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.,
4
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
5
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
6
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
units.
Argument
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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