QAPI 105 - Diagnostic Stewardship Using “ticket to Culture” Results in Reduction of Central Line Associated Bloodstream Infections

Background: An estimated 30,100 central line-associated bloodstream infections (CLABSI) occur in intensive care units and wards of U.S. acute care facilities each year. April 2020 through June 2021, the hospital-wide CLABSI Standardized Infection Ratio (SIR) was 0.82 with 11 cases, 10 out of which were in the Intensive Care Unit (ICU).

Methods: A Plan Do Study Act (PDSA) cycle was used in this performance improvement project. In order to reduce CLABSIs, a multi-disciplinary team composed of nursing leaders, physicians, infection preventionists and laboratory personnel was formed. Since the majority of the CLABSIs had occurred in the ICU, having Intensivists as Physician Champions helped drive the success of the project. One action taken was initiation of the “Ticket To Culture”. The purpose of this initiative was to hardwire diagnostic stewardship. This initiative provided support for selecting the right test, for the right patient, at the right time, in order to optimize clinical care and antimicrobial usage. The Ticket was created by Infection Prevention, and was distributed to nursing. All nurse leaders were educated on completing the form prior to sending blood cultures to the laboratory. All phlebotomists were also in-serviced for the process. Laboratory staff would not process any blood culture without a completed Ticket.

Results: The actions above resulted in a CLABSI SIR of 0.23, with a total of 3 incidences July 2021 through September 2022. This was a 72% reduction in SIR which is statistically significant with two-tailed t test, p value of 0.038. The ICU had 76% reduction in the CLABSI SIR and total cases decreased to 2.

Conclusions: Ticket To Culture prevented the overdiagnosis of CLABSI which could lead to inappropriate antimicrobial use, unnecessary cost, antimicrobial resistance, and adverse drug events. The initiative highlighted that beside Infection Prevention and the involvement of physician and nursing champions can contribute to preventing HAIs.