Prevention of central line-associated bloodstream infections through quality
improvement interventions: a systematic review and meta-analysis
Koen Y Blot, Jochen Bergs, Stijn I Blot, Dominique M Vandijck
Affiliations
Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium (KY Blot BSc, Prof SI Blot
PhD, Prof D Vandijck PhD); General Internal Medicine and Infectious Diseases, Ghent University Hospital,
Ghent, Belgium (Prof D Vandijck PhD); and Health Economics and Patient Safety, Hasselt University,
Diepenbeek, Belgium (J Bergs MSc, Prof D Vandijck PhD)
Corresponding author
Koen Blot, Ghent University, Faculty of Medicine and Health Sciences, 9000 Ghent, Belgium,
koen.blot@ugent.be, +32476992438
Keywords
Central line-associated bloodstream infection, catheter-related bloodstream infection, quality improvement
intervention, compliance, meta-analysis.
Summary (39 of 40 words)
Nosocomial central line-associated bloodstream infections are associated with the use of central venous
catheters. Quality improvement interventions aim to improve professional adherence to prevention
measures. The results of the meta-analysis provide evidence that quality improvement interventions decrease
infection rates.
1
Abstract (146 of 150 words)
Background
A systematic review and meta-analysis was performed to examine the impact of quality improvement
interventions on central line-associated bloodstream infections in adult ICUs.
Methods
Studies were identified through Medline (1995–June 2012) and manual searches. Odds ratios (OR) and 95%
CIs were calculated for infection rate reductions using a random-effects model. Subgroup analysis assessed
the impact of bundle/checklist interventions and high baseline rates on treatment effect.
Results
Forty-three studies were included. Meta-analysis of interrupted time series studies revealed an infection rate
reduction three months post-intervention (OR 0.30; 95% CI 0.10–0.88; p=0.03). Likewise, before-after
studies identified an infection rate decrease (OR 0.39; 95% CI 0.33–0.46; p<0.001). This effect was more
pronounced for before-after trials implementing bundle or checklist interventions (p=0.03).
Conclusion
This analysis suggests that quality improvement interventions contribute to the prevention of central lineassociated bloodstream infections. Implementation of care bundles and checklists appears to yield stronger
risk reductions.
2
Introduction
Central venous catheters, central lines that terminate at or close to the heart, are indispensable devices in the
intensive care unit (ICU). Approximately half of patients admitted require a central line for infusion of
medication, fluid, or blood products, hemodialysis, withdrawal of blood, or hemodynamic monitoring.
However, use of these invasive devices predisposes for the development of central line-associated
bloodstream infections (CLABSI). These serious, preventable complications increase patient morbidity,
leading to increased length of hospitalization and resource use.[1,2] Moreover, CLABSI might impact
mortality and compromise patient prognosis.[3-5]
Infection prevention measures during insertion or maintenance of central lines, such as hand hygiene, use of
maximal sterile barriers upon catheter insertion, disinfecting the skin with chlorhexidine, optimal catheter
site selection, and daily review of line necessity with prompt removal of unnecessary lines, have been
proven to decrease the risk of CLABSI incidents.[6,7] The Institute for Healthcare Improvement (IHI)
recommends use of the aforementioned items, in the form of a central line care bundle, to decrease CLABSI
occurrence. Despite the presence of evidence-based interventions, summarized in guidelines,[8,9] CLABSI
remain a substantial threat for hospitalized patients, with pooled estimated mean occurrence rates of 4.4
CLABSI per 100 devices inserted (95% confidence interval [CI] 4.1–4.9) and 2.7 CLABSI per 1000 catheter
days (95% CI 2.6–2.9).[10]
In recent years it has become clear that the limiting factor to infection prevention is the implementation
rather than publication of recommendations.[11] Introducing prevention measures may be hampered by
multiple factors, such as lack of problem awareness, poor familiarity or non-agreement with the guidelines,
low self-efficacy, inability to change previous practice, or lack of resources.[12,13] Quality improvement
interventions such as personnel education, feedback reporting of infection rates, or use of central line care
bundles and checklists aim to decrease CLABSI incidence by improving adherence to prevention
measures.[14] However, the efficacy of these interventions has not yet been fully assessed.
The objective of this study was to examine whether quality improvement strategies, defined as a
combination of quality improvement interventions, reduce CLABSI rates in the adult ICU. Subgroup
analyses were conducted to determine whether certain quality improvement interventions led to stronger
3
infection rate reductions.
