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. 2021 Jun 22;22(5):186–193. doi: 10.1177/17571774211012471

Reduction of central line-associated bloodstream infections in a large acute care hospital in Midwest United States following implementation of a comprehensive central line insertion and maintenance bundle

Abraham E Wei 1,✉, Ronald J Markert 1, Christopher Connelly 2, Hari Polenakovik 3
PMCID: PMC8512874  PMID: 34659456

Abstract

Background:

Central line-associated bloodstream infection (CLABSI) is a preventable medical condition that results in increased patient morbidity and mortality. We describe the impact of various quality improvement interventions on the incidence of CLABSI in an 848-bed community teaching hospital from 1 January 2013 to 31 December 2017.

Aim:

To reduce CLABSI rates after implementation of a comprehensive central line insertion and maintenance bundle.

Methods:

A comprehensive bundle of interventions was implemented incorporating the standard US Centers for Disease Control and Prevention bundle with additional measures such as root-cause analysis of all CLABSI cases, use of passive disinfection caps on vascular access ports, standardisation of weekly central venous catheter (CVC) site dressing changes, and use of antithrombotic and antimicrobial-coated CVCs with fewer lumens. A retrospective study evaluated CLABSI rates and time of CLABSI onset after CVC placement in both intensive care unit (ICU) and non-ICU settings.

Results:

The annual number of CLABSI cases declined 68% (34 to 11 patients) from 2013 to 2017. There was a 30% decline in CVC days from years 2014 to 2017. Over the same period, CLABSI cases per 1000 CVC days decreased from 0.624 to 0.362: a 42% decline.

Conclusion:

Following the implementation of a comprehensive bundle of interventions for CVC insertion and maintenance, we found a reduction in rates of CLABSI.

Keywords: Central line-associated bloodstream infection, hospital-acquired infection, central venous catheter

Introduction

Central line-associated bloodstream infection (CLABSI) is a preventable medical condition that results in increased patient morbidity and mortality as well as increased medical costs. Among all types of healthcare-associated infections, CLABSIs have the highest mortality rate ranging from 12 to 25% (CDC, 2011). The cost per CLABSI averages US$70,696 with a range of US$40,412 to US$100,980 (AHRQ, 2012).

The US Centers for Disease Control and Prevention (CDC) estimated that an average of 30,100 cases of CLABSI occurred annually from 2008 to 2013 in intensive care units (ICUs) and non-ICUs of acute care facilities in the USA. CLABSI rates decreased 46% during that five-year period (CDC, 2020), and the latest national study found a 9% decrease from 2017 to 2018 (CDC, 2018). While significant improvements in reducing CLABSIs have been achieved over the years, there remains thousands of CLABSI cases each year.

Some of the reduction in CLABSI rates can be attributed to the application of central line bundles (CDC, 2011), which are a set of interventions that should be implemented to prevent infection. Common components of bundles include hand hygiene (HH), skin antisepsis, use of maximal sterile barriers during central venous catheter (CVC) insertion and prompt removal of unnecessary lines. The CDC has recommended its bundle of interventions, and medical facilities have implemented their own modified CLABSI bundles. In our 848-bed hospital we instituted additions to our CLABSI bundle from January 2013 to December 2017. Our multidisciplinary approach involved collaboration among medical providers (physicians and physician extenders), nurses and infection prevention staff. Retrospective analysis evaluated the impact of these quality improvement interventions on CLABSI rates.

Methods

Both ICU and non-ICU CLABSI cases in our hospital’s adult patient population from 1 January 2013 to 31 December 2017 were included in the study. Positive blood cultures with organisms on the CDC’s National Healthcare Safety Network blood stream infection eligible organism list (CDC, 2020) that occurred in patients with a CVC were flagged and sent to infection prevention staff for investigation. Cases in the study met the CDC definition of CLABSI if the following criteria were met: (a) presence of a central line that intravascularly terminates at or close to the heart or in one of the great vessels; (b) central line in place for greater than two consecutive days following first access and in an inpatient location during current admission up until the day after removal from the body or patient discharge, whichever comes first; (c) no reported site-specific infection at another body site that has seeded the bloodstream. Cases were excluded if the patient was less than 18 years of age or a consulted infectious disease specialist deemed the source of infection to be definitely from somewhere other than a central line. Equivocal cases were included as CLABSI cases. The study protocol was approved by the Institutional Review Board at our institution (IRB No.: 06549).

