU)
NNIS Pooled Mean
2009
2010
NHSN Pooled Mean
3. Surgical Intensive Care Unit
The CLABSI rate per 1000 central line-days of in Singapore public hospitals’ SICUs
has decreased from the baseline of 1.79 in 2004 to 0.40 in 2010. This follows the
trend shown by the US hospitals reporting from 4.6 to 1.80 per thousand central line
days. As in the other ICUs, Singapore’s rates are lower than those of the NHSN.
Chart 4 Central Line- Associated BSIs per 1000 central line-days in SICU (Years
2004 – 2010)
5
4.6
4.6
NHSN
succeeded
NNIS in
2005
Per Thousand Central-line Days
4.5
4
3.5
3
2.70
2.70
2.30
2.5
2
2.30
1.80
1.79
1.25
1.5
0.92
1
0.73
0.79
0.5
0.34
0.40
2009
2010
0
2004
2005
Singapore (Public Hosp -SICU)
2006
2007
2008
NNIS Pooled Mean
NHSN Pooled Mean
CONCLUSION
The stringent infection control measures instituted in local public hospitals have led
to a marked reduction of the CLABSI rates in critical care settings. Through a
programme of surveillance, benchmarking and quality improvement, application of
CLABSI bundle2 instituted at the public hospitals in Singapore, the CLABSI rates in
the ICUs have been brought down to levels that are comparable with those achieved
by US hospitals enrolled in the NHSN.
Feedback to MOH
If you have any comments or questions on the information paper, you can email us directly at
[email protected]. Alternatively, you can also fax or write to us at:
Ministry of Health
College of Medicine Building
16 College Road
Singapore 169854
Tel: 63259220
Fax: 62241677
2
The Central Line Bundle consists of a set of concurrent measures that has been shown elsewhere to be
effective in controlling infection rates (a) hand hygiene, (b) maximal barrier precautions, (c) Chlorhexidine skin
antisepsis, (d) optimal catheter site selection, with the subclavian vein as the preferred site for non-tunneled
catheters, and (e) daily review of line necessity, with prompt removal of unnecessary lines.