Beyond the bundle - journey of a tertiary care medical intensive care unit to zerocentral line-associated bloodstream infections
© Exline et al.; licensee BioMed Central Ltd. 2013
Received: 20 September 2012
Accepted: 22 February 2013
Published: 4 March 2013
We set a goal to reduce the incidence rate of catheter-related bloodstreaminfections to rate of <1 per 1,000 central line days in a two-year period.
This is an observational cohort study with historical controls in a 25-bedintensive care unit at a tertiary academic hospital. All patients admitted to theunit from January 2008 to December 2011 (31,931 patient days) were included. Amultidisciplinary team consisting of hospital epidemiologist/infectious diseasesphysician, infection preventionist, unit physician and nursing leadership wasconvened. Interventions included: central line insertion checklist, demonstrationof competencies for line maintenance and access, daily line necessity checklist,and quality rounds by nursing leadership, heightened staff accountability,follow-up surveillance by epidemiology with timely unit feedback and case reviews,and identification of noncompliance with evidence-based guidelines. Molecularepidemiologic investigation of a cluster of vancomycin-resistant Enterococcus faecium (VRE) was undertaken resulting in staff education forproper acquisition of blood cultures, environmental decontamination and dailychlorhexidine gluconate (CHG) bathing for patients.
Center for Disease Control/National Health Safety Network (CDC/NHSN) definitionwas used to measure central line-associated bloodstream infection (CLA-BSI) ratesduring the following time periods: baseline (January 2008 to December 2009),intervention year (IY) 1 (January to December 2010), and IY 2 (January to December2011). Infection rates were as follows: baseline: 2.65 infections per 1,000catheter days; IY1: 1.97 per 1,000 catheter days; the incidence rate ratio (IRR)was 0.74 (95% CI = 0.37 to 1.65, P = 0.398); residual seven CLA-BSIsduring IY1 were VRE faecium blood cultures positive from central linealone in the setting of findings explicable by noninfectious conditions. Followingstaff education, environmental decontamination and CHG bathing (IY2): 0.53 per1,000 catheter days; the IRR was 0.20 (95% CI = 0.06 to 0.65, P = 0.008)with 80% reduction compared to the baseline. Over the two-year interventionperiod, the overall rate decreased by 53% to 1.24 per 1,000 catheter-days (IRR of0.47 (95% CI = 0.25 to 0.88, P = 0.019) with zero CLA-BSI for a total of15 months.
Residual CLA-BSIs, despite strict adherence to central line bundle, may be relatedto blood culture contamination categorized as CLA-BSIs per CDC/NHSN definition.Efforts to reduce residual CLA-BSIs require a strategic multidisciplinary teamapproach focused on epidemiologic investigations of practitioner- or unit-specificetiologies.
Healthcare-associated infections (HAI) are a significant cause of morbidity andmortality for hospitalized patients accounting for approximately 100,000 deaths yearlyin the United States . Though intensive care unit (ICU) beds make up the minority of hospital bedsnationwide, they account for the highest burden of nosocomial infections . Specifically, in the ICU, central line-associated bloodstream infections(CLA-BSI) account for much of the excess morbidity, health cost expenditures, andmortality associated with nosocomial infections [3–6].
The risk of developing a CLA-BSI depends on a variety of factors such as the duration ofcatheterization, location of catheter, and type of ICU to which a patient is admitted [4, 5, 7]. Evidence-based interventions effective in combating CLA-BSIs include: usingchlorhexidine skin preparation and maximal sterile barriers (MSB) during insertion ofcentral venous catheters (CVC), use of checklists for insertion, using the subclavian orinternal jugular vein instead of the femoral vein, and daily review of line necessity [5–13].
These techniques have been validated in the literature and put together in a 'bundle',which was installed by the Institute for Healthcare Improvement (IHI) to help providersdeliver more consistent care [14–18]. However, many of these studies have focused primarily on the insertion ofthe central line [15, 17–19] rather than ongoing line maintenance. Other studies using compliance coupledwith adherence to safe line maintenance standards and prompt removal, despiteimprovement in CLA-BSI rates, have not necessarily documented rates below the NationalHealth Safety Network (NHSN) benchmarks for CLA-BSI and certainly continue to show ratesof CLA-BSI above the ultimate goal of 'near-zero' [15, 16]. There have been suggestions that the high sensitivity of the CLA-BSIsurveillance definition by the Center for Disease Control (CDC)/National Health SafetyNetwork (NHSN) leads to categorization of positive blood cultures as CLA-BSI when theymay not actually be related to infections, rather contamination . Some authors have made suggestions that zero CLA-BSI may not be realistic atall . Regardless of the cause of these positive blood cultures, they have apotential to lead to increased antibiotic use, removal of catheters with placement ofnew catheters and even increased hospital length of stay.
We implemented a systematic team approach with very aggressive interventions surroundingthe IHI CLA-BSI bundle resulting in marginal success toward the target of reducinginfections to near-zero in our ICU. However, our innovative approach toward implementingthese interventions allowed us to reexamine the central line bundle efficacy and augmentour process improvement strategy with accessory interventions as our unit's journeyprogressed to a near-zero rate of CLA-BSI.
Materials and methods
This was an observational cohort study that used historical controls. The project wasdeemed as quality improvement by the Institutional Review Board of this organizationand need for research approval and informed consent was waived.
