Melanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole. And we have a panel for you today to highlight the prevention of central line-associated bloodstream infections or CLABSI. Joining me in this panel is Mary Duncan. She's the Senior Director of Infection Prevention at UAB Medicine, and Dr. Rachel Lee. She's the Chief Healthcare Epidemiologist at UAB Medicine. Thank you both so much for joining us today. And Dr. Lee, I'd like to start with you. What is CLABSI, and why is this such a significant and ongoing challenge for healthcare organizations despite years of prevention efforts?

Dr Rachael Lee: CLABSI stands for Central Line-Associated Bloodstream Infection. So clinically, what we're talking about is when a patient develops a bloodstream infection, when they have a central venous catheter, and there's not another clear source explaining where that bacteremia came from.

From a patient safety perspective, CLABSI is just one of the clearest examples that we have on how necessary interventions can become to prevent harm to patients. Central lines we know are essential. we need them for vasopressors, for chemotherapy, parenteral nutrition, even things like hemodialysis or patients that have very difficult access.

But every central line also creates this, ongoing risk, and it provides direct access to the bloodstream. So, for both our clinicians and our nursing leaders, the key point here is that CLABSI prevention doesn't really end after insertion. We care a lot about that insertion technique, but then we have to continually remind ourselves of how to take care of it.

and, you know, I think to your second point, why is it a significant and ongoing challenge for healthcare organizations? I think it, really leans into that piece, right? We have different teams and different ways that we assess our best practices. So for nursing, we know that they have incredible maintenance bundles, really do best practice to prevent infections.

But then on the clinician side, we have to know good technique and when can this line be removed. And there needs to be discussion between both of those teams around that single patient. And then finally, I think it's important to point out that from an organizational standpoint, CLABSI's ch- not just an internal metric, it's a nationally reported patient safety measure.

And so hospitals report our CLABSI data through NHSN, which is a sub, section of the CDC. And that data is then used in CMS quality programs, public reporting, and payment-related programs. So we're really compared to our, academic peers based on how well we're doing. And the peer comparison can really be helpful, cause it keeps an attention on a preventable harm, but it also creates real challenge for organizations.

And so we're judged a-about this number, but it doesn't really tell us where the opportunity is. And so I think that's where we need people like Mary and, myself and our large teams where we kind of swarm around these, infections to find best practice.

Melanie Cole (Host): Well, thank you for that. So then, Mary, based on what Dr. Lee was just saying, how are we distinguishing organizations that consistently achieve low CLABSI rates from those that are struggling? As she's talking about all of the parameters and criteria that are included with these CLABSI rates, what distinguishes these organizations?

Mary Duncan: Well, I think that the organizations that are doing really well with preventing these CLABSIs are following the best practices. And the good thing is, like infection preventionists, we've been working on ways to prevent vascular access device infection for decades now. And we have a really strong understanding about the factors that contribute to these infections and the practices that reduce the risk.

So the organizations that are doing really well understand these, and they focus on two major sources of infection risk. So at the insertion site, but then also the catheter hub. And when we're thinking about the prevention strategies, they generally fall into two broad categories. So the insertion prevention and the maintenance prevention.

And organizations, that create these really good bundles that address the risk factors at these two sites tend to have lower infection risks across the board. but when we look at the, insertion piece of it, we know that the evidence-based elements include, doing hand hygiene. So this is really the cornerstone of preventing all healthcare-associated infections, using the appropriate skin antiseptics to reduce the microbial burden on the skin before catheter insertion, using a full sterile barrier precautions and, picking the optimal site selection.

So as we are doing these practices, it's also important that we use a checklist and, high-reliability organizations use these checklists, and it's not just paperwork. it really is a safety tool, and it creates the shared expectation that the team can pause if a sterile technique is compromised or supplies or positioning or processes aren't right.

And then after the line is inserted, it's important to pull in the maintenance bundle elements, because these are essential to preventing infection after the line has been placed. The essential pieces of this are, again, hand hygiene before line care, using aseptic technique every single time that that line is accessed, doing proper disinfection of the hubs and the needleless connectors so that the bacteria is not introduced into the bloodstream.

And then we also need to make sure that we're maintaining a clean, dry, and intact dressing and doing appropriate site assessments during the line maintenance period. but we can also do additional prevention strategies that many facilities across the country have implemented, such as doing chlorhexidine bathing when indicated.

and this has been shown to reduce bloodstream infections in the appropriate patient population. And then I think one of the most important things that, organizations have been able to do is doing the daily line necessity review. So we need to make sure that every patient that has a central line has a clear indication of why that line is in place every single day.

And we shouldn't be asking the question, you know, "Can we leave this in one more day?" We need to be asking the question like, "What is the specific reason this patient still needs this central line today? Or is there a safer alternative that we could use?" So I think hospitals that, consistently show decreased infections have been able to implement both of these bundle, element, processes.

Melanie Cole (Host): That's very interesting. So, Dr. Lee, I'd like you to expand on what Mary was just saying when we think of central line necessity and maintenance. And she was just saying the checklist and really looking at high reliability. How can healthcare leaders and the seniors, in this organization create that culture where the necessity and maintenance are evaluated and not taken to heart when they're evaluated?

Does that make sense to be able to create that culture where everybody feels the evaluation is as important as the thing itself?

Dr Rachael Lee: I think leaders help create that culture, and they embed that central line review into our routine cl-clinical work. I think some of the things that we've done best here at UAB, you know, Mary was talking about best insertion practices. and one of the things that we have done here is really, have a collaborative connection with our simulation team.