4
Methods
Search strategy
Medline was systematically searched (1995–June 2012) through PubMed MesH terms. Extra studies were
identified by scanning reference lists of articles, manually and through Ovid and ScienceDirect databases. A
combination of the following search terms was used: catheter-related infections/prevention and control;
catheterization,
central
venous/adverse
effects;
catheters,
indwelling/adverse
effects;
infection
control/methods; infection control/standards; intensive care units; quality control; quality of health care; and
bundle. (webappendix 1). The search strategy was developed by two authors (KB and DV) and performed
by one investigator (KB).
Study selection
Eligible studies used before-after, interrupted time series (ITS), controlled before-after, non-randomized
controlled trial, or randomized controlled trial study designs that complied with the Cochrane EPOC Group
methodological criteria. ITS studies report at least three data points before and after a defined point in time
in which the intervention is implemented. Participants consisted of adult ICU patients with central line
catheters. Trials implemented a quality improvement intervention aimed at increasing professional
adherence to evidence-based infection prevention processes. The primary outcome measure was the
CLABSI rate: the number of CLABSI per catheter days during pre- and post-intervention. Only English
language papers were included. Medline search results were screened and excluded by their title or abstract
(KB). Selected papers underwent a full-text assessment (KB) and eligibility issues were resolved between
authors (KB, SB, DV).
Data extraction
Extracted data included author and year of publication, settings and study populations, study designs and
periods, implemented quality improvement and preventive interventions in the baseline and intervention
periods, number of CLABSI and catheter days, and applied CLABSI definitions. Secondary outcome
5
measures such as length of stay, mortality, hospital costs and savings, and compliance reporting were
likewise noted for the systematic review. Two authors (KB and DV) developed a data extraction sheet and
one reviewer (KB) retrieved the data from included studies. Study authors were not contacted for additional
data. To obtain effect sizes for ITS studies, infection rate data was extracted from figures published in
original papers using the program PlotDigitizer. Results reported as a mix from both included and excluded
study participants were included. When studies provided only two of three CLABSI rate parameters
(number of CLABSI, catheter days, and CLABSI per 1000 catheter days), the third was derived through
manual calculation. To avoid adding extraneous data, quality improvement interventions were classified
under general headers (webappendix 2) and only preventive interventions described by the CDC
guidelines[8] and applicable to the majority of ICU patients were noted.
Quality assessment
The Downs and Black checklist was applied to ascertain study methodological risk of bias (KB).[15] The
tool consists of 27 questions concerning the reporting, external validity, internal validity, and power of nonrandomized studies of health care interventions. Studies were scored based on whether they sufficiently
fulfilled the items. The criteria for these individual checklist items were adapted for CLABSI studies
following discussion between authors (KB, SB, DV). A power analysis was performed to determine whether
studies had a sufficient sample size to detect an odds ratio (OR) of 0.50 with a p-value of less than 5%.
Statistical analysis
A random-effects meta-analysis was performed using the DerSimonian-Laird estimator to obtain the OR and
95% CI for CLABSI rate reductions. Clinical heterogeneity was assessed by comparing study settings,
CLABSI definitions, and intervention implementation methodology. The Higgins I2 test was predefined to
quantify heterogeneity (I2≤25% for low, 25%<I2<50% for moderate, and I2≥50% for high). Subgroup
analysis by means of meta-regression was carried out for before-after study designs by comparing treatment
effects between studies that did and did not implement bundle/checklist interventions and studies with a
baseline rate above or equal to and below 4.0 CLABSI per 1000 catheter days. A funnel plot was
6
constructed to assess publication bias and a sensitivity analysis was performed to identify heterogeneous
studies that could influence the meta-analysis model. Monthly ITS study data was standardized by dividing
the outcome and standard error (SE) by the pre-intervention standard deviation (SD). One study reported
annual data points; these were used for the 12 and 24 month follow-up analyses.[16] The intervention effect
was calculated through SPSS version 22, using segmented time series regression analysis, taking into
account time trend and autocorrelation among the observations. A negative change in level or slope
indicates an intervention effect: an infection rate reduction.[17] A p-value less than 0.05 was used to denote
statistical significance.
Role of the funding source
There was no funding source for this study. SB holds a research mandate of the Specific Research Fund at
Ghent University. The corresponding author had full access to all the data in the study and had final
responsibility for the decision to submit for publication.