Setting and participants
The study setting was a 25-bed medical ICU located in 1200-bed tertiary care academichospital at the Ohio State University Wexner Medical Center. All patients admitted ortransferred into the unit were included in the intervention. The patient populationdid not include surgical ICU patients. The nursing to patient ratio averaged 1:1.5and varied between 1:1 and 1:2 as patient acuity mandated.
Routine surveillance for CLA-BSI
We measured CLA-BSI rates during the following time periods: baseline (January 2008to December 2009), intervention year (IY) 1 (January to December 2010), andintervention year 2 (January to December 2011). All blood cultures obtained frompatients admitted to the ICU were reviewed by the infection preventionist and allsuspected CLA-BSI were confirmed by an epidemiologist/infectious diseases physicianutilizing the definition put forth by the CDC through the NHSN . We defined a central line as a catheter that ends in the superior orinferior vena cava at or near the heart. Specific lines present in our populationincluded peripherally inserted central catheters (PICC), central venous catheters(CVC), and pulmonary artery catheters (PA). Arterial lines were not included inCLA-BSI surveillance per NHSN definition. However, we have not noticed any centralarterial line infections during our routine surveillance. Total patient days werecalculated daily by number of patients on the ICU service census at midnight. Thepresence of at least one central line in a patient was counted as one catheter day inaccordance with the NHSN guidelines . There were no changes to the epidemiology staff during the interventionperiod, nor were there any changes to the CLA-BSI definition utilized over the courseof the study.
Interdisciplinary team formation - December 2009
A multidisciplinary team that included an infectious diseases physician and infectionpreventionist, ICU medical directors (critical care physicians), nurse manager andclinical nurse specialists (CNS) was convened. Each individual's role in theperformance improvement process was clearly defined in the initial meetings.
Interventions related to central line bundle - January 2010
Several interventions focused on the central line insertion bundle, dressingmaintenance and line access practices were simultaneously introduced or reemphasizedto ICU physicians and nurses in January 2010. This marked the beginning of theintervention period.
1. At the start of each rotation, education was reinforced to all house staff to use the Vascular Access Selection Criteria to ensure proper selection of catheter site with emphasis on internal jugular or subclavian placement . This education was part of a refresher course in the hospital simulation laboratory on line placement and sterile technique.
2. Lines in the ICU were placed by resident physicians, critical care or nephrology fellows, critical care attending physicians, or the hospital PICC insertion nursing team. Ultrasound was used to place nonemergent central lines.
3. The continued need for a CVC was reviewed daily, during interdisciplinary ICU rounds by the critical care fellow as part of the daily goals checklist, with removal of the catheter wherever possible [3–5]. In addition, the critical care fellow and the CNS reviewed line necessity during quality rounds that were conducted each afternoon.
4. Nurses placed peripheral intravenous catheters with ultrasound guidance wherever possible to avoid CVC placement and to facilitate removal.
5. Removal within 24 hours of all CVCs placed emergently, that is 'code lines' or any line placed without maximum sterile barrier precautions (sterile gown, sterile gloves, full-size sterile drape, face mask, cap, and chlorhexidine skin preparation solution). A label was used to identify these catheters as emergently placed central lines.
6. CNS led mandatory demonstration session for dressing change and proper line access on a manikin for all nursing staff at the beginning of the study. During this session, all nursing staff was assessed for competence in their dressing change and line access techniques. Chlorhexidine gluconate (CHG) Tegaderm™ dressings were used on all central lines from the beginning of IY1. Nursing performance was evaluated annually by unit management staff as part of annual mandatory education.
7. A CVC insertion checklist, with all requirements to comply with the sterile procedure for CVC placement, was attached to all central line kits. All CVCs placed were antimicrobial catheters. Nursing staff was instructed to use the checklist at the time of line insertion. All providers in the room were required to wear sterile cap, mask, and gloves. Nurses were empowered to stop procedures if sterile technique was not correctly employed. Arterial lines were placed in a similar fashion using full barrier precautions.
8.All CVC and PICC insertion trays were augmented with components to comply with the central line bundle including the use of chlorhexidine sponges for cleaning the skin.
9. The infection preventionist gave feedback to the unit on adherence to protocol based on the central line dressing maintenance audits performed each month and any CLA-BSI every week. These audits assessed compliance with keeping the dressings clean, dry and intact. In addition, staff nurses were encouraged to practice proper line access techniques on a monthly basis by the nurse manager via emails and during staff meetings.
Timely feedback on CLA-BSI occurrence and sentinel event investigation on CLA-BSIat the unit level - January 2010
Clinical Epidemiology provided weekly feedback on CLA-BSI occurrence to the unitleadership that included the ICU medical directors, CNS and nurse manager. The CNSresponsible for each investigation was able to evaluate practitioner variation,nursing variation, CVC access and blood culture collection techniques, and anatomicalCVC site of placement among other factors that may have contributed to each CLA-BSI.The nurse manager and medical directors shared the results of the investigation withthe unit's nursing and medical staff, respectively.
Positive reinforcement strategy - June 2010
We engaged hospital leadership to establish milestones for CLA-BSI avoidance (100,200, and 365 days) and provide incentives upon achieving the milestones to sustainCLA-BSI improvement. These included coat pins indicating the days without a CLA-BSIand recognition breakfasts for the unit staff.
