Central line catheter-associated blood stream infection rate for ICU and high-risk nursery (HRN) patients (NQF 0139)

eMeasure Name Central line catheter-associated blood stream infection rate for ICU and high-risk nursery (HRN) patients eMeasure Id 7947C78E-89E8-4246-86FF-A0E418EBA387
Version number 1 eMeasure Set Id B9D41100-0946-4752-995A-C2BB296378DE
Available Date No information Measurement Period January 1, 20xx through December 31, 20xx
Measure Steward Centers for Disease Control and Prevention
Endorsed by National Quality Forum
Description Standardized Infection Ratio (SIR) of healthcare-associated, central line-associated bloodstream infections (CLABSI) among patients in intensive care units (ICUs) and Neonatal Intensive Care Units (NICUs).
Copyright
Measure scoring Ratio
Measure type Outcome
Stratification
Facility-specific data (i.e., bed size, affiliation, and level of affiliation with a medical school - teaching statuses: major, graduate, limited, not affiliated) and individual patient location data (i.e., type and bed size of location).
•Major: A hospital that is an important part of the teaching program of a medical school and the majority of medical students rotate through multiple clinical services.
•Graduate: Hospital is used by the medical school for graduate training only (residency and/or fellowships).
•Limited: Hospital is used in the medical school's teaching program to only a limited extent.
            
NICU numerator and denominator information is further stratified by five birth weight categories.
Risk Adjustment
None
Data Aggregation
NQF-endorsed version: This measure is reported as a rate comprised of the number of central-line associated bloodstream infections per 1,000 central line days for each hospital unit location included in scope for the measure. 
            
Updated version undergoing endorsement evaluation: This measure is reported as a ratio of the observed number of central-line associated bloodstream infections to the predicted number of central-line associated bloodstream infections calculated for each hospital location in scope for the measure and summarized across all locations.
Rationale
An estimate 248,000 bloodstream infections occur in U.S. hospitals each year. It is believed that a large proportion of these are associated with the presence of a central vascular catheter, though this is an area where more study is needed. For the purposes of NSHN, such infections are termed central line-associated bloodstream infections (CLABSI). Bloodstream infections are usually serious infections typically causing a prolongation of hospital stay and increased cost and risk of mortality.
                
A range of estimates for the attributable cost of CLABSI ($5,734 to $22,939 in 2003 dollars) that would be representative of all hospitalized patients.
Clinical Recommendation Statement
CLABSI SIRs are relevant to patient populations because prevention recommendations have been published to reduce the incidence of CLABSI. A high SIR indicates an opportunity for improvement.
                
CLABSI can be prevented through proper management of the central line. These techniques are addressed in the CDC's Healthcare Infection Control Practices Advisory Committee (CDC/HIPAC) Guidelines for the Prevention of Intravascular Catheter-Related Infections.
Improvement notation
Better quality equals a lower score.
Reference
Klevens RM, Edwards JR, et al. Estimating healthcare-associated infection and deaths in U.S. hospitals, 2002. Public Health Reports 2007; 122: 160-166
Reference
Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. http://www.cdc.ncidod/dhqp/pdf/Scott_CostPaper.pdf Accessed April 12, 2010.
Reference
O'Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki D, et al. Guidelines for the prevention of intravascular catheter-related infections. MMWR 2002;51 (No. RR-10:1-26).
Reference
Clinical and Laboratory Standards Institute (CLSI). Principles and Procedures for Blood Cultures; Approved Guidelines. CLSI document M47-A (ISBN 1-56238-641-7). Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne, Pennsylvania, USA, 2007.
Reference
Baron EJ, Weinstein MP, Dunne Jr WM, Yagupsky P, Welch DF, and Wilson DM. Blood Cultures IV. ASM Press: Washington, DC; 2005
Definition
Primary bloodstream infections (BSI) are laboratory-confirmed bloodstream infections (LCBI) that are not secondary to an infection meeting CDC/NHSN criteria at another body site (see criteria in Chapter 17 CDC/NHSN Surveillance Definition. Report BSIs that are central line-associated (i.e., a central line or umbilical catheter was in place at the time of, or within 48 hours before, onset of the event.
NOTE: There is no minimum period of time that the central line must be in place in order for the BSI to be considered central line-associated.
                
Location of attribution: The location where the patient was assigned on the date of the BSI event, which is further defines as the date when the first clinical evidence appeared or the date the specimen used to meet the BSI criteria was collected, whichever came first.
                
Central line: An intravascular catheter that terminates at or close to the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring. The following are considered great vessels for the purpose of reporting central-line BSI and counting central-line days in the NHSN system: Aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins, common iliac veins, femoral veins, and in neonates, the umbilical artery/vein.
NOTE: 
•Neither the insertion site nor the type of device may be used to determine if a line qualifies as a central line. The device must terminate in one of these vessels or in or near the heart to qualify as a central line.
•An introducer is considered an intravascular catheter.
•Pacemaker wires and other nonlumened devices inserted into central blood vessels or the heart are not considered central lines, because fluids are not infused, pushed, nor withdrawn through such devices.
                