Our CLABSI bundle included the main interventions listed in the CDC bundle checklist and additional measures listed in Table 1. Various methods were implemented to minimise the use of CVCs. To decrease the use of CVCs for venous access in difficult venepuncture cases, nurses were trained to put in peripheral venous lines via use of a vein finder. In addition, there was ongoing education of the medical staff on limiting the use of CVCs for routine blood draws. Medical providers ordering peripherally inserted central catheters (PICCs) were prompted with an order menu to specify a reason for ordering a CVC and to consider ordering a midline instead.

Table 1.

Components of the CLABSI bundle.

Insertion
• Hand hygiene before CVC insertion
• Adhere to aseptic technique
• Use maximal sterile barrier precautions
• Avoid femoral site in obese patients
• Use of antimicrobial-coated non-PICC CVCs
• Antithrombotic PICCs
• Use of CVCs with fewer lumens
• Reduced use of CVCs (Use midline catheters, if feasible)
Maintenance
• Hand hygiene when handling CVCs
• Use only sterile devices to access CVCs
• Immediately replace dressings that are wet, soiled, or dislodged
• Standardised weekly CVC site dressing changes
• Daily chlorhexidine bath for all patients with CVCs (including non-ICU patients)
• Addition of Curos™ passive disinfection caps on vascular access ports
Other
• Daily audits assessing need for CVCs
• Educating healthcare personnel on proper insertion and maintenance of CVCs
• Root-cause analysis and re-education for each CLABSI case
• Avoidance of blood culture draws from CVCs
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Italicised components are additional interventions not part of the CDC’s CLABSI bundle.

CLABSI, central line-associated blood stream infection; CVC: central venous catheter; ICU, intensive care unit; PICC: peripherally inserted central catheter.

When a CLABSI event was identified, root-cause analysis (RCA) was completed promptly. If appropriate, re-education on CLABSI prevention was provided for medical staff involved in the event. An RCA established that triple lumen PICCs led to more venous thrombus formation and CLABSIs. Therefore, we started using Best Practice Advisory alerts within our electronic medical record system to encourage providers to order a catheter with fewer lumens when ordering a PICC. At around the same time, we advised the hospital logistics service to purchase and medical providers to use antithrombotic and antimicrobial-coated CVCs instead of standard poly-urethane CVCs as the former were shown to decrease CLABSI rates (Hockenhull et al, 2009; Long and Coulthard, 2006). PICC team feedback revealed antimicrobial-coated catheters were more slippery and difficult to handle compared to antithrombotic catheters (Angiodynamics BioFlo catheters); consequently, the latter was used. All non-PICC CVCs had antimicrobial coating; chlorhexidine-silver sulfadiazine-impregnated catheters (Arrowg+ard Blue Plus CVC) were used.

Curos™ port protectors were utilised to eliminate the need for nurses to scrub access ports for disinfection prior to use. This intervention was implemented after several RCAs showed that nursing staff were unable to consistently adhere to scrubbing of the catheter hub with isopropyl alcohol for the full 15 s in the setting of CLABSI cases that occurred > 7 days after insertion. RCA also showed that a CLABSI was more likely to occur if the CVC site dressing had not been changed timely (by 7 days). Therefore, weekly CVC site dressing changes were implemented. They were scheduled for the same day of the week to increase standardisation and quality.

To reduce the incidence of blood culture contamination, nurses and phlebotomists were regularly educated not to draw blood cultures from CVCs unless explicitly stated. Computer screensavers were also implemented reminding the medical staff not to draw blood cultures from CVCs, as well as encouraging removal of CVCs when no longer needed. Data on the HH compliance rates and product-use metrics showed no significant change during the study period. Specifically, no intervention was done to improve the HH compliance rates during this study period.

Figure 1 shows the time periods when various interventions were put in place and then continued indefinitely. Weekly unit-based RCA and medical staff education (including use of screensavers) were implemented around 2013 and continued indefinitely. However, the content of the screensavers changed periodically and reflected the outcomes of RCA.

Figure 1.

Figure 1.

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Monthly CLABSI cases and time periods for full implementation of various interventions. Interventions include: (1) using lower lumen PICCs, antithrombotic PICCs and antimicrobial-coated non-PICC CVCs; (2) weekly CVC site dressing change and peripheral venous line insertion training; (3) using CurosTM passive disinfection caps on CVC access sites; (4) using midlines instead of CVCs if feasible; (5) all patients with CVCs receive daily chlorhexidine gluconate baths.

CLABSI, central line-associated blood stream infection; CVC: central venous catheter; PICC: peripherally inserted central catheter.