Clinical epidemiologic investigation - November 2010
We conducted an epidemiologic investigation at the end of IY1 when, despite a modestimprovement in CLA-BSI rates, there was a continued CLA-BSI burden in the face ofimplementation of and compliance with aggressive measures toward the CVC bundle andline maintenance practices. We investigated the types of organisms causing CLA-BSIsand the location of CLA-BSI patients within the ICU to evaluate for clustering ofinfections. Upon noting a surge and clustering of vancomycin-resistantEnterococcus (VRE) faecium CLA-BSIs from certain ICU rooms,Epidemiology performed environmental cultures of 42 high-touch surfaces (HTS) withinthe rooms where patients with VRE faecium CLA-BSI were identified. HTScultured included bed rails, bedside tabletops, and keyboards, call buttons, supplycart handles and television remote controls.
Molecular epidemiologic investigation - December 2010
Based on the results of the clinical epidemiologic investigation, a molecularepidemiologic investigation was conducted. Molecular typing of VRE faecium isolated from blood cultures and patients' environment was performed usingrepetitive extragenic palindromic sequence-based polymerase chain reaction (rep-PCR)DiversiLab kits (bioMérieux, Durham, NC, USA) following the Diversilab™Enterococcus kit package insert and previously described methods [24–26]. An ATCC™ E. faecalis 51299 strain was used as controlalong with another E. faecium control strain obtained from a patient's bloodculture from a different area in the hospital. The modified Kullback-Leibler distancemethod was used to create a pairwise percent similarity matrix, and a dendrogram wasgenerated using the unweighted pair group method of arithmetic averages. Isolatessharing greater than 97% similarity and/or indistinguishable (no band difference)were grouped for further analysis. The graph overlay feature was utilized to observesmall differences between isolates that were otherwise not apparent on virtual gelimages. Each new rep-PCR pattern identified was based on one peak difference and wasassigned a sequential numeric classification based on the overlay. VRE organisms wereconsidered similar if they had a one-peak difference.
Environmental decontamination and nursing staff education - end of December2010
Hospital policy already specified that all patients with VRE required contactisolation including a gown and gloves for anyone entering the room. Based on theresults of the above investigation, in addition to continuation of contact isolationprotocols an intensive terminal cleaning of all ICU rooms was conducted. Each pod ofthe ICU was emptied for a day at a time by moving patients into a different pod tofacilitate this cleaning. The walls, floors and all surfaces and equipment in therooms were spot cleaned and wiped down with a disinfectant. Environmental Services(EVS) personnel created a dedicated cleaning team that was specifically trained toclean the ICU rooms. Nursing staff was educated about proper technique for obtainingblood cultures by the clinical nurse specialists to reinforce their knowledge.
Follow-up environmental culturing - March 2011
We repeated environmental culturing to document decontamination of VRE following deepcleaning of ICU rooms. Over 200 HTS from all ICU rooms were cultured for VRE toassess for continued effectiveness of cleaning by our EVS staff that were unaware ofthis surveillance.
Chlorhexidine gluconate bathing - April 2011
We introduced CHG bathing of all patients in the ICU in response to one VRE CLA-BSIthat occurred three months after environmental decontamination. This intervention wasintroduced to reduce the potential bacterial burden on patients . Patients admitted to the ICU underwent a CHG bath on admission and dailywith a diluted solution of 4% chlorhexidine gluconate in tap water based on previousstudies showing eradication of VRE and methicillin-resistant Staphylococcusaureus (MRSA) colonization at this dose [27, 28].
We measured CLA-BSI incidence per NHSN definition  before (baseline period) and after (post-intervention period) theimplementation of the 'line bundle' and subsequent process improvement methods. Thequarterly rate of infections was calculated as follows: (number of CLA-BSIs/number ofcentral line days) × 1,000 for each three-month period. Quarterly rates wereassigned to one of four categories based on when the study intervention wasimplemented: at baseline, during the early post-intervention period (year 1), or latepost-intervention period (year 2). We also collected data on the number of temporaryCVCs, including PICCs used in ICU patients over the study years. Device utilizationratio was calculated as follows in accordance with NHSN guidelines: number of deviceor catheter days/number of patient days . Patient days were counted using the daily ICU census at midnight.
Outcome measures and study hypotheses
Primary outcome measure was quarterly CLA-BSI rate per 1,000 central line days.Secondary outcome measures were compliance with CVC insertion and dressingmaintenance practices. The primary study hypothesis was that the CLA-BSI rate wouldbe reduced by at least 50% after implementation of the study intervention as comparedto the baseline over a two-year intervention period. We did not evaluate the relativeeffectiveness of the separate components of the intervention.
As used in previous studies , and because CLA-BSIs are rare events, a Poisson regression analysis wasused to generate an incidence rate ratio (IRR) compared with baseline CLA-BSI rates(Stata software, version 10; Statacorp, College Station, TX, USA).
CLA-BSI incidence rate/1000 patient days, incidence rate ratio (IRR) in thepost-intervention period compared to baseline period.
Number of CLA-BSI
Central line days
CLA-BSI rate/1000 central line days
IRR (95% CI)
Baseline (two-year period)
Post-intervention year 1
Post-intervention year 2
Compliance with insertion, dressing maintenance, and line removal
Monthly CLA-BSI during the study period, device utilization ratio and organismscausing CLA-BSI in each month.
