Central Line-Associated Bloodstream Infections

Central Line-Associated Bloodstream Infections.
Healthcare-associated infections (HAIs) are infections that patients get while receiving treatment and many are preventable. Modern healthcare employs the use of invasive procedures and devices in treating various conditions but the risk of such advancements comes with at a cost.

Healthcare-associated infections are an important cause of mortality and morbidity in the US. The infections also have a substantial effect on increased healthcare costs each year. According to statistics, one out of twenty-five hospitalized individuals gets affected by an HAI (ODPHP, 2020). One of the most common healthcare-associated infections is a central line-associated bloodstream infection (CLABSI). It is a serious infection that occurs when germs enter the bloodstream through a central line. The Centers for Disease Control and Prevention (CDC) estimate that about 250,000 cases of CLABSI occur in the US each year (CDC, 2017). The seriousness of the infections has led to the development of various strategies that can be implemented in acute care, ambulatory surgical centers, dialysis facilities, outpatient care and long-term care facilities to prevent the occurrence of the infections.


Central line-associated bloodstream infections result in thousands of deaths each year in the US and billions of dollars are added to the healthcare costs. Central lines are placed on a large vein in the neck, chest or groin to give medication or fluids for critically ill patients. A central line bloodstream infection occurs when germs especially viruses and bacteria enter the bloodstream through the CVC. The infections can occur at various stages including insertion, maintenance of the line and during removal (Wichmann et al., 2018). Central lines can stay in the patient’s body for weeks or months thus increasing the risk of infection. Therefore, healthcare providers must use stringent infection control practices each time they check the line or change dressing (CDC, 2017).

Healthcare organizations have set standards and guidelines to help prevent hospital-acquired infections such as CLABSIs. Prevention of CLABSI in the past has used three basic approaches including care during insertion, care when the line is in place and removal of the CVC once it is not needed (Haddadin and Regunath, 2019). During insertion, healthcare providers maintain hygiene and sterility by washing hands, ensuring preparation of the insertion site using the antiseptic solution and use of maximum barrier precautions. When the line is in place, healthcare providers ensure that hand washing and sterility is maintained when accessing the central lines. Patients are also asked to do proper hand washing using soap before touching the line. Removal of the catheter should be done whenever the patient doesn’t require its use anymore to reduce the chances of infection.

Maintenance of zero CLABSI rates in intensive care units is a priority for every healthcare organization. Following insertion, maintenance and removal protocols are crucial in achieving zero CLABSI cases. For many years my healthcare organization has maintained CLABSI rates at negligible levels through following standard operating procedures and guidelines. Recently, it has been realized that the rate of infections has increased even with the use of the set standards. One key factor that is attributed to the increased rate is lack of teamwork in caring for patients in the intensive care unit. The doctors want to perform the procedures alone; nurses won’t consult on crucial aspects regarding the central lines; new employees and students have little information regarding the care of the central lines, and periodic assessment of the need for the CVCs is not performed. Secondly, the guidelines available for preventing CLABSI have been neglected. Some employees complain that there should be an update on the guidelines to ensure everyone is on the same page of CLABSI prevention. Such factors have caused confusion in the department and the consequence is increased CLABSI rates in the hospital ICU.

Problem Statement

Central venous catheters (CVCs) are life-saving, and many patients in the intensive care units (ICU) have them inserted purposely to give fluids and medicine. Patients in cardiogenic shock, those with decompensated heart failure and pulmonary hypertension are among the group that benefits from this intervention. Despite the life-saving nature of the central lines, they can cause serious problems for the patients. Central line bloodstream infection is defined as a laboratory-confirmed bloodstream infection not related to an infection on another site that develops within 48hrs of central line placement (Haddadin and Regunath, 2019).

CLABSIs lead to prolonged hospital stays and increase health care costs and mortality. According to estimates, a single case of CLABSI costs approximately $46,000. Many factors are associated with increased rates of CLABSI ranging from host factors to factors related to patient care. Some factors that increase the rate of CLABSI in patients include malnutrition, extremes of age, prolonged hospitalization before line insertion, chronic illnesses and catheter location. Apart from the patient factors, poor handling of the central venous lines during insertion, maintenance and removal can lead to infection. Data from the International Nosocomial Infection Control Consortium (INICC) reveals that the incidence rate of CLABSI is 4.1 per 1000 central line days (Haddadin and Regunath, 2019). CLABSIs that occur beyond 10 days of hospitalization usually result from contamination of the hub by healthcare providers. With the proper following of procedures, teamwork and the use of CLABSI prevention guidelines, the infections can be prevented.

