Prevention of Central Line–Associated Bloodstream Infections: A Journey Toward Eliminating Preventable Harm
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- Weeks, K.R., Goeschel, C.A., Cosgrove, S.E. et al. Curr Infect Dis Rep (2011) 13: 343. doi:10.1007/s11908-011-0186-8
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Central line–associated blood stream infections (CLABSI) are among the most common, lethal, and costly health care–associated infections. Recent large collaborative quality improvement efforts have achieved unprecedented and sustained reductions in CLABSI rates and demonstrate that these infections are largely preventable, even for exceedingly ill patients. The broad acceptance that zero CLABSI rates are an achievable goal has motivated and stimulated diverse groups of stakeholders, including public and private groups to develop policy tools and to mobilize their local constituents toward achieving this goal. Nevertheless, attributing reductions in CLABSI rates achieved by multifaceted quality improvement efforts solely to the use of checklists to ensure adherence with appropriate infection control practices is an easily made but crucial mistake. National CLABSI prevention is a shared responsibility and creating novel partnerships between government agencies, health care industry, and consumers is critical to making and sustaining progress in achieving the goals toward eliminating CLABSI.
KeywordsCentral line infectionsHealth care–acquired infectionsHealth care–associated infectionsHealth policyCLABSI
Health care–associated infections (HAIs) exact a significant toll on human life. They are among the top 10 causes of death in the United States, accounting for an estimated 1.7 million infections and 99,000 associated deaths in 2002 [1••]. In hospitals, they are a significant cause of morbidity and mortality. In addition to the substantial human suffering exacted by HAIs, the financial burden attributable to these infections is staggering. Studies suggest that HAIs cause an estimated $28 to $33 billion in excess health care costs each year [2•].
Major site of infection
Hospital cost per infection
Total annual hospital cost (in millions)
Deaths per year
Surgical site infection
Central line–associated blood stream infection
Catheter-associated urinary tract infection
In this manuscript, we will review the pathophysiology and microbiology of CLABSI, escalating pressure from stakeholders to reduce CLABSI, and describe successful collaborative efforts that have achieved unprecedented and sustained CLABSI reductions. As the paradigm shifts from viewing CLABSI as “an inevitable complication of complex care” to a “preventable cause of unnecessary harm,” these successful efforts highlight existing opportunities to save patients’ lives and the expense of device-associated infections.
Definitions of CLABSI
Catheter-related bloodstream infections in patients > 1 year of age, as defined by the Centers for Disease Control and Prevention National Healthcare Safety Network
Criterion 1: Patient has a recognized pathogen cultured from one or more blood cultures
Organism cultured from blood is not related to an infection at another site
Criterion 2: Patient has at least one of the following signs or symptoms:
Fever (temperature > 38°C), chills, or hypotension
Signs and symptoms and positive laboratory results are not related to an infection at another site
Common skin contaminant (ie, diphtheroids [Corynebacterium species], Bacillus [not B. anthracis] species, Propionibacterium species, coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus species, Micrococcus species) is cultured from two or more blood cultures drawn on separate occasions
Pathophysiology and Microbiology of CLABSI
Most CLABSI are caused by contamination of the insertion site or by contamination of the catheter hub with subsequent tracking of bacteremia down the external or internal surface of the catheter into the blood . CLABSI can also be caused by seeding of the catheter hematogenously from another source of infection or from contaminated infusate, although these mechanisms are uncommon. Insertion site contamination is most likely if the CLABSI occurs early after insertion and hub contamination is more likely if the CLABSI occurs later .
The microbiology of CLABSI relates directly to the pathophysiology of infection. In a recent report summarizing data on the etiology of CLABSI identified through NHSN, 60% of CLABSI were caused by Gram-positive organisms which are commonly found on the skin (34% coagulase-negative staphylococci, 16% Enterococcus species, and 10% Staphylococcus aureus) . The remainder of CLABSI was caused by a mix of Gram-negative organisms (18%), Candida species (12%), and other organisms (10%). CLABSI reported to NHSN are from ICU patients, although the distribution of causative agents was almost identical in a study that evaluated the etiology of CLABSI in non-ICU patients in a single academic center (57% Gram-positive cocci, 17% Gram-negative rods, and 14% Candida species) . Understanding the pathophysiology and microbiology of CLABSI is essential to future efforts to develop effective strategies for CLABSI prevention.
Race to Zero CLABSI Rates
The burden of HAIs is at the forefront of many public health debates and recent pressure to reduce these infections comes from several sources. The Department of Health and Human Services (HHS) and other stakeholders, both public and private, recognize that many HAIs, including CLABSI, are preventable and have taken definitive steps toward reducing the occurrence of these infections using different regulatory and policy tools. In 2009, The Joint Commission added the elimination of CLABSI as a national patient safety goal . Most recently, the US Secretary of Health and Human Services established a national goal to reduce CLABSI by 75% over the next 5 years [9••].
