Enhancing the CLABSI Bundle for Optimal Patient Outcomes

Purpose:
In our facility, an interdisciplinary committee strives to achieve sustained reductions in central line-associated bloodstream infection (CLABSI). Using a strategy to reduce intraluminal contamination, we aimed to achieve sustained CLABSI rates well below national benchmarks.

Significance:
Central venous catheters (CVCs) are a leading source of nosocomial infection, causing more than 40,000 bloodstream infections annually. With an attributable mortality of up to 25%, and associated hospital costs exceeding $29,000, CLABSI prevention has become a healthcare priority.

Strategy and Implementation:
Hospitals have made striking reductions in CLABSI using a bundle of evidence-based actions for care of central lines. Because CVC manipulation is a well-recognized risk factor for CLABSI, we focused on additional strategies to reduce intraluminal contamination, such as aseptic management of the catheter hub, eliminating blood sampling from central lines, avoiding catheter-tubing disconnections during routine patient care, and reinforcing the policy of dedicating a lumen of the device for parenteral nutrition. Reports linking higher CLABSI rates to the use of positive-pressure needleless connectors led us to replace them with neutral caps. Comprehensive education and continuous unit-based feedback of results promoted culture change. Coaching and mentoring took place in a cascading manner, flowing from high levels of the organization to the bedside. Seeking to partner with our patients, we also developed a brochure describing these policies and encouraging them to speak up with concerns.

Evaluation:
The focus on limiting CVC hub manipulation marked the start of more than 2 years of sustained declines in CLABSI. In 2010, the entire hospital had zero infections for 5 consecutive months. Rates for ICU and non-ICU were 0.37 and 0.15/1000 device days respectively in 2010.

Implications for Practice:
Comprehensive CLABSI prevention strategies that specifically target intraluminal contamination can further enhance results achieved through the currently recognized bundle approach. On-going education and timely reporting to all stakeholders is an essential component of this process.