771. COVID-19 on the Line: A Significant Increase in CLABSI in Hospitalized Patients with COVID-19 at a Major Teaching Hospital

Background We observed an increase in central line associated bloodstream infections (CLABSI) associated with the 2020 COVID-19 pandemic and performed a retrospective analysis to better understand the impact of COVID-19 on CLABSI rates. Figure 1. CLABSI rate in 2019 vs CLABSI rate in 2020 A comparison of CLABSI rates (displayed in infections/1000 catheter days) in all adult inpatients at our institution for calendar-years 2019 and 2020 Methods Retrospective review was done for all CLABSI in adults meeting National Healthcare Safety Network (NHSN) criteria in 2020 at an 889-bed teaching hospital. CLABSIs in encounters with PCR-confirmed COVID-19 (COVID CLABSI) were compared with CLABSIs in encounters without a COVID diagnosis (non-COVID CLABSI). As a secondary analysis, we also reviewed all CLABSI occurrence in 2019. Characteristics were compared using Mid-P Exact (Poisson) and Chi Squared (categorical) Tests. Subjective data collected by infection preventionists during real-time case reviews with clinical staff of each CLABSI was also reviewed. Results In 2020, the rate of COVID CLABSI (CLABSI/1000 catheter days) was 6.6 times greater than the rate of non-COVID CLABSI (5.47 vs. 0.83, p< 0.001). In the COVID CLABSI group we observed higher rates of occurrence in the ICU setting (94% vs 28%, p< 0.001), in house mortality (53% vs 26% P=0.0187), presence of arterial lines (91% vs 20%, p< 0.001) and increased number of catheter lumens (4 vs 3, p< 0.001). No significant difference was observed in the distribution of pathogens. No significant differences were observed between 2019 CLABSI and 2020 non-COVID CLABSI. Real-time case reviews identified changes in nurse staffing, increased nurse: patient ratios, delays in routine central line dressing changes, and inconsistent use of alcohol-impregnated port protectors as possible contributing factors. Table 1. 2020 COVID CLABSI vs 2020 non-COVID CLABSI A comparison of selected patient and catheter characteristics in COVID CLABSI vs non-COVID CLABSI in 2020 Table 2. 2019 CLABSI vs 2020 non-COVID CLABSI A comparison of selected patient and catheter characteristics in CLABSI in 2019 vs non-COVID CLABSI in 2020 Figure 2. CLABSI rate in 2019 vs COVID CLABSI and non-COVID CLABSI in 2020 A comparison of CLABSI rates (displayed in infections/1000 catheter days) in all adult inpatients at our institution for calendar years 2019 and 2020, with the infections in 2020 divided into those that occurred during an encounter with a PCR -confirmed diagnosis of COVID-19 and those without. Conclusion We observed a dramatically higher rate of CLABSI in patients with COVID-19 in 2020, while the rate of CLABSI in patients without COVID-19 remained unchanged from the year prior. Higher rates of ICU admission, critical illness, increased numbers of lumens, increased presence of arterial lines, nurse staffing changes, and gaps in routine line prevention processes associated with emergency measures in the COVID-19 cohort ICU may have contributed to this finding. Further work is needed to better understand how to minimize process-related disruptions in central line care during a hospital response to a pandemic. Disclosures Jonathan Grein, MD, Gilead (Other Financial or Material Support, Speakers fees)

