In the United States, 15 million central catheters are inserted in the ICU per year

(McMullan et al., 2013). To put that in perspective for patients in critical care, Exline (2013)

stated “nearly 50% of the patients will have a central venous catheter (CVC) inserted at some

point in their care” (p.6). The prevalence of central lines signifies that it is crucial instrument to

sustain life but so is the parallel of preventing risk of infection. Despite increased hospital wide

infection prevention campaigns, emergence of evidence-based practices and mandatory reporting

to national and federal networks, CLABSI continues to be a burden to the healthcare system. It is

important that we evaluate strategies to challenge and improve the current state as CLABSI

incidences continue to persist amidst the landscape of these advances. The research reviewed is

from three observational cohort studies that examines the impact of a collaborative multi-

disciplinary approach to implementing the bundle interventions on the reduction of CLABSI

rates through a quality improvement initiative.

Walz et al. (2015) conducted a 9-year observational study of critically ill patients with

central lines in 8 ICUs at UMass Memorial Medical Center, Worcester, MA, a tertiary level

medical center. The primary findings described a multidisciplinary approach of insertion and

care of central lines that was associated with a 92 % reduction in CLABSI rates (Walz et al.,


2015). Several of the ICUs also had no CLABSIs occurring for more than 2 years (Walz et. al.,

2015). The system was implemented through the formation of a Critical Care Operations sub-

committee that includes physicians, nurses, pharmacists, and hospital administrators to address

CLABSIs (Walt et al., 2015). Interventions included “hand hygiene education program,

dedicated catheter cart with all the necessary supplies, catheter insertion procedure checklist

using maximum barrier precautions, empowering bedside nurses to stop the procedure if

elements of checklist not followed, catheter maintenance bundle, root cause analysis and daily

assessment of the need for CVCs” (Walt et al., 2015, p.869). Also uniquely incorporated was a

pay for performance measure of the different units as a financial incentive to prevent CLABSIs

to ICU leadership and the medical directors (Walt et al., 2015). According to Waltz et al. 2015,

the nature of a quality improvement study by design is not as rigorous compared to a randomized

controlled trial. Other limitations include not being able to demonstrate which element of the

bundle of interventions was responsible for the reduction in CLABSI rates and the study cannot

infer causality from the data extrapolated (Walz et al., 2015). Also, into consideration, the study

was done in a single institution and it mentioned that adherence to best practice guidelines was

self-reported. There were no independent audits to determine the fidelity of the data compliance

(Walz et al., 2015). The strength of this investigation included the long period for evaluation,

large number of different ICUs in the sample, and no apparent association between the unit’s

patient population’s acuity and chronic health background with CLABSIs as a potential

confounding factor.

Another study, Exline et al. (2013) conducted a 2-year study in a 25-bed medical ICU in

Ohio State University Wexner Medical Center, an academic tertiary hospital. A multidisciplinary

team was formed that consists of infection preventionist, epidemiologist, physician, and nursing


leadership. During the first fiscal year, the study noted that despite being “aggressive” with

emphasis on central line bundles it only introduced marginal success. During the second year,

they utilized a more in-depth additional measure by doing root cause analysis with clinical

epidemiology investigation. The study reported 80% reduction in CLABSI rates in year 2

compared to the baseline period. There were zero CLABSIs for the last 10 months of the

intervention period and zero for 15 months (Exline et al., 2013). The authors attributed their

success to a “synchronized model for multidisciplinary team” by promoting a culture of safety,

engaged hospital leadership that foster positive morale and facilitated staff compliance with new

standards of care (Exline et al., 2013). They believed these strategies play an important role in

sustaining the progress of the CLABSI reduction (Exline et al., 2013). The study acknowledged

the limitation of a focus sample on homogeneous ICU population and staff that may be not

extrapolated to other ICUs (Exline et al., 2013). Historical controls were also the baseline. The

study also did not do continuous monitoring during the intervention period due to being labor

intensive and similarly did not evaluate the separate components of the intervention related to the

central line bundle on CLABSI rates (Exline et al., 2013).

Han et al. 2019 conducted a 22-month prospective study at Renmin hospital of Wuhan

University, a general teaching hospital in China from January 2017 to October 2018. The patient

population included general ward, emergency rooms, operating rooms, and ICUs. The study

preface that CLABSI rates in China and other developing countries is still a prominent issue

(Han et al., 2019). Compared to the previous studies, this design focused on non-ICU patients

which there has not been adequate research despite large non-ICU patients having central lines

and CLABSI (Han et al., 2019). The data showed statistical significance in the reduction of

CLABSI from baseline. CLABSI rates decrease from 2.84 per 1000 CVC to 0.56 in ICUs and


from 0.82 to 0.47 in non-ICUs (Han et al., 2019). The authors concluded that “a reduction of

hospital wide CLABSI was reached with a comprehensive, multidisciplinary and multi modal

quality improvement program, including aspects of behavior age and key principles of good

implementation practice in a developed country” (Han, 2019, p.1362). The authors reasoned that

infection control program and hospital wide surveillance is effective in reducing CLABSI. The

study does acknowledged limitations of low compliance to the CLABSI bundle by staff. Also, as

a quality improvement study, it cannot make a definitive conclusion concerning the effectiveness

of a specific intervention (Han et al., 2019). This was also a single center study in a tertiary care

hospital, the researchers stated results may be biased by the relatively large proportion of patients

with acuity (Han et al., 2109). This study overall set a precedent to report both on CLABSI in

ICUs and non-ICUs patients in China.

The research above of all observational single center studies, the theme of utilizing a

multidisciplinary comprehensive strategy to implement evidence-based practice of central lines

have been shown to enhance the outcomes of infection prevention and reducing CLABSI rates

from their baseline. These studies validate that an effort to champion an “innovative team

approach” can further reduce and refine CLABSI that can be translated and reproducible to other



Over the last decade there has been a significant reduction in CLABSIs. The CDC and

NHSN (2021) reported a 46 % decrease in CLABSIs across U.S. hospitals from 2008-2013 (p.3).

This can be attributed to behavioral changes such as hand hygiene, education training, catheter

bundles, checklist, and maximum barrier precautions as well as technological ad

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