Application of an Outpatient CLABSI Surveillance Definition: Results and Lessons From 7 Infusion Clinics

Abstract

Background: The NHSN does not have a published surveillance definition for central-line–associated bloodstream infections (CLABSIs) related to healthcare in ambulatory settings. With the increasing reliance on services involving central-line care in the ambulatory setting, there is opportunity to improve healthcare performance by developing standardized surveillance. Methods: Chart review was performed on 320 patients who had a visit at an infusion clinic and a positive blood culture in 2018. A qualifying infusion clinic visit involved accessing of the central line during the encounter. Ambulatory-associated cases were defined as having a qualifying infusion clinic encounter within 7 days prior to blood culture collection. Cases were excluded if the patient’s central line had been accessed in an inpatient setting between the positive blood culture and infusion clinic visit. All other criteria were based on the NHSN inpatient CLABSI case definition. Results: Application of the proposed surveillance definition revealed 17 of 320 (5.3%) patients who met criteria for an ambulatory CLABSI. All 16 patients who met criteria (94%) had an inpatient hospital stay within 7 days of the qualifying infusion clinic encounter, for an average of 8.8 hospital days (range, 2–20). Positive blood cultures were collected on average 3.2 days after the patient’s qualifying infusion clinic encounter (range, 0–7). Moreover, 20 causative organisms were identified: 6 common commensals, 2 Staphylococcus aureus, and 12 gram-negative bacteria. Also, positive blood cultures for 7 patients (41%) were collected in ambulatory clinics. Patients reported symptom onset on average 1.2 days prior to telling a healthcare professional (range, 0–5) and an average of 2 days from their last qualifying infusion clinic visit (range, 0–6). In addition, 1 patient (6%) met for a site-specific infection outside of the defined window period during their subsequent admission. Conclusions: Application of the surveillance definition resulted in the identification of 17 CLABSIs. These results highlight important limitations in ambulatory CLABSI surveillance: Patients who access emergency services closer to their residence may have had their bloodstream infection (BSI) identified elsewhere. Ensuring comprehensive interfacility communication would increase the value of an institution’s surveillance. Additionally, ambulatory surveillance for BSI should include all possible collection locations. Although subject to recall bias, the event date could be based on symptom onset to allow for variation in healthcare-seeking behavior. In the ambulatory setting, because diagnostics are not readily available, delayed diagnosis of site-specific infections could result in an inflated ambulatory CLABSI rate.

Funding: None

Disclosures: None