A Comprehensive Strategy to Eliminate Catheter Associated Bloodstream Infections in the Intensive Care Unit

Background: Central line associated bloodstream infection (CLABSI) is a persistent problem in intensive care units (ICU) resulting in increased costs, length of stay, and mortality. Research aimed at infection reduction through improved insertion methods has been published; however, little information or research regarding the effect of daily maintenance on infection rates is available. Insertion provides opportunity for contamination, but daily access, maintenance, and environmental practices by staff provide multiple opportunities for contamination each day.

Objective: The objective of our study was to identify the potential sources of contamination in daily maintenance of central lines, and then target each opportunity for infection with specific interventions. Each activity was audited monthly and feedback shared with staff.

Methods: Investigators received institutional review board approval. Based on initial flow mapping of processes, findings in research, and a staff questionnaire, a data collection plan was developed. Three months of observations helped identify variations in practice and deviations from best practice. Based on this data, changes were made to equipment, policies, and documentation. An education module was presented to all nurses in the ICUs. Data regarding variability and barriers identified as problematic were monitored continuously, and feedback was presented to staff monthly at meetings. The specific data points measured included central line days, compliance with dressing and cap changes, length of time for disinfection of ports prior to access, whether the nurse left the room during a procedure, hand hygiene before and after access, preferred site placement, and removal of femoral lines within 48 hours. A patient safety liaison compiled data and presented findings, and continued work as a staff nurse while acting as a resource.

Results: Despite variations in monthly individual data points, there were zero CLABSI following implementation of the program in both ICUs. Although direct education was a portion of the project, continuous feedback on multiple data points facilitated sustained change in a variety of areas including hand hygiene, adherence to documentation requirements, avoidance of femoral lines, and reduction in overall central line days. Regarding catheter access, increased time and friction were stressed, resulting in a significant increase in the length of time devoted to disinfection. Multiple behaviors were targeted, and monthly reporting and reinforcement continues.

Conclusions: A multiple method, continuous approach to sustained behavioral change was essential to success. A major advantage of this approach is that it could be tailored for any institution, unit, or problem. The use of staff members to collect data, drive change, and disseminate education likely contributed to both acceptance and sustainability of changes.