Number of CLA-BSI
Central line days
CLA-BSI rate/1000 central line days
Device utilization ratio
Organisms causing CLA-BSI
Methicillin-resistant Staphylococcus epidermidis
Methicillin-resistant Staphylococcus epidermidis
Group B Streptococcus agalactiae
Methicillin-resistant Staphylococcus epidermidis
Methicillin-resistant Staphylococcus epidermidis
Prevotella buccae and Achromobacter xylosoxidans
Pseudomonas fluorescans, Peptostreptococcus, VREfaecium
Candida albicans, VRE faecium
Candida glabrata, VRE faecium, E.coli
Acinetobacter baumannii, VRE faecium
Enterococcus faecalis, Acinetobacter baumannii
VRE faecium, VRE faecium
Methicillin-resistant Staphylococcus epidermidis, VREfaecium
Morganella morganii, Enterobacter cloacae
VRE faecium, VRE faecium
VRE faecium, Methicillin- resistant Staphylococcusepidermidis
VRE faecium, Enterococcus faecalis
Clinical epidemiologic investigation
Molecular epidemiologic investigation
Sentinel event investigation of residual CLA-BSI
All seven residual CLA-BSIs were caused by VRE faecium. All VRE werecultured from one bottle from a CVC with one or more negative culture bottles fromsimultaneous peripheral blood cultures in all patients. Scenarios where bloodcultures were obtained included: in response to hypotension caused bygastrointestinal bleed in two patients, pulseless electrical activity (PEA) in twopatients (one after a radical neck dissection, one after transjugular intrahepaticportosystemic shunt (TIPS) procedure), one temperature recording of 100.8 in apatient with deep venous thrombosis (DVT), in response to leukocytosis in a patientwho was afebrile and was treated with corticosteroids, and in response toleukocytosis in a patient with acute coronary syndrome. All seven patients had theircatheters removed. Three patients died within three days of diagnosis of bacteremiasecondary to their presenting diagnosis with none of the deaths attributed to theCLA-BSI. Four patients were treated for bacteremia for 14 days.
CLA-BSIs continue to be a challenge in healthcare delivery, especially in the ICU, wherenearly 50% of patients will have a CVC inserted at some point in their care . CLA-BSIs are responsible for significant morbidity resulting in extendedhospitalizations, hospital costs accounting for a loss of up to $26,000 per CLA-BSI , and increased mortality accounting for approximately 100,000 deaths a year . Though multiple investigators have reported interventions surrounding thecentral line bundle to successfully reduce the burden of CLA-BSIs in their units, fewhave reported the results of continued process improvements and secondary interventionsthat can be utilized when, as is often the case, compliance with the CVC bundle alonehas not resulted in a significant reduction in these infections.
Our unit's culture in the baseline period likely mirrored what may be the standardculture in many institutions. Physicians and nurses were aware of the dangers ofCLA-BSIs and educated on the expectation for strict adherence to sterile techniques forinsertion and access of central lines. Physicians were expected to utilize full-barrierprecautions and ultrasound guidance for CVC insertion. However, as with many academicinstitutions, there was a high turnover of new trainees into the environment making asustained cultural change more difficult. Into this environment, our epidemiology teamchampioned a systematic team-oriented approach to optimally reduce CLA-BSI to anear-zero rate. The implementation of a central line 'bundle' resulted in excellentcompliance with sterile insertion techniques and substantial improvements in centralline dressing care. However, despite improved compliance with the bundle, our initialefforts resulted in only a modest improvement of our CLA-BSI rate and the use of CHGTegaderm™ dressings may or may not have contributed to this modest improvement; wewere still far from our goal.
Our innovative team approach engaged hospital epidemiologists and clinicians with weeklyCLA-BSI surveillance followed by immediate, unit-level, root cause analysis, whichfacilitated feedback to clinicians in a timely fashion when they still remembered thecircumstances surrounding the infection. In the majority of our CLA-BSIs in IY1 wesuspected potential blood culture contamination with VRE coupled with clinicaldeterioration from a noninfectious etiology as a likely cause of persistence of CLA-BSIsdespite our compliance with bundle elements. Our interdisciplinary approach withinfection prevention experts, critical care physicians and nursing staff working as oneteam facilitated an investigation that identified geographic clustering of VRE cases inour ICU. As VRE can cause both monoclonal and polyclonal outbreaks [32–35], we performed environmental cultures coupled with a molecular epidemiologicinvestigation based on our finding of geographic clustering and our suspicion of bloodculture contamination. This documented environmental contamination with VRE anddemonstrated the genetic similarity between environmental VRE and the VRE associatedwith these CLA-BSIs. We then implemented a very aggressive intervention of cleaning ourICU by systematically emptying one ICU pod at a time and engaging our EnvironmentalServices team in our process improvement strategy. This investigation also recognizeddeficiencies in the structure of our environmental cleaning plan and identified the needto have more highly trained cleaning staff that was dedicated to an ICU. As a result, wehave now employed environmental cleaning teams that are dedicated to ICUs and aretrained to clean around ICU equipment in our institution. Studies have shown eliminationof VRE colonization events by meticulous attention to environmental cleaning [36, 37], but very few have utilized environmental decontamination as an interventionto achieve a reduction in VRE CLA-BSIs. We observed a decline in our VRE CLA-BSI uponimplementation of meticulous environmental cleaning. We chose not to conduct admissionand/or weekly surveillance cultures for VRE colonization followed by contact isolationas an intervention as it is an expensive strategy. Instead, based on our investigationand findings, we focused on improving environmental cleaning and reducing potentialbacterial burden on our ICU patients [4, 27, 28].