Infusion: The introduction of a solution through a blood vessel via a catheter lumen. This may include continuous infusions such as nutritional fluids or medications, or it may include intermittent infusions such as flushes or IV antimicrobial administration, or blood, in the case of transfusion or hemodialysis.
                
Umbilical catheter: A central vascular device inserted through the umbilical artery or vein in a neonate.
                
Temporary central line: A non-tunneled catheter.
                
Permanent central line: Includes
•Tunneled catheters, including certain dialysis catheters
•Implanted catheters (including ports)
Definition
Initial Patient Population(s): All patients with central line, (as defined by the CDC/National Healthcare Safety Network [NHSN]) in intensive care units (ICUs).  The measure specifies 29 populations to stratify results by each type of ICU identified.  For acute care facilities, adult ICU is defined as caring for persons > 18 years of age; Pediatric ICU (PICU) is defined as caring for children and adolescents 1 day to < 18 years of age; Neonatal ICU (NICU) is defined as caring for premature infants and infants 1 day of life up to 12 months of age.
Definition
Denominator(s): The expected number of CLABSIs for the facility location.
Definition
Denominator Observation(s): The expected number  of central line blood stream infections for the facility location  is calculated by multiplying the total number of catheter days by the applicable referent CLABSI population rates by location and in the NICU by birthweight category.   Applicable referent CLABSI population rates are determined by using the CLABSI data reported to NHSN in 2009 and are published in AJIC 201;39:349-67 and  can be found at http://www.cdc.gov/nhsn/PDFs/dataStat/2010NHSNReport.pdf
The denominator observations identify the number of catheter days for all ICU and PICU and NICU children and adults having 1 or more NHSN-defined central line (temporary or permanent) in place and accessed at the time line days are counted daily; For NICU infants, central lines include NHSN-defined central or umbilical lines in place at the time line days are counted daily.
Definition
Denominator Exclusion(s): Patients without a central line in place or line not accessed during current hospital admission.
Definition
Numerator(s): The number of laboratory-confirmed bloodstream infections (LCBI) identified using NHSN Bloodstream infection LCBI criteria 1, 2, and /or 3.
Definition
Numerator Exclusions(s):  Positive blood cultures in a patient not meeting NHSN bloodstream infection LCBI criteria 1, 2 and/or 3. These are specifically removed from the Numerator logic and not listed in this section.
Guidance
SIR is an indirect standardization method for summarizing HAI experience across any number of stratified groups of data. CLABSI incidence rates stratified by patient care location and in some instances, location bed size and type of medical school affiliation. Example: expected number of CLABSI (and CLABSI rates) in an adult ICU are not the same as in an NICU.
            
CLABSI rates per 1000 central line device days are used to calculate the expected number of CLABSI for the denominator in SIR. They are indirectly standardized rates accounting for the influence of length of stay and length of central line use, and are stratified by patient care location, adjusting for differences in patient morbidity and disease-specific variables, which may influence CLABSI risk.
            
All potential sources of bloodstream infection would require a comprehensive compendium of infectious disease definitions for the EHR. The inclusion criteria for primary bloodstream infection are specified for this measure. As primary bloodstream infection is sometimes a diagnosis of exclusion, the user is expected to identify other potential sources for the bacteremia based on the Centers for Disease Control (CDC) criteria located at: [Link].
            
In addition, differentiation of sources of inflammatory reaction is complex. 

The user is expected to differentiate infectious vs. non-infectious sources based on CDC criteria: [http://www.cdc.gov/nhsn/PDFs/pscManual/6.4/2-Identifying-HAIs-NHSN-06_11.pdf and http://www.cdc.gov/nhsn/PDFs/pscManual/6.4/4-CLABS_06_11.pdf].
            
The denominator for this measure is the summation of the count of central line days. The start and stop times for this calculation are dependent on when and where the central line was inserted and removed (i.e., prior to arriving at the ICU, during the ICU stay, or after transfer out of the ICU). For reporting purposes, the denominator should report the calculated central line days.
            
The elements 'Procedure performed: central line accessed' and 'Procedure performed: central line removed' are referencing the same central line, not different lines.
Supplemental Data Elements
Report "Patient Characteristic: Gender" using "Gender HL7 Value Set (2.16.840.1.113883.1.11.1)"; Report "Patient Characteristic: Race" using "Race CDC Value Set (2.16.840.1.114222.4.11.836)"; Report "Patient Characteristic: Ethnicity" using "Ethnicity CDC Value Set (2.16.840.1.114222.4.11.837)"; Report "Patient Characteristic: Payer" using "Payer Source of Payment Typology Value Set (2.16.840.1.113883.3.221.5)".

Table of Contents


Population criteria

Reporting Stratification

Data criteria (QDM Data Elements)

Supplemental Data Elements




Measure set CLINICAL QUALITY MEASURE SET 2011-2012