Quality Improvement Program

Central line-associated bloodstream infection (CLABSI) is a very common problem in the intensive care unit. These infections are associated with over 28,000 deaths each year and cost over 21 billion US dollars (Lee, Cho, Jeong, Kim, Han, & Song, 2018). CLABSI increases the length of hospitalization for patients causing poor satisfaction especially when the cause is related to poor quality care. The patient’s families become depressed due to the cost incurred and the uncertainties involved with the infection. Likewise, the healthcare organization gets to spend more time in designing quality improvement, innovations and practice change guidelines to deal with the concern.

Various healthcare organizations have set guidelines that can be used to prevent CLABSI in ICU and non-ICU care settings. Among the top institutions with well-designed guidelines include the CDC, the Institute for Healthcare Improvement (IHI) and the Infectious Disease Society of America (IDSA). These bodies acknowledge the use of well-designed guidelines also known as Central Line (CL) bundles that focus on three areas; insertion of catheters, maintenance of catheters and timely removal of unnecessary central lines. The following components are critical for every healthcare organization in the prevention of CLABSI.

  1. Hand hygiene by washing hands with soap and water or with alcohol-based gels or foams. Gloves do not obviate the need for hand hygiene.
  2. Strict aseptic technique by using maximal sterile barrier precautions, including a full-body drape when inserting central venous catheters.
  3. Use of 2% Chlorhexidine skin preparations for disinfecting/ cleaning skin before insertion.
  4. Ultrasound guidance by an experienced provider for placement to circumvent mechanical complications and reduce the number of attempts.
  5. Avoid the femoral vein as a choice for central line placement, and prefer the subclavian vein when possible for non-tunneled catheters.
  6. Promptly remove any central line that is no longer required.
  7. Replace central lines placed during an emergency (asepsis not assured) as soon as possible or at least within 48 hours.
  8. Use a checklist.

Healthcare institutions use these general guidelines to ensure proper procedure is followed during insertion. It is also critical to understand that central lines should be inserted by a dedicated team that consists of the surgeon, nurses, and pharmacists who will monitor the patient (Wichmann et al., 2018). In 2011, the CDC developed a comprehensive checklist for the prevention of central line-associated bloodstream infections. The guidelines address the physicians, nurses and the healthcare organization at large regarding the necessary care required for central lines (Lee et al., 2018). Evidence-based practice has demonstrated that proper following of these guidelines is critical in maintaining the CLABSI rate at zero. Consequently, it is critical for the healthcare organization to use a multidisciplinary approach in ensuring compliance with the CDC guidelines. To properly implement these prevention guidelines, a team will be selected to ensure nurses, surgeons, infection prevention personnel and patients are involved in the implementation of the CDC CLABSI prevention guidelines.


Achieving a CLABSI rate of zero percent is every organization’s dream because it demonstrates quality care and improves satisfaction among staff and the patients. Healthcare-associated infections cause harm to the patient through prolonged hospitalization, increased healthcare costs and sometimes death. Institutions must manage CLABSI through implementation and compliance with the CDC guidelines. The CDC CLABSI prevention guidelines provide steps that are crucial to the insertion and maintenance of the CVCs. Proper insertion using the aseptic technique ensures there is no introduction of bacteria or viruses into the lines.

The CDC guidelines are in support of evidence from other internationally recognized bodies such as IHI and IDSA which require timely removal of the catheters. Timely removal ensures that the line does not stay in the patient for too long providing the route of entry for bacteria. The guidelines also require the healthcare organization to educate healthcare personnel about indications of CVCs and periodically assess knowledge of and adherence to the guidelines (CDC, 2014). The performance of such practices will ensure that healthcare providers are updated with CLABSI prevention. The use of a multidisciplinary approach to implementing the CDC guidelines is crucial for all teams to ensure teamwork and accountability. Through a multidisciplinary approach the nurses, surgeons, infection prevention team and the patients will be able to work together in achieving zero CLABSI rates in the hospital ICU department.

Credible Sources

Credible sources are preferred for research because they contain true, accurate and up-to-date information concerning the topic of interest. Researchers identify credible sources to be materials published within the last 10 years, research written by well-known authors, materials from government and educational institutions’ websites, and sources from academic databases. The central line-associated blood-stream infection is a topic that has been widely covered through qualitative and quantitative research. Numerous articles are available describing the causes of CLABSI, preventive measures in acute and ambulatory care facilities and evidence-based research of best practices that can be used to reduce CLABSI cases. Most of the research articles available provide evidence on the incidence rate of CLABSI in intensive care units (ICUs). The research articles from healthcare organizations such as the CDC and the IHI provide standard guidelines on prevention of CLABSI and they have been used as the primary source of information in other research. A total of 30 credible sources were reviewed in this research, all published within the last five years. The sources are presented in the reference page of the paper.