Based on our experience, there can be an underlying cause for reminiscent CLA-BSIs afterimplementation of a process improvement project emphasizing bundle compliance. How todeal with these residual infections is not frequently reported in the literature. Thereare many potential interventions including patient cohorting, purpose-made cathetersterilizing devices, dedicated line teams or, as in our case, environmentaldecontamination to name a few. Deciding which intervention to use next could bedifficult and using all or some interventions randomly can be costly. We suggest thatunit leaders should investigate the root cause of their residual infections rather thanimplementing further measures piecemeal.
This work demonstrates the success of this positive approach to the issue of CLA-BSIs,investigating the underlying cause of reminiscent CLA-BSI thereby sustaining CLA-BSIreduction. We have demonstrated that with an iterative team approach and by eliminatingunderlying causes of residual CLA-BSI and basing our approach on internal evidence forthe need for further interventions, CLA-BSI reduction is possible and sustainable. Ourefforts to reduce CLA-BSI incidence demonstrate a synchronized model formultidisciplinary teams, which included a hospital epidemiologist and administrativeleaders to increase compliance with bundle elements and to decrease blood culturecontamination. We engaged hospital leadership to establish milestones and recognize theunit at the institutional level upon milestone achievement. This strategy resulted in apositive effect on morale, and facilitated staff compliance with the new standards ofcare. At the same time, it promoted the culture of safety: no one wanted to be thepractitioner that started the clock back to zero days since the last CLA-BSI. We believethat these two strategies played an important role in sustaining our success withCLA-BSI reduction.
We observed a stability of the device utilization ratio, which may be due to the factthat a patient with multiple lines; for example, a triple-lumen CVC, and dialysiscatheter counts as one line day, even with discontinuation of one of the lines thepatient would still count as a central line day. Thus the device utilization ratio mayunderrepresent how many lines were being removed even with aggressive removal based on adaily goals checklist. While the burden and exposure may be reduced, the deviceutilization ratio will not account for this. This may argue for counting the number oflines or even lumens for a lumen/patient/day count. Unfortunately, this may beunfeasible in most settings leading to inaccurate counts. However, improved line daycounts might be possible in future studies as electronic medical record tracking ofvascular access days in ICUs increases.
Our experience also validates the existent concerns that all CLA-BSI may not bepreventable given the high sensitivity and low specificity of CDC/NHSN definition, assome of these positive blood cultures with significant pathogens may be related tocontamination or catheter colonization . This may especially be true in units colonized with resistant bacteria suchas VRE or MRSA. Eventually, these units may be penalized financially if, as planned,healthcare providers in the United States receive only limited reimbursement from theCenters for Medicare and Medicaid Services (CMS) for any CLA-BSI acquired in thehospital, since this is now accepted as 'preventable' . An acceptable compromise may envision CMS accounting the reasons why thereminiscent CLA-BSIs were not preventable on a case-by-case basis (for example, an'infection' per definition may not be an infection at all or the 'infection' may be asecondary bloodstream infection with another potential primary site) instead of basingreimbursement merely on CLA-BSI rate per institution.
Our study does have several limitations. First, we studied one particular ICU populationwith a homogeneous group of nurses and house staff. Thus, our results may not beextrapolated to surgical, cardiac, or other ICU populations. However, the principle ofour process is the continuous reporting of CLA-BSIs and refinement of unit-specificinterventions, which should be reproducible in other ICU populations. Second, we did notcontinuously monitor central line insertion and dressing maintenance throughout theintervention period. Even at baseline, the compliance with sterile technique forinsertion was extremely high and in addition, these audits were labor intensive and wefelt that intermittent auditing was an acceptable alternative to continuous audits oncecompliance with the sterile line insertion techniques and dressing maintenance had beenachieved. In addition to intermittent audits, we continue to conduct educationalsessions with periodic (yearly) reinforcement of education related to central linemaintenance and access. Our CNSs continued to investigate any new CLA-BSIs includingassessment of line access practices and insertion technique. In addition, house stafftrainees are given a half-day training session in our simulation laboratory emphasizingcentral line placement prior to each rotation in the ICU. Third, we only cultured theICU rooms where patients were diagnosed with VRE CLA-BSI during the first round ofenvironmental culturing. However, we felt the high prevalence of VRE on HTS in the roomscultured justified the deep cleaning of every room in the unit. In addition, we culturedall HTS in all ICU rooms during our follow-up environmental culturing to documentdecontamination of the rooms post environmental cleaning and to assess continuedeffective cleaning by our environmental staff. Fourth, we monitored hand hygiene uponentry and exit of the rooms through audits performed by the unit staff, which showedvery high compliance of greater than 90% during early months of the study, but we didnot monitor whether staff cleaned hands prior to accessing central lines. Doing suchaudits anonymously for accurate data gathering would be a challenge but we believe thatwith increased awareness of CLA-BSI prevention, this practice improved over time duringthis study. Last, we did not evaluate the relative effectiveness of the separatecomponents of the intervention related to central line bundle. However, our goal was toattain maximal improvement of patient safety in our ICU; this quality improvementinitiative was designed to optimize the use of well-documented best practices andoffered the greatest probability of reducing CLA-BSI incidence. We saw a stepwisedecline in CLA-BSIs as we strategically introduced accessory interventions beyond thecentral line bundle. It remains unknown whether implementation of CHG bathing alone orenvironmental cleaning alone (given enough time) in the absence of the other would haveeliminated reminiscent sporadic CLA-BSI in our ICU. However, we believe that deepenvironmental cleaning along with correction of deficiencies in the daily environmentalcleaning for ICUs was necessary to reduce bacterial burden in the environmentsurrounding the patients in our ICU. We saw a decline in VRE CLA-BSIs after thisintervention but extended the decontamination approach to patients with anotheroccurrence of VRE CLA-BSI since our follow-up cultures did not reveal VRE on multipleHTS. Our approach demonstrates our zero tolerance for CLA-BSI occurrence in our ICU. Wealso validated the currently existing thoughts about the high sensitivity and poorspecificity of CDC/NHSN definition for CLA-BSI. We showed that multidisciplinary effortstoward clinical epidemiologic investigation could actually lead to a near-zero rate evenin a complex ICU in a tertiary care hospital such as ours despite these concerns.