These policy tools act as the overarching mechanism of many coordinating forces to improve quality of care, and are the result of a growing body of evidence demonstrating that these infections are largely preventable, even for exceedingly ill patients [9••], , [11••]. Broad acceptance that CLABSI rates of zero are an achievable goal [12••] has motivated and stimulated a diverse group of stakeholders to mobilize their local constituents toward achieving this goal. In 2010, as part of the annual update to its Inpatient Prospective Payment Schedule (IPPS) rule, CMS announced that hospitals must begin reporting CLABSI rates for adult, pediatric, and neonatal intensive care unit (ICU) patients to the CDC NHSN database and that these publically reported rates will be tied to the payment rate for all Medicare and Medicaid inpatients starting in fiscal year 2013. Moreover, CMS will publically report these hospital-specific rates on the Hospital Compare website. In an example of increasing interagency collaboration, the CDC is partnering with state health departments to facilitate reporting these hospital data to the CDC NHSN database. The CDC released its first state-level report of CLABSI rates based on NHSN data in 2010 [13•]. The CLABSI data are summarized using standardized infection ratio (SIR; observed [actual] number of events / expected [predicted] number of events [13•]), a statistic used to measure relative difference in HAI occurrence during a reporting period compared to a common referent period (ie, standard population). In HAI data analysis, the SIR compares the actual number of HAIs in a facility or state with the baseline US experience (ie, standard population), adjusting for several risk factors that have been found to be most associated with differences in infection rates. The CLABSI SIRs serve as a starting point for analysis and action that will help states identify HAI priorities and guide prevention efforts; these data are meant to be helpful for public health and policy decisions [13•].
Other large organizations and professional societies are also playing an active role in efforts to achieve national CLABSI reductions. A 2010 publication announced the partnership and call to action toward the elimination of HAIs by the Association for Professionals in Infection Control and Epidemiology (APIC), the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the Association of State and Territorial Health Officials (ASTHO), the Council of State and Territorial Epidemiologists (CSTE), Pediatric Infectious Diseases Society (PIDS), and the CDC [12••]. Clearly outlined within the document is the declaration that “there exists a real opportunity to eliminate specific HAIs, including CLABSI.” Consumers Union, The Leapfrog Group, and many other consumer and business groups are also mobilizing efforts to support the goal of zero CLABSI.
Interventions to Prevent CLABSI
Numerous guidelines summarize effective interventions and provide recommendations for the prevention and monitoring of CLABSI [14••]. These guidelines focus on best practices for prevention before, at the time of, and after catheter insertion. Before insertion, for example, health care personnel need to be educated about CLABSI prevention and perform appropriate hand hygiene. At the time of insertion, personnel should avoid the femoral site in adult patients, use maximal sterile barrier precautions and chlorhexidine-based antiseptic for skin preparation, use a catheter cart or kit that contains all necessary components for aseptic catheter insertion, and use a checklist to ensure adherence to infection prevention practices. After insertion, catheter hubs, needleless connectors, and injection ports should be disinfected prior to access, clear occlusive dressings and proper aseptic technique during dressing changes should be used, nonessential catheters should be removed, and surveillance for signs of infection should be conducted.
Since the publication of the most recent prevention guidelines in 2008 [5, 14••], additional studies have focused on anti-infective compounds such as chlorhexidine gluconate–impregnated sponges, chlorhexidine/silver sulfadiazine, 5-fluorouracil, bismuth, minocycline/rifampin, and trisodium citrate to reduce bacterial transmission along the catheter tract [15–17] and anti-infective lock solutions containing gentamicin or ethanol to reduce bacterial transmission through the catheter ports [18–20]. Future guidelines, including updated guidelines from the Healthcare Infection Control Practices Advisory Committee (HICPAC), will likely evaluate the strength of this recent evidence in the context of existing prevention strategies.
Successful CLABSI Program Prevention Program Efforts
The Pittsburgh Regional Healthcare Initiative  and Johns Hopkins CUSP/CLABSI program implemented in Michigan as the “Keystone ICU project”  are the first large-scale statewide efforts that clearly demonstrate that the vast majority of CLABSIs are preventable. The Michigan Keystone ICU project, recognized by the HHS as the first in a series of success stories in American health care , combined a formal model to translate evidence into practice  with a comprehensive unit-level patient safety intervention to improve culture, learn from mistakes, and develop partnerships with senior leaders .
