Central line associated bloodstream infection or CLABSI is a term that is used only when it applies to surveillance data collection within a given facility. This data is reported to the National Healthcare Safety Network (NHSN) database at the CDC and is used for public reporting in many states. There are very specific criteria that must be met for a bloodstream infection to be counted as a CLABSI. Note this definition only applies to “central lines” and only to bloodstream infections. It does not include short peripheral or midline catheters.
Catheter related bloodstream infection or CRBSI is used when making a clinical decision about the causes and management of a bloodstream infection in a specific patient. It requires diagnostic tests and appropriate treatment decisions. Note this term is not limited to central lines and encompasses all types of vascular access devices.
So, what is the definition of a “central line”? Does this definition differ based on how or when it is used? The answer is a decided yes, about the differences.
The NHSN is a national database tracking healthcare associated infections (HAI) from almost 15,000 healthcare facilities of all types. To learn more about NHSN, click here.
For purposes of accurate and consistent HAI data collection, a “central line” is defined by NHSN as
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:
- Pulmonary artery
- Superior vena cava
- Inferior vena cava
- Brachiocephalic veins
- Internal jugular veins
- Subclavian veins
- External iliac veins
- Common iliac veins
- Femoral veins
- In neonates, the umbilical artery/vein.
To read the entire document, “Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and Non-central line associated Bloodstream Infection) click here.
Please take notice of the fact that this definition is specifically for the purpose of reporting CLABSI and counting central line days. It does not differentiate between insertion sites and tip location.
Clinicians who are deeply involved with vascular access devices have fought an uphill battle for many years about the most appropriate tip location. Some may be concerned about this definition doing harm to those efforts. I do not think this definition can or should alter or harm our efforts.
Recommendations for appropriate central vascular access device (CVAD) tip location is based on clinical evidence that the best outcomes are achieved when the catheter tip is positioned in the lower third of the superior vena cava (SVC) at or near the cavaatrial junction (CAJ). If veins from the lower extremity are used, tip location with better outcomes are seen when the tip is located in the inferior vena cava (IVC) above the level of the diaphragm.
We also recognize several facts about CVADs:
- Tips are prone to migrate. PICCs can move inward due to arm movement. Subclavian or jugular insertion sites may have the tip move upward in the vein. Intrathoracic pressure changes lead to tip migration.
- There are pathophysiololgical reasons in some patients that prohibit tip location in the most appropriate location. Tumors encroaching on the SVC, surgical reconstruction of vessels or aberrant cardiac anatomy, SVC syndrome or large thrombosis may prevent use of these appropriate tip locations in a few patients. While we make every known attempt to reach the CAJ, it is simply not possible in a few patients, although I have not found good documentation of what percentage that would be. In these patients, we are forced to make a clinical decision about leaving a CVAD tip in these suboptimal locations.
- Some of our colleagues do not accept the CAJ as the most appropriate tip location and will accept any vein of the thorax as the tip location.
Given these circumstances, I interpret the NHSN list of veins to provide instructions that all of these catheters must be counted as central lines for purposes of reporting CLABSI to this system. I do not interpret this to mean that the NHSN is making a statement that all of these tip locations are acceptable or desirable or appropriate.
As professionals involved with infusion and vascular access, we must remain current on the evidence about tip location, continue to educate and advocate for CVAD tip location in the CAJ. However, I do not think these NHSN definitions are harmful to our work.