So, it is expected that our new budding physician leaders and clinician leaders go through this process. If you're going to be placing a central line, you have to prove that you know how to do that. and similarly for our nursing colleagues, we have competencies to kind of make sure that we are doing what's best, and that's an expectation that's created by our leaders so that we are doing what's right for our patients.

The other piece to that, so now that the central line is placed, is that daily interdisciplinary round. Every central line should be discussed. does the patient still need this line? Are there any maintenance concerns? And I think best practice is having a close connection. me as a clinician, I care deeply about what the nursing teams are telling me, how things are looking from their perspective, and then continue to have that conversation with them.

Like, "Okay, we still need this central line, because we're still on a vasopressor and, let's make sure that we're doing everything we can to prevent any harm." So that focus and that really leaning into having a conversation every single day about whether or not it's needed is key. I think the other piece is, making expectation, like the making the standards visible for everyone.

So Mary and I are very much embedded in the, quality domain structure and, with our chief medical and quality office, and so we know, very well kind of the ins and outs of, what we're held accountable to. But we should be open and visible with our numbers and, the why behind what we're doing, not just about a metric, but really about that patient harm.

When I see patients on infectious disease service with a bloodstream infection, the number that sticks in my head is, 20%, 20% risk of death when you have a bloodstream infection. So we have to do everything we can to really, swarm around this and, protect our patients.

Melanie Cole (Host): And really what I'm hearing from you, Dr. Lee, is that you are effectively engaging physicians, nurses, support staff in that shared ownership

of the CLABSI prevention

Dr Rachael Lee: Yes. I agree. And, I think we do a really good job saying how important every single person that walks into a patient's room is to the care of that patient. Even our, EVS workers that do the hard work of cleaning the rooms in between patient care, that's just as important for preventing harm as it is for me to place a central line or for nursing to maintain that central line.

So, we're all working together. and I think that's that psychological safety that is needed, for inter-interdisciplinary teams

Melanie Cole (Host): Mary, looking at it from your perspective, how are you balancing competing operational priorities, which there are significant, while maintaining that strong focus on CLABSI prevention?

Mary Duncan: As we look at our patients and they seem to be getting sicker as they're coming into the hospital, and so there's all kinds of opportunities for, other types of infections to happen. but I think if we just look at it as what is the best care for the patient, and over the years there's been a lot of bundle elements that have been developed, and we know these are the best practices that, can prevent all types of infection within the hospital.

And so as we focus on just making sure that people have the knowledge of what they can do to prevent infections, and as they're walking into the room, see all of the different risks of what could impact the patient, and then know, these are the things that I can do to make their care safer. And so it's more about the holistic care of the patient and doing everything possible to prevent the infections versus, "Oh, now we're just gonna focus on CLABSIs," or, "Now we're just gonna focus on CAUTIs."

Where we do have to do that, but I think for the frontline clinicians that are taking care of the patients, it works a lot better if they just see and know everything that they can do to prevent these, and not focus so much on a infection specific type

Melanie Cole (Host): Well, this really is a very interesting conversation and so important for other clinicians and other institutions to hear. I wanna give you each a chance for a final thought. So Mary, lessons that you've learned from successful CLABSI reduction initiatives that can be applied to other prevention efforts.

what would you like to tell other institutions about these initiatives and why they work?

Mary Duncan: so the lessons I've learned, 'cause I've been doing this a long time, and the consistent thing that I find every time that I implement something is you have to pull the right people in and have the hard conversations about what is really happening at the bedside, what are the barriers that are happening, what is the knowledge gap, what are their supply issues, what are the process issues?

And be able to have those difficult conversations and work it out to make processes that work for the frontline staff. It does me no good to sit up in my office and dictate what needs to happen. I really need the feedback from the frontline staff to have those conversations. But from an infection prevention perspective, we can partner with them and pull in the best practices and say, "Okay, this is what we need to do.

Help us figure out how we're gonna implement this." And I think the more people you pull in and, make it a group project, the better off you are. But the other more important thing is you have to get leadership buy-in because you need their support to make sure that the resources are available to get the products or set up the processes or hold people accountable.

So, it really is everybody within the organization that needs to support this, know what our end goal is, and be working towards the same, processes and the same end goal

Melanie Cole (Host): Well, that's certainly true. And Dr. Lee, last word to you. What lessons do you feel are important to impart to not only other institutions that are looking to better their outcomes for CLABSI prevention, but to residents and incoming nurses and support staff? And for all of them, when we talk about the evaluation and kind of keeping track of these numbers and making sure and going through every day when you were talking about rounds, what would you like to see happen?

What would you like them to know are some of the most important aspects?

Dr Rachael Lee: I agree with, everything that Mary said. I think culture matters, I think a lot of times we think central line infection, okay, nursing knows what to do with that, or that's a nursing-related issue. But we've come to realize how important it is to have everyone's aspect that's been at the front lines to really kind of bring in and make sure we're doing best practice.

So I think our understanding of central line infection prevention has really blossomed a lot with having this ability to bring teams together, not just nursing, not just PCTs, not just infection prevention, but also include the clinician aspect and say, "Okay, t- let's talk about why did you order those blood cultures?

what was going on with the patient at the time to really understand more of what we can do, behind the scenes so that it doesn't happen to another patient. So I think just consistent communication is really key.

Melanie Cole (Host): I agree with both of you and everything was so greatly pointed out. Really, you made great points and, this was really such an important topic. So thank you so much for joining us today and sharing your incredible expertise. And for more information, please visit our website at uabmedicine.org/physician.

That concludes this episode of UAB MedCast. I'm Melanie Cole.