Implementation of Interventions to Sustain Reductions in Central Line
Associated Bloodstream Infections
Andre Schotte, PhD, RN
PICC Team Leader
Riverside County Medical Center
26520 Cactus Avenue
Moreno Valley CA 92555
951-486-4920
[email protected]
Andre Schotte, RN, PhD, Victor Lange, MS, MSPH, CRC, Tim Royer, BSN, CRNI, Barbera Herzog-Taft, RNC, MS, NNP, CNS,
Karen Anderson, MT, CIC, Lee Steininger, RN, CIC, Deborah R. Campbell, MSN, RNC, CCRN
ABSTRACT
Issue: Central line associated bloodstream infections (CLABSIs) are a preventable cause of poor patient
outcomes. The aim of this study was to systematically review successful programs implemented at seven
different facilities to reduce CLABSIs.
Project: A multicenter retrospective time series study was conducted to compare CLABSI rates before and
after intervention periods at seven hospital facilities. Participating facilities were alike in their desire to
reduce CLABSI rates and the interventions which were introduced, but varied in facility type, size, patient
population and geographic location. CLABSI rates were tracked by all facilities as defined by the National
Healthcare Safety Network (NHSN).
Results: Before the interventions, the mean* CLABSI rate was 1.93 per 1000 catheter days in these ICUs.
After the interventions were implemented, the mean CLABSI rate dropped to 0.58 per 1000 catheter days, a
reduction of 70%, and was sustained as of the data collection date for periods varying from 6 to 30 months.
All seven facilities attributed their success in reducing CLABSIs to both the Central Line Bundle (CLB) and to
the more recent interventions with less supportive evidence. The experienced Vascular Access Teams at
these facilities were able to critically analyze the potential value of implementing these newer
interventions, and as a result of their efforts, found the following additions to the central line bundle were
associated with significant reductions in their CLABSI Rates, adding additional evidence to support the value
of these interventions:
•
•
•
•
•
Vascular Access Team
Staff Education
Chlorhexidine Eluting disc
Manufactured Catheter Securement Device
Swabable, positive displacement needleless connector, or clear version of the same connector
which provides a visible fluid path allowing assessment of flush technique
Lessons Learned: This multicenter retrospective study provides evidential support for the CLB as well as for
recently introduced interventions which resulted in a large and sustained reduction in CLABSI rates in these
seven (7) facilities.
PROJECT
RESULTS
A multicenter retrospective time series study was conducted to compare CLABSI rates before and after intervention
periods at seven hospital facilities. Participating facilities were alike in their desire to reduce CLABSI rates and the
interventions which were introduced, but varied in facility type, size, patient population and geographic location.
CLABSI rates were tracked by all facilities as defined by the National Healthcare Safety Network (NHSN).
Before the interventions, the weighted mean CLABSI rate was 1.93 per 1000 catheter days in these ICUs. After the
interventions were implemented, the weighted mean CLABSI rate dropped to 0.58 per 1000 catheter days, a
reduction of 70%, and was sustained as of the data collection date for periods varying from 6 to 30 months.
All seven facilities implemented a variant of the Central Line Insertion Bundle, and then went further and
implemented specific strategies and technologies to complement the bundle. Data analysis and sharing of
information revealed commonalities in practices and products, listed in the Table below.
Implemented at Hospitals (Each Hospital is identified by a letter)
Interventions Implemented
A
B
C
D
E
Central line associated bloodstream infections (CLABSIs) are a preventable cause of poor patient outcomes.
The aim of this study was to systematically review successful programs implemented at seven different
facilities to reduce CLABSIs.
Patient in Hospital B – 26 Bed Level 3 NICU
with 3 swabable, positive displacement
needleless connectors on a tri-fuse
extension set
G
Before
BSI
Rate*
Before
Catheter
Days
(Avg/Mo)
Before
Duration
(Months)
After
BSI
Rate*
After
Catheter
Days
(Avg/Mo)
After
Duration
(Months)
%
Reduction
A - Cardiac ICU of a 523
Bed Hospital
3.65
302/Mo
7
0.60
300/Mo
6
83%
B - 26 Bed Level 3 NICU
2.65
112/Mo
24
1.63
120/Mo
30
38%
C - 26 Bed PICU
3.57
201/Mo
36
0.40
218/Mo
12
89%
D - 337 Bed County
Hospital - 3 Adult ICUs**
3.40
155/Mo
36
0.49
185/Mo
12
85%
E - 51 Bed Long Term
Acute Care Facility
2.24
746/Mo
12
1.18
569/Mo
12
47%
F - 1500 Bed Acute
Tertiary Care Teaching
Facility MSICU
2.50
392/Mo
12
1.30
313/Mo
12
48%
17
100%
Central Line Bundle: Hand Hygiene, Maximal
Barrier Precautions upon insertion,chlorhexidine
skin antisepsis, optimal catheter site selection
with avoidance of femoral vein for central
venous access in adult patients, daily review of
line necessity with prompt removal of
unnecessary lines
YES
Vascular Access Team
YES
YES
YES
YES
YES
YES
YES
Staff Education
YES
YES
YES
YES
YES
YES
YES
G - 350 Bed Acute Care
VA Hospital
0.44
1,150/Mo
18
0.00
1,020/Mo
Chlorhexidine Eluting Disc
YES
NO
NO
YES
YES
YES
YES
A - G Weighted Mean
CLABSI Rate
1.93
436/Mo
avg.
20.7 avg.
0.58
389/Mo
avg.
Manufactured Catheter Securement Device
YES
NO
NO
YES
YES
YES
YES
Swabable, positive displacement needleless connector
or
Same swabable, positive displacement needleless
connector but with a clear housing
*Rates are based on central-line associated BSIs per 1000 central venous catheter days
**PICC line only
ICU = IntensiveCare Unit; NICU = Neonatal ICU, PICU = Pediatric ICU, MSICU = Medical/Surgical ICU
YES
YES
YES
YESClear
YESClear
YESClear
YESClear
YES
YES*
YES
YES
*NICU did not use CHG skin antisepsis, used saline wipes
YES
YES
14 avg.
70% avg.
CONCLUSIONS
All seven facilities attributed their success in reducing CLABSIs to implementing successful interventions. In reviewing
the inventions implemented, there were four interventions that were common to all seven facilities:
*Weighted means were used
ISSUE
F
Hospital
When these devices are partnered
together they create a new standard of
care by dramatically reducing the
incidence of catheter-related
complications.
A clear needleless
access device
reminds nurses to
complete best
practices - priming,
swabbing and flushing
•
•
•
•
Central Line Bundle
Vascular Access Team
Staff Education
Swabable, positive displacement needleless connector, or clear version of the same connector which
provides a visible fluid path allowing assessment of flush technique
The one common technology implemented by all facilities was the swabable, positive displacement connector. The
general theme in discussions between the contributing members of this study was that all facilities implemented
some form of an IV Team, the Central Line Bundle and staff education. These interventions succeeded in reducing
CLABSI rates to a certain extent, but then rates would reach a plateau. It was the implementation of a swabable,
positive displacement needleless connector which helped break through the plateau and decrease CLABSI rates even
further. Participating clinicians also agreed that the features provided by this needleless connector aided in sustaining a low CLABSI rate over a prolonged period of time.
LESSONS LEARNED
This multicenter retrospective study provides evidential support for the CLB as well as for recently introduced
interventions which resulted in a large and sustained reduction in CLABSI rates in these seven (7) facilities.