7
Results
The search algorithm identified 633 abstracts (627 in PubMed and six in Ovid and ScienceDirect). Fortythree studies, published in English between January 1995 and June 2012 consisting of 584 ICUs, were
included for meta-analysis (figure 1). Two studies[18,19] continued their quality improvement initiatives
and republished their old data with new results.[7,20] The older study by Coopersmith et al.[18] was
included for the meta-analysis of ITS studies and the paper by Pronovost et al.[19] was accessed to
supplement information. One trial could not be included for meta-analysis because although baseline and
intervention period interventions were qualitatively different, no new intervention types were
implemented.[21] Another study included multiple sets of data, for which the set with the longest follow-up
period was chosen.[22] Eleven studies could not included for ITS analysis because they implemented
interventions in a step-wise manner.[20,21,23-31]
The majority of the 43 studies were prospective before-after intervention trials in medical-surgical ICUs
(webappendix 3). Most trials implemented quality improvement interventions without simultaneously
introducing new prevention measures and used CDC definitions for CLABSI diagnosis.
The 584 included ICUs consisted of 564 adult, 11 pediatric,[22,32,33] and nine neonatal units.[22] Four
studies, reported the number of adult ICUs studied, but did not specify the ICU type (n=270).[33-36] The
remaining 294 adult ICUs were primarily mixed medical-surgical (n=135), medical (n=51), and surgical
(n=61).
The analysis consisted of 35 before-after,[6,20,22,24-26,31-59] seven interrupted time series,[16,18,38,6063] and one controlled before-after study.[64] Five of the ITS studies were eligible for inclusion in the
meta-analysis consisting of primarily before-after study designs.[16,38,61-63] Duration of study periods
ranged from nine[56] to 180 months,[16] with a mean length of 26.75 months.
Multiple quality improvement interventions were implemented in combinations (figure 2). Up to 14
different types of interventions were reported: personnel education, feedback reporting of infection or
compliance rates, use of care bundles or checklists, prepackaged catheter carts or kits, surveillance of
compliance with infection prevention processes, posters that raise awareness or report infection or
compliance rates, designation of leaders or champions for CVC prevention measures, empowering nurses to
8
stop incorrectly performed procedures, clinical reminders, distribution of fact sheets or leaflets, personnel
training, organizational changes, and installation of hand-rub dispensers (figure 3).
There were levels of variability between implemented quality improvement interventions, the detail with
which they were reported, and the methods used to apply them. Nearly all trials implemented educational
interventions (n=33) consisting of single, monthly, quarterly, or yearly sessions on CLABSI prevention.
Feedback reporting of infection or compliance rates to personnel occurred at monthly or quarterly intervals.
Likewise, surveillance of compliance with preventive interventions was implemented daily, periodically, or
at random intervals.
Half of trials implemented bundle or checklist interventions (n=20). Trials either initiated bundle
interventions without checklists (n=2),[6,43] only checklists because bundles were used during the baseline
period
(n=9),[36,42,50,51,53,55,57,60,61]
or
both
bundle
and
checklist
interventions
(n=9).[25,26,31,33,35,39,41,45,52]
Differing amounts of care items were grouped together to form a care bundle or checklist. Two trials[50,57]
did not report which care items comprised their bundle and one used a checklist for one sole care
process.[51] Other trials used either all five (n=7),[6,25,35,36,41,52,61] four (n=5),[26,31,39,45,60] three
(n=3),[33,42,53] or two (n=2)[43,55] IHI care items in their bundle or checklist.