Yearly CLABSI rates per 1000 CVC days were examined using MedCalc® comparison of two rates (Sahai and Khurshid, 1996). Time of CLABSI onset after catheter placement was analysed according to year, ICU v. non-ICU settings, and catheters with different number of lumens. Time to CLABSI onset was investigated with the Mann–Whitney Test using IBM SPSS Statistics 25.0 (IBM, Armonk, NY). We also analysed the microbial aetiologies of CLABSI cases. A tally of each microbial aetiology was completed according to year of infection and whether it occurred in an ICU or non-ICU setting.

Results

During the study period 126 CLABSI cases were identified. Infectious disease specialists excluded two cases in 2013, five annually from 2014 to 2016 and three in 2017. The number of CLABSI cases per year in both ICU and non-ICU settings is shown in Figure 2. There was a 67.6% decline in number of CLABSI cases from 34 to 11 patients between 2013 and 2017.

Figure 2.

Figure 2.

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CLABSI cases and CVC days from 2013 to 2017.

CLABSI, central line-associated blood stream infection; CVC: central venous catheter; ICU, intensive care unit.

CVC days decreased from 43,240 in 2014 to 30,361 in 2017, a decline of 4293 CVC days per year and a total reduction of 29.8% (Figure 2). Data for 2013 were not available in the medical records system. The decrease in CVC days was likely due to lower utilisation of CVCs after training nursing staff to insert peripheral venous lines via a vein finder and encouraging medical providers to order midlines instead of CVCs when feasible. CLABSI cases per 1000 CVC days decreased 42% from 0.624 to 0.362 from 2014 to 2017 (p = 0.12) (Figure 2). There was a 59% decline from 2015 to 2017, from 0.889 CLABSI cases per 1000 CVC days to 0.362 per 1000 CVC days (p = 0.007). Device utilisation ratio (i.e. number of central line days divided by number of patient days) from 2014 to 2017 was 0.210, 0.179, 0.172 and 0.162, respectively.

The number of cases by time of CLABSI onset after catheter placement is shown in Figure 3. When separating cases by time of CLABSI onset (< 7 days v. ⩾ 7 days), the yearly results were: 5 v. 29 (2013); 10 v. 17 (2014); 14 v. 21 (2015); 8 v. 11 (2016); and 3 v. 8 (2017). The mean time of CLABSI onset in the ICU and non-ICU setting was 9.04 (SD 6.98) days and 55.27 (SD 144.31) days (p < 0.001). When excluding cases with time of CLABSI onset > 60 days, the mean time of CLABSI onset for ICU cases remained the same while non-ICU cases decreased to 14.05 (SD 9.09) days (p = 0.006).

Figure 3.

Figure 3.

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Central line-associated blood stream infection time of onset after central venous catheter placement for (a) 2013–2014 and (b) 2015–2017.

Mean time of CLABSI onset for CVCs with two lumens v. CVCs with three lumens was 31.47 (SD 67.48) days and 11.88 (SD 12.49) days (p = 0.11). Excluding cases with CLABSI onset after 60 days of CVC insertion, time to CLABSI onset was 13.97 (SD 11.90) days and 9.84 (SD 7.02) days (p = 0.17). For the 78 two-lumen CVCs, 55 (71%) were PICCs and 52 (67%) were in the ICU. For the 26 three-lumen CVCs, two (8%) were PICCs and 12 (46%) were in the ICU. Only three cases utilised four-lumen CVCs, and all were non-PICC CVCs and in the ICU. Their time of CLABSI onset after catheter insertion was 4 (SD 2) days.

Supplementary appendix 1 lists the CLABSI cases by microbial aetiology. Some CLABSI cases had more than one pathogen. The percent of cases caused by Staphylococcus epidermidis from 2013 to 2017 were 15, 27, 35, 9 and 8%, respectively; for Enterococcus spp.: 20, 8, 8, 3, 0; for Klebsiella spp.: 15, 10, 8, 5, 0%; and for Candida and other yeast: 10, 13, 13, 5, 3%. ICU and non-ICU did not differ significantly in incidence of specific pathogens.