It may be argued, in light of the fact that the majority of our residual CLA-BSIs weresuspected to be contaminants, that our improvement comes at a significant resource costand that we implemented aggressive interventions to try to curtail nonexistentinfections in the setting of contamination; however, we submit that these werereasonable interventions since we suspected central line contamination which, in thesetting of high environmental burden, reflects the risk of impending invasive infectionsunless action is taken. In addition, it is difficult for physicians to choose not totreat a patient who has a positive blood culture with a significant pathogen.Retrospectively, we suspected that the majority of these cultures were contaminants;however, the treating team presented with the culture results on critically ill patientsin real time had to treat the culture as a real result. Thus the elimination of thesepotentially erroneous CLA-BSIs has the added effect of reducing unnecessary antibioticuse. Unnecessary antibiotic use, however, can lead to increased hospital length of stayamong other complications thus making it important to eliminate blood culturecontamination via both compliance with line insertion bundle and environmentaldecontamination. We encouraged clinicians to avoid drawing blood cultures from theexisting catheters at the same time as we instituted these interventions. However, wesaw improvement in CLA-BSI before there was a change in this behavior. We are slowlyseeing a change in this behavior and are continuing to work on changing the culture ofdrawing blood cultures from existing CVCs. We felt that it was important to address therecognized deficiencies in the structure of our environmental cleaning plan and addressthe environmental contamination as soon as we identified the problem.
In conclusion, strict adherence to the central line bundle is essential to prevention ofCLA-BSIs, but may not completely eliminate these infections as blood culturecontamination contributes to CLA-BSIs that are detected by CDC/NHSN surveillancedefinition. Efforts to further reduce residual CLA-BSIs require a strategicmultidisciplinary team approach focused on epidemiologic investigations of practitioneror unit-specific etiologies. Continuous process improvement can then be targeted atlocal factors contributing to a CLA-BSI, such as environmental contamination in ourcase, with evidence-based interventions. Sustained reduction of CLA-BSIs requireslongitudinal support of hospital and unit leadership to continue to improve the care ofour most vulnerable ICU patients.
Our study methods and findings include:
• Use of a multidisciplinary team including Clinical Epidemiology for root causeinvestigations.
• With reeducation and reemphasis on the central line bundle we achieved modestreductions in our rate of central line-associated bloodstream infections (CLA-BSIs)during our first year.
• During the second year, we utilized a root cause analysis approach toinvestigating our CLA-BSIs leading to the discovery of environmental contamination anderadication of CLA-BSIs with patient chlorhexidine bathing and deep environmentalcleaning.
• Use of PCR techniques to confirm environmental contamination as the source ofCLA-BSIs.
• Discussion of the CDC definition of CLA-BSI that includes inclusion ofpotentially contaminated line cultures in the calculated rate of CLA-BSIs for theunit.
Center for Disease Control
centralline-associated bloodstream infections
Centers for Medicare and Medicaid Services
clinical nurse specialists
central venous catheters
intensive care unit
incidence rate ratio
methicillin-resistant Staphylococcus aureus
maximal sterile barriers
National Health Safety Network
Institute forHealthcare Improvement
pulmonary artery catheters
peripherally inserted central catheters
repetitive extragenicpalindromic sequence-based polymerase chain reaction
transjugular intrahepaticportosystemic shunt
We would like to thank the critical care physicians, house staff, nursing andancillary staff at The Ohio State University Wexner Medical Center Medical IntensiveCare Unit for their diligent attention to this quality improvement initiative. Wewould like to thank Joshua Smith and Meghan Baranec for their oversight of theEnvironmental Services staff and for working with us on this project.
