Appendix 8: CLABSI Investigation Nurse Letter
As part of our commitment to eradicate central line-associated blood stream infections (CLABSIs), we are performing a root cause analysis of all CLABSIs. Patient _______________ met the U.S. Centers for Disease Control and Prevention criteria for a CLABSI on (insert date). Because the event occurred more than 48 hours from the time of line insertion, it is clear that this CLABSI is likely related to line maintenance.
We are asking the clinical personnel who cared for this patient in the days prior to the CLABSI to help us in our root cause analysis. Please take a moment to think about the (insert type of line) maintained from (insert dates of the 72 hour period before infection), and please let our team know about any factors you think could have introduced infection. If nothing particular stands out in your mind, please answer as many of these questions that you are able:
- Were there any observed breaches of proper hand hygiene by anyone involved in line care for this patient?
- Was the dressing integrity assessed and dressing change date addressed during your shift?
- If there was a dressing change during your shift, was 2 percent chlorhexidine/70 percent alcohol used instead of iodine?
- Was the hub scrubbed with 70 percent alcohol or 2 percent chlorhexidine/70 percent alcohol followed by air dry each time the line was accessed?
- Was this line manipulated or used by any other staff besides the unit's physicians or nurses (e.g., anesthesia, radiology, etc.)?
- If there was an IV administration sets change on your shift, were the old IV administration sets outdated (24 hours for lipids and blood, 96 hours for all others)?
- If you changed parenteral fluids on your shift, were the parenteral fluids you changed older than 24 hours?
- Was the necessity of lines for this patient discussed on daily patient rounds?
- What was the nursing ratio for this patient (e.g., 1:1, paired, etc.)?
- Can you identify any other possible sources of contamination for the closed/sterile tubing-central venous catheter circuit?
- Were there any mechanical problems (not drawing, difficult to infuse, repositioned, etc.) with the central venous catheter prior to infection date?
- Are there any patient factors that you believe may have contributed to this infection?
- Are there any issues related to central line care on the unit that you would like to share?
Thank you for improving patient care and your commitment to patient safety.
The CLABSI Eradication Team