770. Impact of COVID-19 Pandemic on Central Line-associated Bloodstream Infections in Metropolitan Detroit

Background Recent publications suggest that central line-associated bloodstream infection (CLABSI) rates have increased in US hospitals during the COVID-19 pandemic. The objective of this study was to evaluate the impact of COVID-19 pandemic on CLABSIs. Methods This was a retrospective cross-sectional study comparing CLABSI rate per 1,000 central line (CL) days, blood culture (BC) utilization rate per 1,000 CL days, CL utilization rate per 1,000 patient days, Standardized Infection Ratio (SIR) and Standardized Utilization Ratio (SUR) in the pre-COVID-19 period from January 1, 2019 to December 31, 2019 to the COVID-19 period from April 1, 2020 to March 31, 2021 at an 877-bed tertiary care hospital in Detroit, Michigan. CLABSI, and BC and CL utilization rate were extracted from the electronic medical record (Epic™ Bugsy). SIR and SUR data were extracted from National Healthcare Safety Network (NHSN). Results The average CLABSI rate per 1,000 CL days increased 24% from 1.66 to 2.06. Twenty percent of patients were hospitalized for COVID-19. The BC utilization rate per 1,000 CL days decreased from 0.43 to 0.32 with a 26% reduction. However, CL utilization increased by 28% from 0.25 to 0.32 (Figure 1). However, CLABSIs due to common commensals decreased from 13.8% to 10.9%. The SIR increased significantly from 1.055 to 1.795 (P-value 0.008), resulting in a 70% increase. The overall SUR also increased from 0.900 to 0.988 (P-value < 0.001). Figure 2 is a control chart of the CLABSI rate from July 2019 to April 2021. Figure 1. CLABSI, blood culture utilization and central line utilization rates pre-and during COVID-19 pandemic Figure 2. CLABSI control chart pre-and during COVID-19 pandemic Conclusion During the COVID-19 pandemic, there was a significant increase in CL utilization, CLABSI rate, SIR and SUR likely due to higher acuity in COVID-19 patients despite a decrease in BC orders. Disclosures All Authors: No reported disclosures

Inequities in CLABSI Rates in a Children’s Hospital by Race, Ethnicity, and Language Preference

Background: Systemic racism results in health inequities based on patient race, ethnicity, and language preference. Whether these inequities exist in pediatric central-line–associated bloodstream infections (CLABSIs) is unknown. Methods: This retrospective cohort study included patients with central lines hospitalized from October 2012 to June 2019 at our tertiary-care children’s hospital. Self-reported race, ethnicity, language preference, demographic, and clinical factors were extracted from the electronic health record. The primary outcome was non–mucosal barrier injury (non-MBI) CLABSI episodes as defined by the NHSN. CLABSI rates between groups were compared using χ2 tests and Cox proportional hazard regression. We adjusted for care unit, age, immunosuppressed status, diapered status, central-line type, line insertion within 7 days, daily CLABSI maintenance bundle compliance, number of blood draws and IV medication doses, and need for total parental nutrition, extracorporeal membrane oxygenation, and renal replacement therapy. In mid-2019, we engaged stakeholders in each care unit to describe preliminary findings and to identify and address potential drivers of observed inequities. Results: We included 337 non-MBI CLABSI events over 230,699 central-line days (CLDs). The overall non-MBI CLABSI rate during the study period was 1.46 per 1,000 CLDs. Unadjusted CLABSI rates for black or African American (henceforth, “black”), Hispanic, non-Hispanic white, and Asian (the 4 largest race or ethnicity groups by CLDs) patients were 2.74, 1.53, 1.42, 1.24 per 1,000 CLDs, respectively (P < .001) (Table 1). Unadjusted CLABSI rates for patients with limited-English proficiency (LEP) and English-language preference were 1.98 and 1.38 per 1,000 CLDs, respectively (P = .014). After adjusting for covariates, the hazard ratio (HR) point estimate for CLABSI rate remained higher for black patients (HR, 1.50; 95% CI, 0.99–2.28) and patients with LEP (HR, 1.33; 95% CI, 0.87–2.05), compared to the reference group based on largest CLD. The differences in CLABSI rate by race or ethnicity and language were more pronounced in 2 of our 6 care units. Stakeholder engagement and analysis of hospital data revealed opportunities on those units for improved (1) interpreter utilization and (2) line maintenance observation practices by race/ethnicity and language preference (data not shown). These findings and CLABSI rates over time by race/ethnicity and language preference (Figures 1 and 2) were shared with frontline staff. Conclusions: In our children’s hospital, CLABSI rates differed based on patients’ self-reported race, ethnicity, and language preference, despite controlling for factors commonly associated with CLABSI. Identifying inequities in CLABSI rates and mitigating their determinants are both essential to the goal of achieving equitable care.Funding: NoDisclosures: None

The Impact of Coronavirus Disease 2019 (COVID-19) Pandemic on Device-Associated Healthcare-Associated Infection

