CLABSI Attribution in Boarding Situations
The CLABSI should be attributed to the physical location where the patient is receiving care (the boarding ICU), not the service home unit, as infection surveillance is based on where the patient physically resides and receives nursing care at the time of infection development.
Rationale for Location-Based Attribution
The fundamental principle underlying CLABSI surveillance is that infections are attributed to the physical unit providing direct patient care, regardless of which service maintains primary responsibility for the patient. This approach is based on several key considerations:
Physical Care Environment Determines Risk
- Nurse-to-patient ratios, catheter care practices, and environmental factors in the boarding unit directly influence CLABSI risk 1
- The International Society for Infectious Diseases identifies reduced nurse-to-patient ratio and care by float nurses as independent CLABSI risk factors, both of which are characteristics of the physical care environment 1
- Inadequate catheter care and daily line access practices occur at the bedside, making the physical location the primary determinant of infection risk 1
Surveillance Methodology Standards
- Central line-days are counted based on physical patient location, not service attribution 1
- The CLABSI definition requires that the central line be in place within 48 hours before infection development, focusing on the temporal and physical relationship rather than administrative service assignment 1
- Device utilization ratios are calculated per physical unit to enable meaningful benchmarking and quality improvement 1, 2
Quality Improvement and Accountability
- Attribution to the boarding unit enables the correct team to implement prevention strategies where they are most needed 1, 3
- Infection prevention programs require accurate location-based data to identify unit-specific problems and target interventions effectively 1
- Misattribution would obscure true infection rates in both units, preventing appropriate quality improvement efforts 1, 3
Common Pitfalls to Avoid
Do not attribute based on which service wrote orders or maintains primary responsibility - this administrative distinction does not reflect the actual care environment that influences infection risk 1
Avoid splitting attribution between units - the infection should be counted entirely against the boarding unit where the patient physically resided when the infection developed 1
Do not delay attribution pending transfer - if the patient develops CLABSI while boarding, it counts against the boarding unit even if subsequently transferred 1
Implementation Considerations
- Ensure clear documentation of physical patient location for accurate central line-day counting 1
- Validate central line-days obtained from information systems by comparing to manual methods, with acceptable error not exceeding ±5% 1
- Establish effective communication between infection prevention teams and unit managers to ensure accurate location tracking 1, 4
This location-based attribution approach, while potentially uncomfortable for boarding units, provides the most accurate epidemiologic data and enables targeted prevention efforts where patients actually receive care 1, 3.