title: Implementing the central venous catheter infection prevention bundle in the emergency department: experiences among early adopters.
abstract: OBJECTIVE
  Central line-associated bloodstream infections (CLABSI) cause preventable morbidity and mortality. Hospitals have reduced CLABSI by using a bundle of evidence-based infection prevention practices. Systems factors in the emergency department (ED) present unique barriers to bundle adoption, and no guidelines exist for bundle implementation. We aim to identify barriers and facilitators to central line bundle adoption in EDs.
  
  
  METHODS
  We used a qualitative, grounded theory approach, enrolling 6 EDs that were early adopters of the central line bundle. We interviewed 49 administrators and staff (nurses and physicians) through 26 semistructured interviews and 3 focus groups of 6 to 8 individuals. Investigators read each transcript and then iteratively built and refined a set of themes that emerged from the data.
  
  
  RESULTS
  Barriers to central line bundle adoption included high acuity, time constraints, staffing, space, ED culture, high ED volume and acuity, role ambiguity, and a lack of methods to track compliance and infection surveillance. Facilitators included champions, staff engagement, workflow redesign that includes a checklist and central line kit or cart, clear staff responsibilities, observer empowerment, and compliance and infection surveillance data.
  
  
  CONCLUSIONS
  The strategies for implementing and sustaining a central line infection prevention bundle in the ED are distinct from those of other clinical settings. Our findings describe the central line bundle workflow in the ED, staff motivations, and the critical systems factors that impede and foster its use. Knowledge of these systems factors should improve bundle adoption in the ED and thereby reduce hospital incidence of CLABSIs.
authors.affiliation: Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; David Geffen School of Medicine at UCLA, Department of Emergency Medicine, Los Angeles, CA. Electronic address: christopher.h.lemaster@kp.org.
authors.forename: Christopher H
authors.initials: CH
authors.lastname: LeMaster
authors.affiliation: Alice Ramez Chagoury School of Nursing, Lebanese American University, Beirut, Lebanon.
authors.forename: Nancy
authors.initials: N
authors.lastname: Hoffart
authors.affiliation: Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA.
authors.forename: Tom
authors.initials: T
authors.lastname: Chafe
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Department of Medicine, Boston, MA.
authors.forename: Ted
authors.initials: T
authors.lastname: Benzer
authors.affiliation: Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Department of Medicine, Boston, MA.
authors.forename: Jeremiah D
authors.initials: JD
authors.lastname: Schuur
mesh_terms: D001291:Attitude of Health Personnel; D055499:Catheter-Related Infections / Q000517:prevention & control*; D002405:Catheterization, Central Venous / Q000379:methods / Q000592:standards*; D057189:Checklist; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D017144:Focus Groups; D006801:Humans; D007407:Interviews as Topic; D064872:Patient Care Bundles / Q000379:methods / Q000592:standards; D036301:Qualitative Research