Table 2.

Translational Research Contributions to Success in Preventing Central Line–Associated Bloodstream Infections

Translational Research Phase	Contribution
Phase 0 (T0): discovering opportunities and approaches to prevent adverse events through surveillance, outbreak investigation, epidemiologic studies, and basic science	Observation that central venous catheters are the most important risk factor for bloodstream infection (National Nosocomial Infection Surveillance system data), especially in critically ill and high-risk patients [19]; microbiologic studies suggesting that contamination of cutaneous insertion site by skin flora is responsible for most early infections, leading to the testable hypothesis that improving methods for cutaneous decolonization before catheter insertion may be an effective preventive strategy [20,21]
Phase 1 (T1): using T0 discoveries to develop and test novel candidate interventions in a small sample of patients or in limited health care settings	Observational study showing that catheters inserted under more stringent barrier precautions had lower risk of infection [20]; evidence that non–subclavian vein insertion sites increase the risk of catheter contamination and infection [20,22]; evidence that chlorhexidine-based preparations are highly effective at sustained suppression of skin colonization [23]
Phase 2 (T2): broadening and strengthening the evidence base for promising interventions and developing evidence-based guidelines	Randomized, controlled single-center trial demonstrates maximal barrier precautions effective in reducing bloodstream infection [24]; randomized, controlled trials demonstrating that chlorhexidine is superior to other skin preparations in reducing bloodstream infection rates [25–27]; meta-analysis of numerous trials evaluating chlorhexidine-based skin disinfection indicating a significant reduction in bloodstream infections [29]; formal economic evaluation indicating that chlorhexidine site disinfection reduces infections and saves money compared with povidone-iodine [30]; systematic review of the few studies evaluating maximum sterile barriers indicating a likely benefit [31]; formal economic evaluation indicating that maximum sterile barriers reduce infections and save money compared with standard barriers [32]; distillation of evidence to prevent central line–associated bloodstream infection in comprehensive evidence-based guidelines [30]
Phase 3 (T3): moving evidence-based guidelines into practice, through delivery, dissemination, and diffusion research	Evidence that collaborative regional extension of bloodstream infection prevention “bundles” leads to significant reductions among critically ill across large and diverse populations of hospitals (ie, Michigan Keystone Initiative, Pittsburgh Regional Health care Initiative) [6,7]
Phase 4 (T4): national implementation and evaluation	National support to state health departments to promote bloodstream infection (and other health care–associated infection) prevention collaboratives [9]; national expansion of Michigan Keystone Projects [6] (Agency for Healthcare Research and Quality); monitoring of population-based changes in outcomes (eg, through National Healthcare Safety Network surveillance [46]) and exploration of positive and negative outliers