Shruti K. Gohil, MD, MPH1,2, Jennifer Yim, RN, BSN, CIC1, Kathleen Quan, RN, MSN, CIC1, Maurice Espinoza, RN, MSN, CNS,CCRN5, Deborah J. Thompson RN, CIC1, Allen P. Kong, MD3, Tom Tjoa, MS, MPH2,

Bardia Bahadori2, Chris Paiji, BA4, Syma Rashid2, Suzie S. Hong2, Linda Dickey, RN, MPH, CIC1, Mohamad N. Alsharif, MD2, Alpesh N. Amin, MD, MBA, MACP, SFHM, FACC4,5, Justin Chang, BS2, Usme Khusbu, MA1, and Susan S. Huang, MD, MPH1,2

1Epidemiology & Infection Prevention Program, UC Irvine Medical Center 2Division of Infectious Diseases, UC Irvine School of Medicine, 3Department of Surgery, UC Irvine School of Medicine, 4University of California Irvine School of Medicine,5UC Irvine Medical Center

BACKGROUND

STUDY POPULATION

SUMMARY & IMPLICATIONS

STUDY DESIGN & ANALYSIS

Progression of locally inflamed/infected insertion sites accounts

for nearly 40% of central line-associated bloodstream infections

(CLABSIs).

We developed and implemented a central line insertion site

assessment (CLISA) score to standardize assessment of

insertion sites for early identification of localized infection and

prompt timely removal of high-risk lines.

Principal Aims

Evaluate prevalence and incidence of pre- and post-CLISA Score

implementation on:

1) Central line insertion site inflammation and infection

2) Incidence of CLABSIs

Adult inpatients with central lines hospitalized in an intensive

care unit or oncology ward at a large academic center

Excluded hemodialysis and port-a-catheters

Study period: April, 2014 - March, 2016

Pre- and post-intervention quality improvement study

Periodic photosurveys of line insertion sites of all eligible patients

were conducted at baseline (4/1/14-3/31/15) and post-

intervention (4/1/15-3/31/16) after hospital-wide implementation

of the following:

1) Electronic nursing documentation of CLISA cascaded into

physician electronic progress notes

2) Physician attestation and determination of line removal for

CLISA 2 or 3 required for finalization of progress notes.

• Cox proportional hazards model compared frequency of localized

insertion site infection pre- and post-intervention. Chi-square

tests compared hospital CLABSI rates (2014 NHSN criteria)

The CLISA score enabled an automated primary

prevention strategy to standardize insertion site

assessment across providers

The CLISA score allowed earlier recognition of

insertion site inflammation and infection with

proactive removal before localized infections led

to CLABSI

The CLISA score was well-received and widely

adopted across training levels and disciplines

Impact of a Standardized Central Line Insertion Site Assessment (CLISA) Score

on Localized Inflammation and Bloodstream Infection

Key Findings Results

Insertion site infection decreased by more than half,

from 40 (10%) at baseline to 14 (4%) after CLISA

score implementation (p=.01), after adjustment for

line type and site

CLABSI rates decreased by 29% post-intervention,

but did not reach statistical significance

Among central lines that progressed to localized

infection, mean dwell time was 10 days

Physician progress notes documenting insertion site

appearance of inflamed lines increased from 0%

during baseline to 100% due to automated process

Nursing acceptance of the CLISA score was high

(92% compliance), due to both desired standardized

language and communication with MDs via linkages

between RN and MD progress note documentation.

After house-wide implementation of CLISA Scoring,

all 5 ICUs and Oncology units reported:

Easy adoptability

Improved RN-RN and RN-MD communication

Increased attention to and recognition of early

signs of infection

Limitations: (1) cohort limited to single academic

center, (2) generalizability may be limited by tertiary

care setting, (3) CLABSI events in 2015 required re-

evaluation with 2014 criteria due to definitional

changes.

Abstract # 59300

Poster Board # 417

Descriptor Baseline Post-Intervention

Number of Central Lines , N 402 322

Number of Assessments with Visible

Insertion Sites, N 696 963

Number of Assessments/Line, mean

(SD) 2 (1.8) 3.5 (4.1)

Mean dwell time, days (SD) 14 (10.6) 14 (19.5)

Mean age, years (SD) 56 (16.5) 55 (17.7)

Line site, N (%)

Brachial 271 (67) 180 (56)

Subclavian 34 (8) 51 (16)

Internal Jugular 79 (20) 78 (24)

Femoral 18 (4) 13 (4)

Unit, N (%)

Medical ICU 61(15) 45 (14)

Cardiac Care Unit 38 (9) 26 (8)

Surgical ICU 99 (25) 98 (30)

Neurosurgical ICU 71(18) 66 (21)

Burn ICU 31 (8) 15 (5)

Oncology (non-ICU) 102 (25) 72 (22)

Central Line Insertion Site Assessment (CLISA) Score

*Baseline and Intervention CLABSI rates normalized to 2014 NHSN Criteria

**Chi-square test comparing baseline and post-intervention CLABSI rates

Central Line Characteristics

Device-Days CLABSI*

CLABSI

Rates

per 1000

line-days

p-value**

Baseline 36,458 19 0.52 0.42

Post-Intervention 35,398 13 0.37

Prevalence of Inflammation/ CLISA

Score Assessments

Baseline

N (%)

Post-Intervention

N (%)

CLISA 0 273 (68) 150 (47)

CLISA 1 72 (18) 153 (48)

CLISA 2 49 (12) 41 (13)

CLISA 3 40 (10) 14 (4)

Days to Inflammation Baseline Mean

(SD)

Post-Intervention Mean

(SD)

CLISA 1 7 (6) 6 (6)

CLISA 2 9 (8) 10 (10)

CLISA 3 10 (7) 10 (11)

Local Infection (CLISA 3) Baseline vs Post-Intervention

Variable OR CI p-value*

Line Site

Brachial -- -- --

Internal Jugular 0.3 0.1-0.1 0.1

Subclavian 0.6 0.2-2.1 0.9

Femoral 0.8 0.2-4.0 0.7

Unit

NSICU -- -- --

SICU 1.9 0.6-6.6 0.3

MICU/CCU 2.3 0.7-7.4 0.15

BICU 4.7 1.3-16.9 0.02

Oncology 3.2 1.1-9.3 0.03

Intervention Period 0.4 0.2-0.8 0.01

CLABSI Rates Baseline & Post-Intervention

*Cox proportional hazards model, adjusted for age.

CLISA Score Embedded Into

Physician Progress Note for Daily Attestation

• Nursing documentation of CLISA score is embedded into physician progress notes

• If CLISA score > 2, physician must remove line or document reason for retaining

• Insertion site infection decreased significantly from 40 (10%) at baseline to

14 (4%) after intervention after CLISA score implementation