Discussion

CLABSI cases decreased after our bundle of interventions was instituted. Much of the reduction may have been due to CVC management, that is minimising unneeded CVC insertions and promptly removing unnecessary CVCs. Our addition of interventions beyond those recommended by the CDC may have led to one of the lowest CLABSI rates (0.36 per 1000 CVC days) reported in the literature to date. Salm et al (2018) and Ong et al (2011) reported modestly lower CLABSI rates, 0.2 and 0.3 per 1000 CVC days, respectively. Others have reported CLABSI rates ranging from 0.50 to 10 per 1000 CVC days (Han et al, 2010; Patel et al, 2018; Son et al, 2012). The CDC reported the average US rate to be 1.65 and 1.14 CLABSI per 1000 CVC days in the ICU and inpatient wards, respectively (CDC, 2011). However, most recent data showed substantial progress in reduction of CLABSI rates has been achieved across the US hospital over the past decade with the incidence decreasing from 1.6 cases per 1000 CVC days in 2009 to 0.9 cases per 1000 CVC days in 2018 (Nkwata et al, 2020).

In our study, CLABSI cases decreased as years advanced except for 2015. The increase in CLABSI cases in 2015 cannot be explained by greater CVC utilisation since CVC days decreased from the year prior. Chart review of providers who inserted CVCs leading to a CLABSI event that year did not find any repeat cases. RCA revealed that a possible explanation is that chlorhexidine gluconate (CHG) biopatch protective disks were replaced by Tegaderm CHG intravenous securement dressings in early 2015 due to cost concerns. Nursing staff reported having initial difficulty removing the old Tegaderm CHG dressing because the gel pad would stick to the CVCs and partially pull the catheter out of the insertion site. RCA revealed that at times the nursing staff would try to push the CVCs back into their original position, likely introducing infection into the CVC insertion site. In response, the nursing staff were re-educated and two-person dressing change teams were deployed to better handle the CVC site dressing changes. Fewer complications were reported afterwards.

Many of our interventions were rolled out simultaneously over an extended period in an effort to further decrease CLABSI rates; therefore, it was difficult to associate specific interventions with a change in CLABSI rate for a yearly time period. Review of the CLABSI cases occurring soon after CVC insertion and seven days or later suggests both insertion and maintenance aspects of the bundle of interventions played a role in decreasing CLABSI cases. Usually, development of CLABSI soon after catheter insertion suggests an extraluminal source of infection due to inadequate skin antisepsis, whereas delayed CLABSI development is a failure of maintenance interventions such as intraluminal colonisation from access port contamination (Chopra, 2020; Ryder, 2006).

The use of antithrombotic and antimicrobial-coated CVCs may have contributed to the decrease in CLABSI rates. After full implementation of these interventions by February 2014, CLABSI cases decreased from 34 in 2013 to 27 in 2014. Further analysis showed that CLABSI cases with onset ⩾ 7 days declined notably from 29 to 17 during this period, suggesting that the use of antithrombotic and antimicrobial-coated CVCs may have decreased intraluminal colonisation. We used Angiodynamics BioFlo antithrombotic PICCs, which yield low thrombosis and infection rates (McDiarmid et al, 2017). Other antithrombotic CVCs, such as those with heparin-coating, also reduce the incidence of catheter-related thrombosis and infection, problems that can interact synergistically (Long and Coulthard, 2006). It is likely that thrombus and fibrin sheath development provide a nidus for growth of bacteria, and, in turn, infection can cause an inflammatory response activating the local coagulation system (Ibeas-Lopez, 2015). Antimicrobial-coated CVCs are also effective in preventing bloodstream infections, especially amongst patients in ICUs and with specific comorbidities such as burns or neutropenia (Hockenhull et al, 2009; Ibeas-Lopez, 2005; Lai et al, 2016). These studies and our current investigation suggest that antithrombotic and/or antimicrobial-coated CVCs be included as part of the standard CLABSI bundle of interventions. Chlorhexidine-silver sulfadiazine, rifampin–minocycline, silver–platinum–carbon are some of the more commonly used antimicrobial coating options.

We found an increase in time to CLABSI onset when using CVCs with fewer lumens. This finding held even when excluding cases where the time to onset of CLABSI was greater than 60 days, in a group that included tunnelled catheters. Thus, our use of CVCs with fewer lumens may have helped to reduce the number of CLABSI cases by delaying onset of infection before CVCs were removed at the end of usage. Although the difference in time to CLABSI onset between the groups was not statistically significant, had the sample size been larger, we may have been able to claim otherwise. Chopra et al also found that CVCs with fewer lumens were associated with decreased rates of infection and later onset (Chopra et al, 2014). Others have shown that larger CVCs with more lumens risk intimal vessel injury with activation of coagulation cascade leading to increased incidence of thrombosis (Evans et al, 2010; Wall et al, 2016) and associated infection (Dezfulian et al, 2003; Templeton et al, 2008). However, in our study this relationship may not be clear-cut since many of our CLABSI cases with two-lumen CVCs also had greater utilisation of PICCs when compared to CLABSI cases with three- and four-lumen CVCs.