Background: The impact of the coronavirus disease 2019 (COVID-19) pandemic on healthcare-associated infection (HAI) is not yet known. Diversion of resources from traditional HAI surveillance and prevention efforts toward institutional COVID-19 response, along with decrease in patient contact due to fear or required quarantine or isolation, may have increased HAI rates. In contrast, increased compliance with hand hygiene and personal protective equipment may have decreased HAI rates. Methods: We sought to determine the impact of COVID-19 pandemic on healthcare-associated central-line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). CLABSI and CAUTI rates and standardized infection ratios (SIRs) reported to the NHSN from the first quarter of 2015 to the fourth quarter of 2020 were obtained for the entire facility and for the medical intensive care unit (MICU), which was converted during the pandemic to an intensive care unit solely for critically ill patients with COVID-19. Changes in CLABSI and CAUTI rates and SIRs before the pandemic (Q1 2015 to Q4 2019) and during the pandemic (Q1 2020 to Q4 2020) were assessed using an independent-sample t test. Results: The CLABSI rate was unchanged, with a mean (SD) of 0.64 (±0.34) CLABSIs per 1,000 central-line days before the pandemic and 0.72 (±0.22) during the pandemic (P = .62) (Figure 1). The SIR remained stable at 0.54 (±0.29) before and 0.96 (±0.59) during the COVID-19 pandemic (P = .25). However, CLABSI rate in MICU increased significantly from 0.92 (±1.00) to 2.75 (±1.00) (p < 0.01), along with SIR from 0.81 ± 0.89 to 2.53 ± 1.07 (p < 0.01) (Figure 1). CAUTI rate was unchanged with 1.17 ± 0.38 CAUTI per 1000 catheter days per quarter before, and 1.04 ± 0.87 during COVID-19 pandemic (p = 0.64). CAUTI SIR remained stable at 0.82 ± 0.31 before and 0.83 ± 0.86 during COVID-19 pandemic (p = 0.96). CAUTI rate in MICU was 0.78 ± 1.20 before and 2.17 ± 3.24 after COVID-19 pandemic (p = 0.45) (Figure 2). Conclusions: Although our institutional CLABSI and CAUTI rates and SIRs remained unchanged, our medical intensive care unit, which housed our critically ill patients with COVID-19, experienced significant increases in CLABSI rate and SIR. This finding is likely multifactorial in the setting of overextended nursing staff, use of prone position, and challenges of infection prevention efforts under isolation precautions.Funding: NoDisclosures: None

Effectiveness of a Multidisciplinary Team-Approach on Central-Line–Associated Bloodstream Infections

Background: Although there has been a significant reduction in central-line–associated bloodstream infection (CLABSI) rates in the past decade with the implementation of evidence-based practices, an estimated 30,100 CLABSI occur each year in acute-care facilities. CLABSIs are associated with increased length of stay, cost, morbidity, and mortality, and they are preventable. In this study, we assessed the impact of a multidisciplinary team approach on CLABSI rates at a 319-bed teaching hospital in northwestern Ohio. Methods: In this before-and-after retrospective study, we compared the CLABSI rate per 1,000 central-line days, standardized infection ratio (SIR), and standardized utilization ratio (SUR) in the preintervention period (January 1, 2016, to December 31, 2018) to those of the intervention period (January 1, 2019, to December 31, 2020). Despite hospital-wide nursing education focusing on central-line maintenance in 2017, our SIR and SUR remained above the national benchmark. Starting in August 2018, we began to focus on insertion practices and physician education. An infection preventionist observed resident central-line insertion training and noted that there was no emphasis on infection prevention measures. There was a best practice knowledge gap. Thus, the indications for central-line use were updated, the insertion checklist was standardized, and the vascular access policy was revised to limit femoral and internal jugular vein use. Infection prevention training was provided to all providers involved in central-line insertions. Nurses were tasked with observing insertion of every central line and stopping the procedure if there is was an observed break in sterile technique. A central-line report listing indications and duration was developed and was sent to the nursing directors who assessed daily need with providers and prompted removal of unnecessary lines. The infection prevention medical director provided CLABSI prevention education to providers. Results: The CLABSI rate per 1,000 central-line days decreased from 0.90 in the preintervention period to 0.34 in the postintervention period, resulting in a 62% reduction in CLABSI rate. The SIR decreased from 0.886 to 0.323 (p-value <0.05), yielding a 64% reduction. The SUR also decreased from 1.156 to 0.874 (p-value <0.001) with a 24% reduction. Conclusion: A multidisciplinary team-approach with emphasis on standardized insertion checklist to ensure adherence to sterile technique and prompt removal of unnecessary central lines, and physician insertion training focusing on IP practices may potentially reduce CLABSI rates.Funding: NoDisclosures: None