- Klevens RM, Edwards JR, Richards CL, Horan TC, Gaynes RP, Pollock DA, Cardo DM: Estimating health care-associated infections and deaths in U.S. hospitals,2002. Public Health Rep 2007,122(1):60-166.Google Scholar
- Weber DJ, Sickbert-Bennett EE, Brown V, Rutala WA: Comparison of hospitalwide surveillance and targeted intensive care unitsurveillance of healthcare-associated infections. Infect Control Hosp Epidemiol 2007, 28: 1361-1366. 10.1086/523868View ArticlePubMedGoogle Scholar
- Edwards JR, Peterson KD, Andrus ML, Dudeck MA, Pollock DA, Horan TC: National Healthcare Safety Network (NHSN) Report, data summary for 2006 through2007, issued November 2008. Am J Infect Control 2008, 36: 609-626. 10.1016/j.ajic.2008.08.001View ArticlePubMedGoogle Scholar
- O'Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, Lipsett PA, Masur H, Mermel LA, Pearson ML, Raad II, Randolph AG, Rupp ME, Saint S, Healthcare Infection Control Practices Advisory Committee: Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control 2011, 39: S1-34. 10.1016/j.ajic.2011.01.003View ArticlePubMedGoogle Scholar
- Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C: An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006, 355: 2725-2732. 10.1056/NEJMoa061115View ArticlePubMedGoogle Scholar
- Soufir L, Timsit JF, Mahe C, Carlet J, Regnier B, Chevret S: Attributable morbidity and mortality of catheter-related septicemia in criticallyill patients: a matched, risk-adjusted, cohort study. Infect Control Hosp Epidemiol 1999, 20: 396-401. 10.1086/501639View ArticlePubMedGoogle Scholar
- Coopersmith CM, Rebmann TL, Zack JE, Ward MR, Corcoran RM, Schallom ME, Sona CS, Buchman TG, Boyle WA, Polish LB, Fraser VJ: Effect of an education program on decreasing catheter-related bloodstreaminfections in the surgical intensive care unit. Crit Care Med 2002, 30: 59-64. 10.1097/00003246-200201000-00009View ArticlePubMedGoogle Scholar
- Berriel-Cass D, Adkins FW, Jones P, Fakih MG: Eliminating nosocomial infections at Ascension Health. Jt Comm J Qual Patient Saf 2006, 32: 612-620.PubMedGoogle Scholar
- Durbec O, Viviand X, Potie F, Vialet R, Albanese J, Martin C: A prospective evaluation of the use of femoral venous catheters in critically illadults. Crit Care Med 1997, 25: 1986-1989. 10.1097/00003246-199712000-00014View ArticlePubMedGoogle Scholar
- Martin C, Eon B, Auffray JP, Saux P, Gouin F: Axillary or internal jugular central venous catheterization. Crit Care Med 1990, 18: 400-402. 10.1097/00003246-199004000-00010View ArticlePubMedGoogle Scholar
- Merrer J, De Jonghe B, Golliot F, Lefrant JY, Raffy B, Barre E, Rigaud JP, Casciani D, Misset B, Bosquet C, Outin H, Brun-Buisson C, Nitenberg G, French Catheter Study Group in Intensive Care: Complications of femoral and subclavian venous catheterization in critically illpatients: a randomized controlled trial. JAMA 2001, 286: 700-707. 10.1001/jama.286.6.700View ArticlePubMedGoogle Scholar
- Hohn DC, Gilbreath BJ, Suleiman N, Hill LA, Bruso PA, Marts K, Mansfield PF, Bodey GP: Prevention of central venous catheter-related infections by using maximal sterilebarrier precautions during insertion. Infect Control Hosp Epidemiol 1994, 15: 231-238. 10.1086/646902View ArticlePubMedGoogle Scholar
- Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S: Central vein catheterization. Failure and complication rates by three percutaneousapproaches. Arch Intern Med 1986, 146: 259-261. 10.1001/archinte.1986.00360140065007View ArticlePubMedGoogle Scholar
- Institute for Healthcare Improvement2013. [http://www.ihi.org]
- Bonello RS, Fletcher CE, Becker WK, Clutter KL, Arjes SL, Cook JJ, Petzel RA: An intensive care unit quality improvement collaborative in nine Department ofVeterans Affairs hospitals: reducing ventilator-associated pneumonia andcatheter-related bloodstream infection rates. Jt Comm J Qual Patient Saf 2008, 34: 639-645.PubMedGoogle Scholar
- Eggimann P, Harbarth S, Constantin MN, Touveneau S, Chevrolet JC, Pittet D: Impact of a prevention strategy targeted at vascular-access care on incidence ofinfections acquired in intensive care. Lancet 2000, 355: 1864-1868. 10.1016/S0140-6736(00)02291-1View ArticlePubMedGoogle Scholar
- Galpern D, Guerrero A, Tu A, Fahoum B, Wise L: Effectiveness of a central line bundle campaign on line-associated infections inthe intensive care unit. Surgery 2008, 144: 492-495. 10.1016/j.surg.2008.06.004View ArticlePubMedGoogle Scholar
- Render ML, Brungs S, Kotagal U, Nicholson M, Burns P, Ellis D, Clifton M, Fardo R, Scott M, Hirschhorn L: Evidence-based practice to reduce central line infections. Jt Comm J Qual Patient Saf 2006, 32: 253-260.PubMedGoogle Scholar
- Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM: Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004, 32: 2014-2020. 10.1097/01.CCM.0000142399.70913.2FView ArticlePubMedGoogle Scholar
- Sexton DJ, Chen LF, Anderson DJ: Current definitions of central line-associated bloodstream infection: is theemperor wearing clothes? Infect Control Hosp Epidemiol 2010, 31: 1286-1289. 10.1086/657583View ArticlePubMedGoogle Scholar
