Beyond the Bundles for Reducing Central-Line Associated Bloodstream Infections: Additional Measures used to reach the Zero Target

Background: Central-Line Associated Bloodstream Infections (CLABSI) is associated with increased morbidity, mortality and costs of care. CLABSI are preventable complications that cause as many as 11 deaths everyday in the U.S.  Mortality rates are reported to be as high as 35% with a resulting 28,000 deaths per year in the United States.  These deaths are avoidable with proper implementation of insertion and care bundles. The cost of treatment of these line infections is staggering and detrimental to both patients and healthcare systems.  Each infection can cost as much as $52,000 to treat.

Objective: The intent of this Evidence Based Practice (EBP) project was to implement the evidence present in the literature with a goal to reduce CLABSI rates.  As this project evolved, it became apparent that data in the literature was less than what was required to meet a zero target. More interventions were melded to best serve our patients.

Methods:  Our institution formed a community wide initiative. The initiative was partially funded through the Institute for Healthcare Improvement (IHI) and Agency for Healthcare Research and Quality (AHRQ) 100,000 Lives Campaign. Recommendations from these government agencies were implemented, including the following insertion bundle:

• Hand hygiene
• Maximal sterile barrier precautions upon insertion
• Chlorhexidine skin asepsis
• Optimal catheter site selection
• Daily review of catheter necessity.

We moved toward a nurse based Vascular Access Team for all PICC and arterial line insertions, and offered several opportunities for education.

In November 2008, we switched from a negative displacement end cap to a positive displacement cap, the MaxPlus Clear.  Results from this change were apparent immediately.  

Results:  Between November 2008 and November 2009 we saw a 66.7% reduction in line occlusions and a 56.5% reduction in Alteplase use.

CLABSI rates decreased from 1.955 infections per 1,000 catheter days to 0.369 per 1,000 catheter days, representing an 81.1% decrease.

Total cost saving through the intervention of changing from negative to positive displacement is as follows: Alteplase reduction savings of $93,340 and CLABSI reduction savings of $420,000 - $600,000,   for an annual savings of $512,240 - $693,340. 

Conclusions:  The implementation of insertion and care bundles along with intensive education of both nursing and physician staff are important cornerstones in the reduction of CLABSIs.  By adding to the basic knowledge that is in the literature and using multiple layers of intervention, the Target Zero can be chased effectively and eventually attained.  The benefits of interventions used go beyond those of simple math calculations.  These include nursing autonomy, nursing satisfaction, improved patient outcomes, improved infection rates, lives saved, and chasing the zero target.