CCMH Achieves 100% Accuracy of CLABSI Reporting

CCMH was recently notified it was one of 12 randomly selected hospitals to receive a validation survey by the Oklahoma State Department of Health (OSDH) regarding mandatory reporting of Central Line Associated Bloodstream Infections (CLABSI).

Oklahoma has mandated reporting of CLABSI in critical care patients for a number of years and subsequently became a CMS mandate this year. Although required reporting has been in place, only recently has the validation process started. In other words, hospitals must be accurate and honest in their reporting.

CCMH was required to submit a list of all positive blood cultures from critical care patients for a six month period. Working from this list, an onsite audit was conducted by the OSDH. A full chart review of the preselected cases showed that of the seventeen patients, there was an accuracy of 100% for the cases that met  exclusion criteria and 100% for those that met reporting criteria.

The audit also included a survey and review of the hospital’s CLABSI surveillance system. Three key system factors were evaluated: microbiology support, Infection Preventionist (IP) competency, and the IP’s surveillance, monitoring and reporting system. The validation survey proved the system at CCMH to be very effective. Most importantly, an accurate system for gathering this type of surveillance data supports focus directed prevention strategies that transforms to better patient outcomes. For 2012, the CLABSI rate for the Critical Care Units is at an historical all time low.