- O'Grady NP: Zero risk for central line-associated bloodstream infections ... Is thisrealistic? Crit Care Med 2012, 40: 657-658. 10.1097/CCM.0b013e3182372ba6PubMed CentralView ArticlePubMedGoogle Scholar
- Horan TC, Andrus M, Dudeck MA: CDC/NHSN surveillance definition of health care-associated infection and criteriafor specific types of infections in the acute care setting. Am J Infect Control 2008, 36: 309-332. 10.1016/j.ajic.2008.03.002View ArticlePubMedGoogle Scholar
- Winslow MN, Trammell L, Camp-Sorrell D: Selection of vascular access devices and nursing care. Semin Oncol Nurs 1995, 11: 167-173. 10.1016/S0749-2081(95)80026-3View ArticlePubMedGoogle Scholar
- Bourdon N, Lemire A, Fines-Guyon M, Auzou M, Perichon B, Courvalin P, Cattoir V, Leclercq R: Comparison of four methods, including semi-automated rep-PCR, for the typing ofvancomycin-resistant Enterococcus faecium . J Microbiol Methods 2011, 84: 74-80. 10.1016/j.mimet.2010.10.014View ArticlePubMedGoogle Scholar
- Chuang YC, Wang JT, Chen ML, Chen YC: Comparison of an automated repetitive-sequence-based PCR microbial typing systemwith pulsed-field gel electrophoresis for molecular typing of vancomycin-resistant Enterococcus faecium . J Clin Microbiol 2010, 48: 2897-2901. 10.1128/JCM.00136-10PubMed CentralView ArticlePubMedGoogle Scholar
- Pounder JI, Shutt CK, Schaecher BJ, Woods GL: Clinical evaluation of repetitive sequence-based polymerase chain reaction usingthe Diversi-Lab System for strain typing of vancomycin-resistant enterococci. Diagn Microbiol Infect Dis 2006, 54: 183-187. 10.1016/j.diagmicrobio.2005.08.004View ArticlePubMedGoogle Scholar
- Climo MW, Sepkowitz KA, Zuccotti G, Fraser VJ, Warren DK, Perl TM, Speck K, Jernigan JA, Robles JR, Wong ES: The effect of daily bathing with chlorhexidine on the acquisition ofmethicillin-resistant Staphylococcus aureus , vancomycin-resistant Enterococcus , and healthcare-associated bloodstream infections:results of a quasi-experimental multicenter trial. Crit Care Med 2009, 37: 1858-1865. 10.1097/CCM.0b013e31819ffe6dView ArticlePubMedGoogle Scholar
- Vernon MO, Hayden MK, Trick WE, Hayes RA, Blom DW, Weinstein RA: Chlorhexidine gluconate to cleanse patients in a medical intensive care unit: theeffectiveness of source control to reduce the bioburden of vancomycin-resistantenterococci. Arch Intern Med 2006, 166: 306-312. 10.1001/archinte.166.3.306View ArticlePubMedGoogle Scholar
- Centers for Disease Control and Prevention. Central line-associated bloodstreaminfection (CLABSI) event2013. [http://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf]
- Mermel LA: Prevention of intravascular catheter-related infections. Ann Intern Med 2000, 132: 391-402. 10.7326/0003-4819-132-5-200003070-00009View ArticlePubMedGoogle Scholar
- Shannon RP, Patel B, Cummins D, Shannon AH, Ganguli G, Lu Y: Economics of central line-associated bloodstream infections. Am J Med Qual 2006, 21: 7S-16S. 10.1177/1062860606294631View ArticlePubMedGoogle Scholar
- Goodman ER, Platt R, Bass R, Onderdonk AB, Yokoe DS, Huang SS: Impact of an environmental cleaning intervention on the presence ofmethicillin-resistant Staphylococcus aureus and vancomycin-resistantenterococci on surfaces in intensive care unit rooms. Infect Control Hosp Epidemiol 2008, 29: 593-599. 10.1086/588566PubMed CentralView ArticlePubMedGoogle Scholar
- Hayden MK: Insights into the epidemiology and control of infection with vancomycin-resistantenterococci. Clin Infect Dis 2000, 31: 1058-1065. 10.1086/318126View ArticlePubMedGoogle Scholar
- Noskin GA, Stosor V, Cooper I, Peterson LR: Recovery of vancomycin-resistant enterococci on fingertips and environmentalsurfaces. Infect Control Hosp Epidemiol 1995, 16: 577-581. 10.1086/647011View ArticlePubMedGoogle Scholar
- Hayden MK, Bonten MJ, Blom DW, Lyle EA, Van de Vijver DA, Weinstein RA: Reduction in acquisition of vancomycin-resistant enterococcus afterenforcement of routine environmental cleaning measures. Clin Infect Dis 2006, 42: 1552-1560. 10.1086/503845View ArticlePubMedGoogle Scholar
- Christiansen KJ, Tibbett PA, Beresford W, Pearman JW, Lee RC, Coombs GW, Kay ID, O'Brien FG, Palladino S, Douglas CR, Montgomery PD, Orrell T, Peterson AM, Kosaras FP, Flexman JP, Heath CH, McCullough CA: Eradication of a large outbreak of a single strain of vanB vancomycin-resistant Enterococcus faecium at a major Australian teaching hospital. Infect Control Hosp Epidemiol 2004, 25: 384-390. 10.1086/502410View ArticlePubMedGoogle Scholar
- Hanna H, Umphrey J, Tarrand J, Mendoza M, Raad I: Management of an outbreak of vancomycin-resistant enterococci in the medicalintensive care unit of a cancer center. Infect Control Hosp Epidemiol 2001, 22: 217-219. 10.1086/501892View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), whichpermits unrestricted use, distribution, and reproduction in any medium, provided theoriginal work is properly cited.