Similar to previous studies, our use of alcohol-impregnated port protectors (e.g. Curos™ caps) likely helped decrease our CLABSI rates (Danielson et al, 2014; Merrill et al, 2014; Sumner et al, 2013; Sweet et al, 2012). After this intervention was implemented, CLABSI cases decreased decidedly in 2016. The considerable drop for CLABSI cases with onset ⩾ 7 days suggests decreased intraluminal colonisation with the use of Curos™ caps. Traditional disinfection of intravenous access ports entails scrubbing the top and sides of catheter hubs with chlorhexidine and alcohol for 15 s and then waiting for the hub to dry before port access. The technical demands and time requirements of traditional disinfection make it difficult to obtain completely successful implementation in the long term. The passive disinfection of Curos™ caps eliminates the “scrub the hub” requirement and decreases the chance of operator error.

After institution of daily CHG baths for patients with CVCs in early 2017, rates of CLABSI declined from 19 in 2016 to 11 in 2017. The number of CLABSI cases with onset <7 days suggests decreased extraluminal colonisation attributable to the daily CHG baths. Prior studies found significant decreases in CLABSI rates with this intervention (Climo et al, 2013; Bleasdale et al, 2007).

In 2017 there continued to be a handful of CLABSI cases from CVCs in place greater than 39 days (Figure 3(b)). RCA showed one case to be due to a PICC left in place unnecessarily for 40 days. The other four cases were due to a tunnelled haemodialysis (HD) catheter and three port-a-catheters; three of these cases grew Staphylococcus aureus. RCAs of these cases disclosed irregularity in the routine CVC dressing changes. Typically, the port-a-catheters and HD catheter dressing changes were not done by the unit nursing staff, but by a specialised IV therapy team and HD/plasmapheresis staff, respectively. Subsequently, an improved communication plan was developed between these services and the unit nursing staff to ensure timely dressing changes for these types of CVCs.

This study has several limitations. First, this investigation was conducted at a single institution. Thus, our findings may not be generalisable to other hospitals. Nevertheless, we believe that hospital practice philosophies are similar, and implementation of interventions can be applied successfully in diverse medical systems. Second, many of our interventions were implemented simultaneously, making it difficult to attribute improvement in CLABSI rates to any single intervention. However, the goal of our study was to evaluate the effectiveness of our bundle of interventions in changing CLABSI rates.

Conclusions

After implementation of a comprehensive bundle of interventions for CVC insertion and maintenance, CLABSI rates decreased. A multidisciplinary approach with additional measures such as the use of antithrombotic or antimicrobial-coated CVCs with fewer lumens resulted in CLABSI rates lower than or comparable to earlier reports. Our findings support the use of a comprehensive bundle of interventions to reduce the incidence of this preventable hospital-acquired infection that has high morbidity and mortality.

Supplemental Material

sj-docx-1-bji-10.1177_17571774211012471 – Supplemental material for Reduction of central line-associated bloodstream infections in a large acute care hospital in Midwest United States following implementation of a comprehensive central line insertion and maintenance bundle
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Supplemental material, sj-docx-1-bji-10.1177_17571774211012471 for Reduction of central line-associated bloodstream infections in a large acute care hospital in Midwest United States following implementation of a comprehensive central line insertion and maintenance bundle by Abraham E Wei, Ronald J Markert, Christopher Connelly and Hari Polenakovik in Journal of Infection Prevention

Acknowledgments

None.

Footnotes

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Peer review statement: Not commissioned; blind peer-reviewed.

Supplemental material: Supplemental material for this article is available online.

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Supplementary Materials

sj-docx-1-bji-10.1177_17571774211012471 – Supplemental material for Reduction of central line-associated bloodstream infections in a large acute care hospital in Midwest United States following implementation of a comprehensive central line insertion and maintenance bundle
Click here for additional data file. (18.7KB, docx)

Supplemental material, sj-docx-1-bji-10.1177_17571774211012471 for Reduction of central line-associated bloodstream infections in a large acute care hospital in Midwest United States following implementation of a comprehensive central line insertion and maintenance bundle by Abraham E Wei, Ronald J Markert, Christopher Connelly and Hari Polenakovik in Journal of Infection Prevention

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