Best Practices

A best practice is a method that has been accepted as superior to any alternatives because it produces results that are superior to those that are achieved by other means. Best practices are always methods that comply with legal or ethical requirements and they have become the standard way of doing things. Best practices are deduced from research studies done either qualitatively or quantitatively to bring about outcomes that can be used in a large population. The central line-associated bloodstream infection is an area that has evidence-based practices dating several years back. Best practices in this area include proper selection of insertion site, multidisciplinary approach to CLABSI prevention, and the use of the central line insertion checklist.

Central venous catheter insertion is required by many critically ill patients and the site of catheter insertion is important. The selection of the insertion site should be based on both the ease of placement and the risk associated with the procedure. The common sites of catheter placement include the internal jugular vein, subclavian vein and the femoral vein (Istar et al., 2016). The internal jugular vein access is associated with a low rate of severe mechanical complications than subclavian access. It is preferred for short term access and hemodialysis. The subclavian vein is the most preferred because it is associated with lower risks of infection and can last for more than seven days (Haddadin & Regunath, 2019). The femoral access is used in patients who pneumothorax or hemorrhage would be unacceptable because it is associated with higher risks of infection.

Evidence Summary

The patient safety movement foundation (PSMF) is an internationally recognized body that provides guidelines, research and best practice recommendations for healthcare problems. The foundation recognizes CLABI to be among the top leading healthcare concerns in hospitals, especially in the intensive care units. The foundation describes guidelines developed by Dr. Peter Pronovost to help healthcare institutions fight CLABSI. According to the study, there should be a commitment from the hospital leadership to eliminate CLABSIs and this can be achieved through multidisciplinary approaches (PSMF, 2016). The Centers for Medicare and Medicaid Services (CMS) has reduced reimbursements for reasonably preventable hospital-acquired infections including CLABSI. Common themes that arise in the implementation of best practices to prevent CLABSI include implementing a catheter insertion checklist, monitoring the continued need for vascular access and implementing a method to detect true incidents of CLABSI. The PSMF strongly recommends the use of a catheter insertion checklist as a measure to prevent CLABSI in hospitals.

Indwelling central venous catheters (CVCs) have the potential to cause bloodstream infections, and the prevention of central line-associated bloodstream infections (CLABSIs) can reduce adverse outcomes, such as excessive medical costs, risk of mortality, and long-term hospitalization. A study was conducted in South Korea to evaluate the effect of central line bundle compliance in reducing CLABI rates in different healthcare departments. The study used the CDC guidelines developed in 2011 to come up with the best strategies to prevent the occurrence of infections. Among the key components of the implementation plan included the use of maximal sterile barrier precautions, Chlorhexidine antiseptic use, and selection of an appropriate site for catheter insertion (Lee et al., 2018). The study recruited 1672 patients from four hospital departments over three years and interventions using the CL bundle were made. The results indicate that full compliance with the CL bundle reduces the CLABSI rate. The research also identified the use of educational programs for healthcare providers to be important in reducing HAIs. The researchers conclude that every healthcare organization should use the CDC guidelines in the management of CLABSI.

Central-line-associated bloodstream infection (CLABSI) is one of the most important problems in intensive care units (ICUs) worldwide. With numerous researches being conducted on the prevention of the problem, many researchers have focused on the use of a central line prevention bundle. A study was conducted in a medical-surgical ICU unit in Turkey from 2010 through 2015 to assess the relevance of CL bundles in preventing CLABSI. Compliance rates with the prevention bundle were measured during the study and feedback provided to staff to reinforce a culture of safety. During the study, 732 central catheters were placed and observed for a cumulative period of 4,366 days. Following the implementation of the guidelines and provision of feedback to staff, the healthcare institution managed to maintain a zero percent CLABI rate for 38 months (Hakko, Guvenc, Karaman, Cakmak, Erdem, & Cakmakci, 2015). There was a strong negative correlation between the level of application of the care package and the rates of central catheter infections. In conclusion, the implementation of this central catheter care package, combined with the emphasis on the level of application of all of its components and a culture of patient safety, made it possible to achieve and maintain a zero rate infection on a central catheter in this intensive care unit.