The 103 Keystone ICU teams achieved a 66% reduction in CLABSI during the 2 years of the project . From baseline to the end of the initial 16 to18-month evaluation period, the mean rate of bloodstream infection significantly decreased by 12% per quarter (95% CI, 9%–15%). Perhaps more significant is the recent confirmation that teams sustained those improvements. During the 19 to 36-month sustainability period, the bloodstream infection rate did not significantly change from the rate achieved at the end of the initial evaluation period (1% decrease per quarter; 95% CI, 9% decrease to 7% increase) [11••]. Furthermore, implementation of the Keystone ICU project was associated with a significant decrease in hospital mortality in Michigan (from any cause), in adults 65 and older compared to more than 350 hospitals in the surrounding regions [25•]. If these results could be replicated, broad use of this intervention could significantly reduce the majority of morbidity, mortality, and costs of care associated with these infections. Several additional single-hospital and multicenter studies have reported decreased CLABSI rates by increasing compliance with evidence-based recommendations [26–28]. Rhode Island was the first state to replicate the Keystone ICU results. CEOs and medical leaders from each hospital in the state joined with leaders from the hospital association, the quality improvement association, the quality institute, and the two major insurers along with researchers from Johns Hopkins to implement the program. Some methods used to implement were culturally driven, and some were geographic. Rhode Island is a small state and half of the ICUs in the state are in one health system. Rhode Island is the first state where every ICU (n = 23) participated in the project, and they achieved dramatic reductions in CLABSI rates. The statewide mean CLABSI rate decreased 74% from 3.73 (median 1.95) infections per 1,000 catheter days to 0.97 (median 0) infections per 1,000 catheter days (P = 0.0032) [29••].
Lessons in Adaptive Change
The Johns Hopkins CUSP/CLABSI program provides a number of tools to assist teams that aim to eliminate CLABSI. The evidence-based central line insertion checklist and a central line maintenance checklist to help ensure adherence with infection control practices for the prevention of CLABSI are among those tools. Yet attributing the reduction of infections in the Michigan Keystone ICU and Rhode Island projects solely to the use of checklists is an easily made but crucial mistake [30•]. Used widely in other industries, checklists are a good way of making certain that technical tasks get done in a standardized fashion, and can help workers perform a task by reducing the ambiguity about what to do. For example, wash your hands before inserting a central line, use chlorhexidine for skin antisepsis, and use full barrier precautions during insertion are all technical tasks.
Nevertheless, this work is far more complicated than simply implementing a checklist. Checklists only work if used consistently, and there are often substantial social and cultural barriers that can get in the way. The checklists were just one component of a multifaceted approach to summarize and simplify what to do; measure and provide feedback on outcomes; and perhaps the most difficult of all, improve culture and teamwork.
In our experience with these large statewide collaborative efforts, many hospitals have participated in prior CLABSI prevention programs and many hospitals often reported “already use a checklist” yet their infection rates remain high. Further exploration often reveals two possible explanations. Either providers were not using the checklist because they did not believe it necessary, or they were using the checklist but nurses were not correcting doctors who failed to follow the checklists for fear of being chastised or humiliated—an all too common occurrence. To eliminate infections, we have to improve the way nurses, doctors, and other staff work together. In contrast to the technical tasks, successful efforts require additional adaptive work to ensure compliance with the checklist. Adaptive work requires changes in local values, attitudes, and beliefs  and is often much more challenging.
Improving Teamwork and Culture
As part of the Michigan Keystone ICU and Rhode Island projects, ICU teams implemented the Comprehensive Unit-Based Safety Program (CUSP). CUSP is a Johns Hopkins intervention that helps organizations improve their safety culture and teamwork and learn from mistakes [24, 32]. CUSP is perhaps the only strategy for improving hospital culture that has worked effectively on a large scale. In the Michigan Keystone ICU project for example, CUSP implementation was associated with dramatic reductions in the number of units that were in the culture “needs improvement” zone—defined as any clinical area where less than three out of five providers agree that there is good teamwork climate or good safety climate [33, 41]. Using the CUSP tools, those teams who were struggling with culture were able to dramatically improve both their safety climate and their teamwork climate. In our experience, CUSP was a critical component in the success of the Michigan Keystone ICU and Rhode Island projects.
Before teams implement CUSP, there is important pre-work that needs to be done. First, this is a multidisciplinary effort and as such, teams need to make sure that important stakeholders are at the table including physicians, nurses, infection preventionists, educators, and senior executives. It is essential that frontline providers take ownership of these efforts. Far too often organizations try to implement these efforts at a mid-level manager or hospital infection control level and they fail to include frontline providers. While engaging frontline providers can be challenging given their clinical commitments, in our experience it is essential to the success of implementation at the unit level. Second, teams evaluate their culture using a validated survey at the start of these efforts and annually .