Four studies concomitantly targeted other healthcare-associated infections such as ventilator-associated
pneumonia (VAP),[34] both VAP and catheter-associated urinary tract infections,[26,57] or VAP and
surgical site infections.[32] Eight studies simultaneously initiated new prevention measures alongside their
quality improvement interventions.[24,37,38,40,41,46,50,51]
The total number of CLABSI and catheter days were provided by 32 studies and manually calculated for
eight.[6,16,34,39-41,48,53] The baseline CLABSI incidence varied between studies: rates ranged from
2.1[32] to 46.3 CLABSI per 1000 catheter days.[44] Sixteen trials[24,25,32-35,41,49-51,55-57,59,60,62]
reported baseline infection rates equal to or lower than 5 CLABSI per 1000 catheter days and six trials
above 15 CLABSI per 1000 catheter days.[16,22,39,44,47,58]
Total scores on the Downs and Black quality assessment tool ranged from 15[57] to 26,[20,22,47] with a
median score of 21 (webappendix 4). The checklist revealed that two studies did not describe their CLABSI
9
definition,[38,57]
nine
did
not
interventions,[22,31,41,44,51,54,55,57,63]
sufficiently
and
27
describe
measured
their
quality
compliance
with
improvement
preventive
intervention.[6,20,22,25,31,33-36,38,39,42-44,46-48,51,53-58,61,64] Twenty-two reported confounding
factors such as duration of catheterization, patient characteristics or injury severity,[18,20,22,2426,37,39,41,44,48-52,55,56,59,61,64,65] which were comparable between baseline and intervention in 18
trials.[18,20,22,25,26,37,44,48,50-52,55,56,59,61,64,65] However, two trials corrected for the measured
differences in patient characteristics.[39,49] The power analysis revealed that studies tended to have either
low (n=24) or high power (n=13).[6,16,20,22,24,32,35,36,45,47,50,54,63]
Nearly all trials demonstrated CLABSI rate decreases, only ten did not achieve statistical
significance.[34,37,39,48,49,53,55,57,62,64] Two studies, reporting outcomes from ICUs separately,
revealed non-significant results for neurosurgical, neurological, cardiothoracic, and coronary care units, yet
decreased their total CLABSI rate.[44,45]
Meta-analysis was performed on 41 before-after and seven ITS study designs to assess the impact of quality
improvement interventions on the occurrence of CLABSI. The before-after trials showed a reduction in the
CLABSI rate (OR 0.39; 95% CI 0.33–0.46; p<0.0001, figure 4) with high statistical heterogeneity
(I2=85.4%). Analysis of six ITS studies, involving 11 ICUs, identified a change in level for the CLABSI rate
at 3 months post-intervention (OR 0.30; 95% CI 0.10–0.88; p=0.028, figure 5) with low heterogeneity
(I2=24.5%). Changes in infection rate slope (OR 0.81; 95% CI 0.59–1.13; p=0.216) and levels at 6 (OR
0.36; 95% CI 0.11–1.19; p=0.094), 12 (OR 0.17; 95% CI 0.02–1.27; p=0.084), and 24 months postintervention (OR 0.052; 95% CI 0.003–1.02; p=0.051) trended towards reductions, yet were not significant.
Subgroup analysis of before-after trials revealed that the CLABSI risk reduction was significantly stronger
(p=0.026; figure 4) in trials implementing care bundles or checklists (OR 0.34; 95% CI 0.27–0.41) than in
those implementing other interventions (OR 0.45; 95% CI 0.36–0.55) (webappendix 5). Further analysis
revealed that studies with baseline rates above 4.0 CLABSI per 1000 catheter days (OR 0.37; 95% CI 0.33–
0.46) did not demonstrate significantly better risk reductions (p=0.18) compared to studies below this
infection rate (OR 0.49; 95% CI 0.37–0.66).
10
Funnel plots displayed asymmetrical patterns for before-after, but not ITS study designs (webappendix 6).
The results of the sensitivity analysis of before-after study designs suggest that two studies contribute to
residual heterogeneity; removing them from the meta-analysis model would reduce variability between
studies.[47,50] However, doing so does not affect the results, therefore the choice was made to retain these
studies (webappendix 7).
11
Discussion
The results of the meta-analysis of 43 studies, involving 584 ICUs, provide evidence that quality
improvement interventions reduce CLABSI rates in adult ICUs. The effect size of 41 studies was significant
yet highly heterogeneous. This infection rate decrease was more pronounced in studies using bundles or
checklists, suggesting that implementation of these interventions as part of a quality improvement strategy
lead to stronger rate reductions. The change in infection rate level for six studies at 3 months follow-up also
demonstrates the beneficial impact of quality improvement interventions, but with a low level of
heterogeneity. Changes in levels at the 6, 12, and 24 month period were not significant yet trended towards
decreases. Reflecting the importance of multifaceted initiatives to improve patient safety culture, studies
often implemented multiple quality improvement interventions, as recommended by guidelines.[8]
Strengths of this study include the comprehensive search strategy encompassing various quality
improvement interventions, the methodological quality assessment of trials, and the random-effects model
analysis with multiple studies and interrupted time series study designs. It is however hampered by certain
limitations: a lack of randomized or controlled study designs, inconsistent reporting of prevention measure
compliance, and heterogeneity. Before-after studies run a higher risk of bias due to their liberal study
design: they hamper the ability to recognize phenomena that influence the CLABSI rate such as virulent
epidemic outbreaks or spontaneous regression to the mean.[14] There is some evidence to suggest that the
effects of quality improvement interventions are overestimated when based on before-after studies. Time
series designs limit this risk of bias by attempting to detect whether an intervention has had an effect
significantly greater than the underlying baseline trend.[66] However, since these designs require initiatives
to begin at a well-defined point in time, 11 studies with step-wise intervention implementation had to be
excluded.