A multidisciplinary approach to the management of CLABSI is among the recognized solutions to alleviating the problem in healthcare organizations. Collaboration between nurses and physicians is crucial for the prevention of CLABSI because monitoring and management of patients are easier. The multidisciplinary approach also improves communication between teams making it possible to detect errors and predict outcomes (Zingg et al., 2014). A study was conducted to evaluate the effectiveness of a multidisciplinary approach to CLABSI prevention in a tertiary care hospital. The strategy used education and training for physicians and nurses regarding CVCs and how working with other teams can help reduce infection rates. The study recruited 146 physicians and 1274 nurses for the exercise and upon complete ion results were monitored in 3952 patients over three years. The results from the study indicated a clinically relevant reduction of hospital-wide CLABSI rates using a comprehensive multidisciplinary and multimodal quality improvement program.

Central venous catheters (CVCs) are life-saving and the majority of patients in intensive care units (ICUs) have them placed to receive medicine and fluids. However, the use of these lines can result in serious bloodstream infections. The Institute of Healthcare Improvement (IHI) in conjunction with the CDC has developed guidelines that are used to prevent the occurrence of CLABSI across healthcare organizations. A research was conducted to determine the effectiveness of using the IHI central line bundle together with a multidisciplinary approach in achieving zero CLABSI rates. Before the implementation of the strategy, the infection rate in the institution was 2.0 per 1000 line days. After two years of evaluation, the CLABSI rate had decreased to 0.7 per 1000 central line days (Yaseen et al., 2016). Subsequent evaluation of the results indicated that the compliance rate had increased from 37% in 2008 to 98% in 2013. A multidisciplinary approach to the implementation of a CL bundle is crucial to the achievement of positive results.

The use of a central venous line (CVL) insertion bundle has been shown to decrease the incidence of CLABSIs. A prospective cohort study was conducted in a healthcare ICU department as from 2011 to determine the effect of a CVL bundle in reducing CLABSIs. The guidelines for the implemented bundle were derived from the CDC and IHI to ensure that evidence-based approaches were used. The implemented bundle had five key areas of concern including hand hygiene by the inserter, maximum barrier precautions, use of Chlorhexidine scrub at the insertion site, optimal catheter site selection and daily examination for the necessity of the central lines (Salama, Jamal, Al Mousa, & Rotimi, 2016). The nursing team was also under instruction to monitor the insertion of the CVCs and halt the procedure if a break in sterile technique was observed. The results from the program saw a reduction of the CLABSI rate from 14.9 to 11.08 per 1000 catheter days. The study demonstrates that the implementation of a central venous catheter bundle is crucial in the reduction of CLABSIs.

Multidisciplinary approaches involve drawing appropriately from multiple disciplines to define problems outside normal boundaries and reach solutions based on a new understanding of complex solutions (Scatliffe et al., 2015). Researchers identify that the prevention of CLABSI in healthcare institutions cannot be solved by one discipline, but a multidisciplinary approach. Nurses, doctors, the infection prevention team, patients and the environmental services team come up together to implement strategies that prevent CLABSI. While doctors and physicians have the expertise to insert the CVCs, nurses should be at the frontline to observe and ensure sterility is maintained during the procedure (Scatliffe et al., 2015). The multidisciplinary approach also ensures that communication is maintained between the teams which can help in early detection and prevention of CLABSI.

Central line-associated bloodstream infections (CLABSI) are a major source of sepsis in modern intensive care medicine. To prevent infection rates, hospitals have used bundle intervention strategies in the past. Perhaps, the addition of checklists can be a good step towards achieving zero CLABSI rates. The Centers for Disease Control and Prevention (CDC) together with the Institute of Health Information (IHI) provide checklists that are used during the insertion of central lines. The checklists highlight the necessary steps and requirements that must be met during insertion, maintenance of the CVCs and removal (IHI, 2019). Both checklists acknowledge that sterility must be maintained throughout the procedure and there should be prompt removal of unnecessary central lines to minimize the risk of infection.


Central venous catheters (CVCs) are life-saving, and many patients in the intensive care units (ICU) have them inserted purposely to give fluids and medicine. The catheters help individuals that are in critical conditions to receive treatment, but the risk of insertion and maintenance is high. Depending on the site of insertion and the condition of the patient, central lines can stay in situ for days, weeks or months. Maintenance of zero CLABSI rates in intensive care units is a priority for every healthcare organization. Following insertion, maintenance and removal protocols are crucial in achieving zero CLABSI cases. For many years my healthcare organization has maintained CLABSI rates at negligible levels through following standard operating procedures and guidelines. Recently, it has been realized that the rate of infections has increased even with the use of the set standards.