In brief, CUSP is a five-step iterative and validated process to improve safety culture [24, 41]. Step 1 educates staff and hospital executives on the science of improving patient safety including systems redesign. Step 2 asks teams to identify defects (defined as any clinical or operational event that should not recur) using a two-question anonymous survey designed to tap their unique knowledge of unit-level safety risks. Step 3 involves “senior executive partnerships” to bridge the gap between management and frontline staff, help prioritize safety hazards and interventions, and provide resources to improve safety. Step 4 asks staff to choose and begin work to address actual and near-miss safety events that happen on the unit. The goal is to learn, not merely recover from mistakes. Step 5 asks teams to implement tools (eg, daily goals, morning briefings, team checkup tool) to help improve teamwork and communication (www.safercare.net).
Accountability for preventable harm is important to ascribe when proven methods to eliminate the harm exist. Unfortunately, little has improved in the 10 years since the IOM report . In fact, performance on some metrics has gotten worse . Yet hundreds of hospitals have achieved and sustained CLABSI rates near zero, and all should be held accountable to do so. Achieving elimination of CLABSI across the country requires action at multiple levels of influence, and those gears are in motion.
At the regulatory level, public reporting of CLABSI may serve a catalyst to stimulate higher levels of performance and payment policy tied to public reporting of hospital-specific CLABSI rates may result in additional hospital attention to this problem. Accreditation standards, national patient safety goals, and professional society guidelines for clinical care based on emerging evidence are all performance levers to foster accountability. Nevertheless, it is not clear that additional regulations and financial incentives alone are sufficient to bring sustained reductions in HAIs across the US. Efficient and effective pursuit of the goal is a shared responsibility. There is a need to leverage and synergize efforts by government agencies, healthcare industry, and consumers.
One promising example of how this is being done is an Agency for Healthcare Research and Quality (AHRQ)–funded national effort to prevent CLABSI in US hospitals (www.onthecuspstopbsi.org). The On the CUSP: Stop BSI project is led by a unique partnership of the Health Research and Educational Trust (nonprofit research and educational affiliate of the American Hospital Association), the Johns Hopkins University Quality and Safety Research Group, and the Michigan Health and Hospital Association’s Keystone Center for Patient Safety and Quality. On the CUSP: Stop BSI requires that participating states have a lead organization that works with hospitals across their state to implement the clinical and cultural changes needed to reduce CLABSI. As of March 2011, 45 state hospital associations and one other umbrella group have committed to leading the project in their states. Collectively, these groups have recruited more than 1,000 hospitals and 1,710 hospital teams to participate in the project. Twenty-two states began the project in 2009, 14 states and the District of Columbia began during 2010, and at least eight states plus Puerto Rico began the effort in early 2011. Preliminary evaluation of the impact of the project focused on patients from the adult ICUs, representing 22 states and more than 350 hospitals that began participating in the project during 2009. Compared to a baseline CLABSI rate of 1.8 infections per 1,000 central line days in these units, after 12–15 months of participation in the project, CLABSI rates have decreased to 1.17 infections per 1,000 central line days, a relative reduction of 35% . Additional analyses are underway.
One significant concern about this national project, however, is that only 20% of hospitals in the United States are participating in the project (as of November 2010). Lack of hospital participation highlights the changes in culture necessary at the organizational or institutional level, endorsing leadership priorities that foster patient-centered care. Hospital boards, for example, need to provide support and oversight of quality improvement, patient safety, and culture change in their organizations—functions that go beyond the traditional board oversight of financial performance, medical staff credentialing, and CEO performance. Board leadership is essential to establish a culture of patient safety and to hold health care organizations accountable for providing high-quality care and reducing CLABSI.
Thus, tools included in the national CUSP/CLABSI project go beyond the clinical team and unit management. Checklists for boards, CEOs, and senior leaders, and infection preventionists describe and link ways they can support efforts to implement CUSP and reduce CLABSI that are task and role specific .
Central line–associated bloodstream infections are among the most common, lethal, and costly HAIs, and they exact a significant toll on human life. The burden of HAIs, including CLABSI, is at the forefront of many public health debates and the increasing pressure to eliminate these infections is unprecedented. The results of recent successful large collaborative efforts have contributed to a paradigm shift from viewing CLABSI as inevitable to preventable. Far too many patients continue to suffer preventable harm from preventable infections. National elimination of CLABSI is an ambitious and challenging goal that will require novel partnerships and synergy between government agencies, health care industry, and consumers.
No potential conflicts of interest relevant to this article were reported.