The Impact of a Dedicated Nurse on the Prevention of Central Line-Associated Bloodstream Infections in the NICU

BackgroundThe neonatal population is at increased risk for central line-associated bloodstream infections (CLABSIs) related to prematurity, critical illness, and compromised immune function.1,4,5MethodsTo address a 30 percent CLABSI rate increase, a quality improvement (QI) project in a Level IV NICU was developed and implemented by the NICU CLABSI team in 2018. The project trialed a dedicated CLABSI prevention-registered nurse (DCP-RN) role with select responsibilities aimed at rate reduction. The DCP-RN spearheaded an RN education plan, addressed prevention bundle compliance, and aided in establishing a reliable apparent cause analysis (ACA) process.ResultsThe outcome resulted in an over 50% reduction in the CLABSI rate and permanent adoption of the DCP-RN role in the NICU.

Mindful organizing as a healthcare strategy to decrease catheter-associated infections in neonatal and pediatric intensive care units. A systematic review and grading recommendations (GRADE) system

Purpose: To explore the clinical evidence available on mindful organizing (MO) that will improve teamwork for positioning and managing central venous catheters in patients admitted to neonatal intensive care and other pediatric intensive care units to decrease central-line-associated and catheter-related bloodstream infections (CLABSI and CRBSI). Methods: We searched several databases (PubMed, Embase, CINAHL, CENTRAL, SCOPUS, and Web of Science) up to June 2018. We included studies investigating the effectiveness of MO teamwork in reducing CLABSI and CRBSI. The systematic review followed the PRISMA guidelines. We used validated appraisal checklists to assess quality. Results: Seven studies were included: only one was a non-randomized case-controlled trial (CCT). All the others had a pre-post intervention design, one a time-series design and one an interrupted time-series design. The methodological heterogeneity precluded a meta-analysis. Despite the low certainty of evidence with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system, three studies including thousands of participants provided numerical data for calculating risk ratios (RR) and 95% confidence intervals (CI) comparing MO with no intervention for decreasing the CLABSI rate in neonatal and pediatric ICUs. The one CCT disclosed no significant difference in the CLABSI rate decrease between groups (RR = 0.96; 95%CI 0.47–1.97). Nor did the pre- and post-intervention interrupted time-series design disclose a significant decrease (RR = 0.80; 95%CI 0.36 1.77). In the study using a before-after study design, the GRADE system found that the CLABSI rate decrease differed significantly in favor of post-intervention (RR = 0.13; 95%CI 0.03 0.57; p = 0.007). Conclusions: Despite the decreased CLABSI rate, the available evidence is low in quality. To reduce the unduly high CLABSI rates in neonatal and pediatric intensive care settings, custom-designed clinical trials should further define the clinical efficacy of MO to include it in care bundles as a new international standard.

Bundle approach used to achieve zero central line-associated bloodstream infections in an adult coronary intensive care unit

BackgroundCentral venous catheterisation is commonly used in critical patients in intensive care units (ICU). It may cause complications and attribute to increase mortality and morbidity. At coronary ICU (CICU) of cardiac hospital, central line-associated bloodstream infection (CLABSI) rate was 2.82/1000 central line days in 2015 and 3.11/1000 central line days in 2016. Working in collaboration with Institute for Healthcare Improvement (IHI), we implemented evidence-based practices in the form of bundles in with the aim of eliminating CLABSI in CICU.MethodsIn collaboration with IHI, we worked on this initiative as multidisciplinary team and tested several changes. CLABSI prevention bundles were tested and implemented, single kit for line insertion, simulation-based training for line insertions, standardised and real-time bundle monitoring by direct observations are key interventions tested. We used model for improvement and changes were tested using small Plan-Do-Study-Act cycles. Surveillance methods and CLABSI definition used according to National Healthcare Safety Network.ResultsThe CLABSI rate per 1000 patient-days dropped from 3.1 per 1000 device-days to 0.4 per 1000 device-days. We achieved 757 days free of CLABSI in the unit till December 2018 when a single case happened. After that we achieved 602 free days till July 2020 and still counting.ConclusionsImplementation of evidence-based CLABSI prevention bundle and process monitoring by direct observation led to significant and subsequently sustained improvement in reducing CLABSI rate in adult CICU.