A new toolkit offers practical approaches and tools for home care professionals and hospital acute care providers to systematically assess the risks for and reduce the incidence of central line–associated bloodstream infections in patients receiving home health care services. The toolkit, which is the result of collaborative work between the grant-making United Hospital Fund and two grant recipients, Montefiore Health System and Northwell Health, will fill an important resource void for home care providers working with patients transitioning from the acute care hospital setting to home with a peripherally inserted central catheter (PICC) or other central lines used for administration of intravenous fluids, blood products, medications, and parenteral nutrition, among other treatments including chemotherapy.                                                                                                      

The substantial number of patients discharged from hospital to home with central lines in place lends an urgency to prevent these infections in the home care setting. A central line is an intravascular catheter that terminates at or near the heart or in one of the great vessels.

One of the challenges facing health care providers is that home care staff, partnering with patients and/or family caregivers, are responsible for safely maintaining central lines inserted in the acute care setting, without having a clear maintenance standard. In contrast, hospitals across the country have instituted efforts to reduce central line–associated infections in the inpatient setting, especially in intensive care units. These efforts have resulted in a 46 percent decline nationally in the incidence of catheter infections in the acute care setting between 2008 and 2013. Much of the work to date in home care settings has focused on defining the number of PICC lines in use and evaluating the extent of infections outside the acute care hospital setting, rather than adopting a systematic approach to infection control.

The strategies, recommendations, and tools included in the toolkit Preventing Central Line-Associated Bloodstream Infection (CLABSI) in the Home Care Setting (https://www.uhfnyc.org/publications/881133) are intended to provide a basic framework that can be customized to meet the needs of individual institutions regardless of size, academic teaching status, staffing model, patient population, or available resources. Among its components are:

• Surveys and related tools to help health care providers assess home care clinicians’ current practices and better understand central line–associated bloodstream infections in the home care setting.
• A data collection tool to help home care providers monitor the number and types of central lines they are overseeing, as well as any related possible or confirmed infections.
• Results of two surveys administered by Montefiore and Northwell Health, which provide insights on some of the special challenges of home care, such as a cluttered environment or unsanitary conditions related to pets.

The toolkit also points readers to a single source (the Centers for Disease Control and Prevention’s Healthcare Infection Control Practices Advisory Committee guidelines) for clinical information about central line maintenance.

“As more and more health care services are delivered in the community, it is becoming increasingly clear that more guidance is required for a broader range of clinicians in settings beyond hospitals,” said Hillary Jalon, director of quality improvement at United Hospital Fund. “Montefiore and Northwell Health identified this particular need and opportunity in 2012. We expect that this work will help address an often overlooked challenge, not just throughout the region, but across the country.”

Montefiore and Northwell—their respective hospitals and home care networks—worked together and with UHF, supported by an aggregate $140,000 in UHF grant funding, to identify and evaluate current practices of caring for central lines in the home care setting, design a methodology for data collection, and, ultimately, create the toolkit.

“There are no uniform procedures or requirements for reporting infections in the home care setting to any national database, or even back to the hospital’s infection control team,” said Donna Armellino, RN, MPA, CIC, vice president for infection control at Northwell Health. “This toolkit provides standardized tools that will allow for better data and better reporting than we’ve ever had.”

“When infections in the home care setting do occur, the tools we’ve created will trigger important conversations between home care providers and a hospital infection prevention control team—conversations that don’t routinely happen today,” said Audrey Adams, RN, MPH, CIC, director of Infection Prevention and Control at Montefiore Health System. “Collaboration between home care and hospital providers will contribute to meaningful root cause analyses to prevent future occurrences.”

The creation of the toolkit was built on earlier work by UHF, which, in partnership with Greater New York Hospital Association, led the Central Line–Associated Bloodstream Infection (CLABs) Collaborative. That collaborative operated from 2005 to 2008 and resulted in the 38 participating hospitals’ recording a 54 percent reduction in the incidence of targeted infections by the final year.

Preventing Central Line-Associated Bloodstream Infection (CLABSI) in the Home Care Setting is available free of charge on the UHF website at https://www.uhfnyc.org/publications/881133.