A review of the literature identifies several ways of preventing CLABSI. I recommend the use of the CDC checklist for prevention of central line-associated bloodstream infections because it provides comprehensive information on what is expected by the physicians, nurses and the healthcare organization at large. Evidence-based research indicates that implementation of the guidelines requires a multidisciplinary approach (Wichmann et al., 2018). A team consisting of physicians, nurses and the infection control personnel can best serve to ensure compliance to the CDC checklist is maintained at 100%.  The CDC checklist has three crucial parts that should be followed to the latter. For clinicians, they should follow proper insertion practices such as practicing hand hygiene, adherence to aseptic technique and the use of maximal sterile barrier precautions. Secondly, the team should perform daily audits to assess whether each central line is still needed (CDC, 2014). The healthcare organization is also opted to educate and periodically assess healthcare personnel on adherence to the CDC guidelines.

Implementation of strategies for quality improvement is a process that requires setting clear objectives and steps. I recommend the use of health education for the multidisciplinary team as a preparation for adopting the quality improvement process. The input of the healthcare administration will be crucial as it will ensure communication between the selected teams and the provision of financial assistance during implementation. Because the strategy will be implemented in one department, a timeline of six weeks will be necessary to organize for implementation of the quality improvement process.



Bell, T., & O’Grady, N. P. (2017). Prevention of Central Line-Associated Bloodstream Infections. Infectious disease clinics of North America, 31(3), 551–559. DOI: https://doi.org/10.1016/j.idc.2017.05.007

Blot, K., Vogelaers, D., & Blot, S. (2015). Central Line-associated Bloodstream Infections: A Critical Look at the Role and Research of Quality Improvement Interventions and Strategies. In Annual Update in Intensive Care and Emergency Medicine 2015 (pp. 15-24). Springer, Cham.

Centers for Disease Prevention and Control (CDC). (2014). Checklist for Prevention of Central Line Associated Blood Stream Infections. Retrieved from https://www.cdc.gov/infectioncontrol/guidelines/bsi/index.html

Centers for Disease Prevention and Control (CDC). (2017). Central Line-associated Bloodstream Infections: Resources for Patients and Healthcare Providers. Retrieved from https://www.cdc.gov/hai/bsi/clabsi-resources.html

Furuya, E. Y., Dick, A. W., Herzig, C. T., Pogorzelska-Maziarz, M., Larson, E. L., & Stone, P. W. (2016). Central line–associated bloodstream infection reduction and bundle compliance in intensive care units: a national study. infection control & hospital epidemiology, 37(7), 805-810. DOI: https://doi.org/10.1017/ice.2016.67

Grigonis, A. M., Dawson, A. M., Burkett, M., Dylag, A., Sears, M., Helber, B., & Snyder, L. K. (2016). Use of a Central Catheter Maintenance Bundle in Long-Term Acute Care Hospitals. American Journal of Critical Care, 25(2), 165-172. https://doi.org/10.4037/ajcc2016894

Haddadin, Y., & Regunath, H. (2019). Central line associated blood stream infections (CLABSI). In StatPearls [Internet]. StatPearls Publishing.

Hakko, E., Guvenc, S., Karaman, I., Cakmak, A., Erdem, T., & Cakmakci, M. (2015). Long-term sustainability of zero central-line associated bloodstream infections is possible with high compliance with care bundle elements. EMHJ-Eastern Mediterranean Health Journal, 21(4), 293-298. Retrieved from https://apps.who.int/iris/handle/10665/255106

Hina, H. R., & McDowell, J. R. (2017). Minimising central line‐associated bloodstream infection rate in inserting central venous catheters in the adult intensive care units. Journal of clinical nursing26(23-24), 3962-3973. https://doi.org/10.1111/jocn.13824

Institute for Healthcare Improvement (IHI).2019. Improving Health and Health Care Worldwide: Central Line Insertion Checklist. Retrieved from http://www.ihi.org/resources/Pages/Tools/CentralLineInsertionChecklist.aspx

Ista, E., van der Hoven, B., Kornelisse, R. F., van der Starre, C., Vos, M. C., Boersma, E., & Helder, O. K. (2016). Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. The Lancet Infectious Diseases, 16(6), 724-734. https://doi.org/10.1016/S1473-3099(15)00409-0

Jeong, I. S., Park, S. M., Lee, J. M., Song, J. Y., & Lee, S. J. (2014). Effect of central line bundle on central line-associated bloodstream infections in intensive care units. American journal of infection control, 41(8), 710-716. https://doi.org/10.1016/j.ajic.2012.10.010

Lee, K. H., Cho, N. H., Jeong, S. J., Kim, M. N., Han, S. H., & Song, Y. G. (2018). Effect of central line bundle compliance on central line-associated bloodstream infections. Yonsei medical journal59(3), 376-382. doi: 10.3349/ymj.2018.59.3.376

Lin, K. Y., Cheng, A., Chang, Y. C., Hung, M. C., Wang, J. T., