How is Central Line-Associated Bloodstream Infection (CLABSI) attributed if an Intensive Care Unit (ICU) patient is boarding in another ICU away from the patient's primary service?

CLABSI Attribution in Boarding ICU Patients

CLABSI is attributed to the physical location where the patient is at the time the infection criteria are met, not to the primary service or intended ICU. 1, 2

Core Attribution Principle

The boarding unit receives the CLABSI attribution because the physical care environment—not administrative service assignment—determines infection risk. 1, 2 This location-based attribution reflects the reality that nurse-to-patient ratios, catheter care practices, and environmental factors in the boarding unit directly influence CLABSI development. 1

Rationale for Location-Based Attribution

The physical location determines CLABSI risk through several mechanisms:

• Reduced nurse-to-patient ratios and care by float nurses in boarding situations are independent CLABSI risk factors, both of which are characteristics of the physical care environment rather than the primary service. 1

• Inadequate catheter care and daily line access practices occur at the bedside, making the physical location the primary determinant of infection risk. 1

• Central line-days are counted based on physical patient location, not service attribution, as this enables accurate device utilization ratios and meaningful benchmarking. 1

CDC Definition and Timing Criteria

The Centers for Disease Control and Prevention defines CLABSI as a primary bloodstream infection in a patient who had a central line within 48 hours before infection development. 2 Attribution is based on:

• The location where the patient is physically present when blood culture collection occurs or when infection criteria are first met. 2

• The 48-hour window before BSI development is the critical timeframe—if the central line was in use during this period, the infection is attributed to that line. 2, 3

• Day 1 of infection is considered the first day on which negative blood culture results are obtained after initiating appropriate therapy. 2

Practical Attribution Algorithm

Follow these steps for accurate CLABSI attribution in boarding situations:

1. Identify the physical location where the patient is when blood cultures are obtained or infection criteria are met. 1, 2

2. Attribute the CLABSI to this physical location, even if the patient is boarding and awaiting transfer to their intended ICU. 1, 2

3. Confirm central line presence within 48 hours before BSI development—if the interval exceeds 48 hours, compelling evidence must link the infection to the central line. 2, 3

4. Document the exact physical location, date, and time of blood culture collection and central line insertion/removal. 2

Quality Improvement Implications

Location-based attribution serves critical quality improvement functions:

• Enables the correct team to implement prevention strategies where they are most needed, rather than obscuring problems through misattribution. 1

• 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 in the boarding unit where the infection actually occurred. 1

Implementation Considerations

To ensure accurate attribution in your facility:

• Establish clear documentation protocols for physical patient location to enable 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

• Create effective communication channels between infection prevention teams and unit managers to ensure accurate location tracking during boarding situations. 1

Common Pitfalls to Avoid

Do not attribute CLABSI based on:

• Primary service assignment or which team is managing the patient clinically. 1, 2

• Intended destination ICU where the patient is awaiting transfer. 2

• Where the central line was originally inserted—only the location during the 48-hour window before infection matters. 2, 3