title: The bundle "plus": the effect of a multidisciplinary team approach to eradicate central line-associated bloodstream infections.
abstract: BACKGROUND
  Central line-associated bloodstream infections (CLABSIs) have decreased significantly over the last decade. Further reductions in CLABSI rates should be possible. We describe a multidisciplinary approach to the reduction of CLABSIs.
  
  
  METHODS
  This was an observational study of critically ill patients requiring central venous catheters in 8 intensive care units in a tertiary medical center. We implemented a catheter bundle that included hand hygiene, education of providers, chlorhexidine skin preparation, use of maximum barrier precautions, a dedicated line cart, checklist, avoidance of the femoral vein for catheter insertion, chlorhexidine-impregnated dressings, use of anti-infective catheters, and daily consideration of the need for the catheter. Additional measures included root cause analyses of all CLABSIs, creation of a best practice atlas for internal jugular catheters, and enhanced education on blood culture collection. Data were analyzed using the Poisson test and regression.
  
  
  RESULTS
  CLABSI, catheter use, and microbiology were tracked from 2004 to 2012. There was a 92% reduction in CLABSIs (95% lower confidence limit: 67.4% reduction, P < 0.0001). Central venous catheter use decreased significantly from 2008 to 2012 (P = 0.032, -151 catheters per year, 95% confidence limits: -277 to -25), whereas peripherally inserted central catheter use increased (P = 0.005, 89 catheters per year, 95% confidence limits: 50 to 127). There was no apparent association between unit-specific Acute Physiology And Chronic Health Evaluation III/IV scores and CLABSI. Three units have not had a CLABSI in more than a year. The most common organism isolated was coagulase-negative staphylococcus. Since the implementation of minocycline/rifampin catheters, no cases of methicillin-resistant Staphylococcus aureus CLABSI have occurred.
  
  
  CONCLUSIONS
  The implementation of a standard catheter bundle combined with chlorhexidine dressings, minocycline/rifampin catheters, and other behavioral changes was associated with a sustained reduction in CLABSIs.
authors.affiliation: From the *Departments of Anesthesiology and Surgery, University of Massachusetts Medical School and UMass Memorial Medical Center; †Department of Medicine, Division of Infectious Diseases, ‡Infection Control Department, §Critical Care Operations Committee, and ∥Department of Surgery, UMass Memorial Medical Center; and ¶Departments of Quantitative Health Sciences and Cell Biology, University of Massachusetts Medical School, Worcester, Massachusetts.
authors.forename: J Matthias
authors.initials: JM
authors.lastname: Walz
authors.forename: Richard T
authors.initials: RT
authors.lastname: Ellison
authors.forename: Deborah A
authors.initials: DA
authors.lastname: Mack
authors.forename: Helen M
authors.initials: HM
authors.lastname: Flaherty
authors.forename: John K
authors.initials: JK
authors.lastname: McIlwaine
authors.forename: Kathleen G
authors.initials: KG
authors.lastname: Whyte
authors.forename: Karen E
authors.initials: KE
authors.lastname: Landry
authors.forename: Stephen P
authors.initials: SP
authors.lastname: Baker
authors.forename: Stephen O
authors.initials: SO
authors.lastname: Heard
mesh_terms: D016470:Bacteremia / Q000453:epidemiology / Q000517:prevention & control*; D055499:Catheter-Related Infections / Q000453:epidemiology / Q000517:prevention & control*; D002405:Catheterization, Central Venous / Q000009:adverse effects*; D062905:Central Venous Catheters / Q000009:adverse effects*; D002710:Chlorhexidine / Q000737:chemistry; D003422:Critical Care; D016638:Critical Illness; D063373:Hand Hygiene; D006801:Humans; D007362:Intensive Care Units; D033183:Interdisciplinary Communication; D010348:Patient Care Team; D012044:Regression Analysis; D013203:Staphylococcal Infections / Q000453:epidemiology / Q000517:prevention & control; D013210:Staphylococcus
chemical_list: D002710:Chlorhexidine