Central line-associated bloodstream infections are among the most serious of preventable health care-associated conditions, costing about $16,500 per incident in addition to needless suffering and death. Fortunately, the adoption of proven practices for reducing CLABSIs has allowed hospitals to make substantial progress in reducing their prevalence. Through a nationwide rollout of the Comprehensive Unit-based Safety Program by the Agency for Healthcare Research and Quality in collaboration with the American Hospital Association and Johns Hopkins Medicine, more than 1,000 intensive care units that participated in the project have dropped their CLABSIs by an estimated 41 percent, preventing more than 2,100 cases of CLABSIs, saving more than 500 lives and avoiding more than $36 million in unnecessary health care costs.

As inspiring as these results may be, experiences among care sites vary substantially. Some organizations have seen no new CLABSIs for extended periods of time; others, after initial gains, have seen their number of infections rise.

What Makes a Difference

Why some organizations are more successful than others in reducing CLABSIs is one of the questions recent research supported by AHRQ sought to address. Using an evidence-informed, high-performance work practices model, researchers from The Ohio State University and Rush University conducted in-depth case studies of nine hospitals, eight of which had participated in the CUSP programs and were selected because of variability in their levels of success and sustainability of CLABSI-reduction efforts. At each hospital, researchers interviewed between 14 and 38 clinicians, clinical leaders and administrative leaders about their efforts and outcomes associated with CUSP and other CLABSI-related initiatives. They interviewed a total of 226 individuals in the nine sites.

Some of the keys to successful efforts:

Strong, visible clinical leadership. The higher-performing hospitals frequently had one or more clinical leaders with whom staff identified as champions of the CLABSI-reduction efforts. The other staff often saw these leaders embodying the efforts and making it their personal mission to ensure success.

Systematic approaches to training. Higher-performing hospitals also tended to place a greater emphasis on ensuring that new staff in the units had full exposure to, and practice with, CUSP and related CLABSI-reduction strategies.

A belief that zero CLABSIs is achievable. Rather than accepting that CLABSIs are unavoidable, staff in the higher-performing hospitals typically viewed all CLABSIs as preventable. They challenged themselves and others to find the ways an incident could have been prevented. In contrast, staff in the lower-performing hospitals were quicker to view a CLABSI as out of their or the hospital's control.

More pervasive information sharing. The hospitals that had relatively higher success rates also communicated with their staff more frequently about the hospital's CLABSI performance. At the lower-performing hospitals, staff were less likely to know what the current performance level was, or have this information posted anywhere they could readily access it.

A greater sense of personal accountability. The staff of higher-performing hospitals tended to hold a stronger view about their own roles in the success of CLABSI-reduction efforts. Often staff within these higher-performing organizations said they did not want to "be the person responsible for breaking our winning streak." This was true not only for their own actions, but also for monitoring the actions of all other members of the care team (including families and friends of patients). In contrast, staff at the hospitals that weren't performing as well were more likely to avoid in-the-moment confrontations, choosing instead to use after-the-fact, formal chains of command to address hygiene-compliance problems.

An eye toward sustainability. As noted above, clinician champions appeared to be critical to the success of CLABSI efforts. However, staff in the higher-performing organizations also recognized that initiatives needed to live on beyond the tenure of these clinical leaders. Interviewees offered many examples of how the CLABSI-reduction efforts were being embedded into the culture and operations of their care units so that over time these efforts would not rely on a single champion to maintain.

The Bottom Line

We cannot say for sure that the techniques described will sustain the gains that hospitals are seeing in reducing CLABSIs. It is simply too soon to tell. However, we can stress the importance of planning ahead for sustainability to ensure that gains are maintained. Future journal articles and reports on the AHRQ website will provide more details and insights from this research. Additional research involving more diverse settings and longer time frames also will help to expand our understanding of how to sustain these important gains.

Andrew N. Garman, Psy.D., M.S., is a professor in the department of health systems management at Rush University and CEO of the National Center for Healthcare Leadership in Chicago; Ann Scheck McAlearney, Sc.D., M.S., is a professor and vice chairwoman of research in the department of family medicine at The Ohio State University Wexner Medical Center in Columbus; Julie Robbins is a Ph.D. candidate in the division of health services management and policy at The Ohio State University; and Michael I. Harrison, Ph.D., is a senior social scientist in the Center for Delivery, Organization, and Markets at the Agency for Healthcare Research and Quality in Rockville, Md.

The content of this article is solely the responsibility of the authors and does not represent the official views or recommendations of the Agency for Healthcare Research and Quality or the Department of Health & Human Services. The article is in the public domain and not subject to copyright.