Innovations Beyond the Bundle: Central Line-Associated Blood Stream Infection Elimination

Background: Central line-associated bloodstream infections (CLABSI) increase hospital costs and length of stay as well as adversely impact patient mortality. Reduction efforts have focused on implementation of a set of measures as part of the CLABSI Prevention Bundle, a strategy that has been successful in various settings. Methodist Charlton Medical Center is a 305-bed, acute care, non-teaching community hospital serving an inner-city population in Dallas, Texas.  After intensive implementation of the CLABSI Prevention Bundle and compliance monitoring, it was determined that our CLABSI reduction efforts could be further enhanced.

Objective: To investigate and implement additional CLABSI preventative measures as part of the “Enhanced CLABSI Prevention Bundle”.

Methods: In March 2010, a staff–based Quality Council was chartered by our 24-bed medical-surgical ICU. The Critical Care Leadership, with input from the ICU Medical Director and Infection Prevention Staff developed goals for the Staff Quality Council, with CLABSI reduction as their inaugural task and top priority. In addition to ensuring implementation of the traditional CLABSI Prevention Bundle, the Staff Quality Council implemented the following action plan in May 2010, as part of the "enhanced CLABSI Prevention Bundle":

• Daily Chlorhexidine Gluconate (CHG) cloth bathing, with simultaneous elimination of re-usable plastic bath basins
• Aggressive “scrub the hub” campaign with 2% CHG
• Continued use of CHG impregnated dressing at the catheter insertion site
• Monitoring of all central line/PICC dressing changes by another RN and documentation on a checklist
• CHG wash of neck and chest or groin prior to surgical prep for central line/ PICC line placement
• Formalized protocol for biweekly IV tubing changes   
• Contract signed by RN staff outlining expectations related to compliance with line care, tubing changes and dressings

As successes of the ICU CLABSI elimination campaign were recognized, units outside the ICU adopted these innovative strategies. CHG baths were performed weekly for any patients with a central line, usage of basins for bathing was reduced when possible, and use of checklists was reinforced for compliance monitoring.  

Results: Since full implementation of the enhanced CLABSI Prevention Bundle measures in June 2010, no CLABSI has been identified in our facility. The quarterly ICU CLABSI rate decreased to zero following implementation of enhanced CLABSI Prevention Bundle measures. The CLABSI rate outside the ICU also decreased to zero for the quarter following implementation of these enhanced measures. Compared to FY09, the house-wide CLABSI rate for FY10 decreased by 38.5%.

Conclusions: Formal implementation of the enhanced CVC Prevention Bundle measures in the ICU, and informal adoption of similar measures outside the ICU, was successful in sustaining our CLABSI reduction efforts for the past 4 months.