Clinical and methodological heterogeneity stemmed from the use of differing intervention strategies, study
designs, population characteristics, and baseline standard of care. No distinction was made between
interventions applied as part of a structured program or introduced to solve a specific recurring problem.
Such differences in intervention implementation cannot be readily quantified. For example, one study
formed a team of nurses to evaluate care processes and data related to an infection rate increase. By applying
12
a comparable yet distinct quality improvement strategy, they decreased their rate from 1.5 to 0 CLABSI per
1000 catheter days.[21] Additionally, this review did not aim to identify strategies that lead to an optimal
uptake of quality improvement initiatives.
Although interventions implemented in settings with higher baseline rates are more likely to be successful,
no significant difference (p=0.18) was found between studies with baseline infection rates above or below
4.0 CLABSI per 1000 catheter days, a rate that is neither optimal nor drastic. Noteworthy is that the study
with the lowest baseline rate (2.1 CLABSI per 1000 catheter days) still achieved a significant rate reduction
by providing feedback of biannual infection rates.[32]
There are several issues related to the meta-analysis of before-after studies. All quality improvement
interventions were considered to have an equal impact, yet this may not be a fair assumption. For instance, if
a new intervention takes months to implement, then those introduced in a later study phase could have less
effect compared to earlier initiatives. Bias could also be present due to inclusion of studies from identical
authors.[22,47,54,58,59,63,64] Two of these studies were performed in the same hospital, which could lead
to an overestimation of the intervention effect due to hospital experience in intervention
implementation.[58,64] Furthermore, results of the forest plot of 41 studies revealed a lack of smaller
studies with less drastic infection rate decreases, suggesting the presence of publication bias. Nevertheless,
analysis of ITS designs aims to avert such barriers, and there was no evidence of publication bias amongst
those studies.
This meta-analysis is the first to include before-after studies researching the prevention of CLABSI through
quality improvement interventions and identify a preventive effect associated with care bundle and checklist
interventions. Two previous systematic reviews concluded that they were unable to ascertain which quality
improvement interventions should be recommended for widespread implementation.[14,67] Another
recommended the use of educational programs and multidisciplinary teams.[68] One other meta-analysis
included ITS studies, yet used differingg population criteria. They reported mixed effects on the CLABSI
rate, with small effect sizes.[17] Comparable points of criticism noted by these papers was the low quality of
included studies due to high baseline infection rates, inadequate reporting of multiple CLABSI data points,
process adherence measurements, and intervention details.
13
In conclusion, the results of this meta-analysis provide evidence that quality improvement interventions
reduce infection rates in intensive care units. Forty-one studies demonstrated consistent, beneficial results,
which appeared to be more pronounced amongst studies implementing care bundle and checklist
interventions. These findings were corroborated by interrupted time series studies.
Conflicts of interest
We declare that we have no conflicts of interest.
Contributors
KB conceived and designed the study, performed the search of published work, literature search, data
acquisition, interpretation and synthesis, statistical analysis, and wrote the paper. JB performed the statistical
analysis, contributed to data interpretation, and revised the statistical portions of the report. SB designed the
study, substantially contributed to the search of published work and data interpretation and synthesis, and
critically revised the final manuscript. DV conceived and designed the study, substantially contributed to
data interpretation and synthesis, and critically revised the final manuscript.
Acknowledgements
The results of this study were partially presented at the 26th annual congress of the European Society of
Intensive Care Medicine, Paris, France, 5–9 October 2013.
14
Figure 1. Summary of literature search and study selection
15
Figure 2. Distribution of quality improvement strategy size
16
Figure 3. Number of studies implementing quality improvement interventions
17
Figure 4. Overall effect of quality improvement interventions on CLABSI rates including subgroup
analysis of bundle and checklist interventions
18
Figure 5. Change in CLABSI infection rate level 3 months post-intervention
19
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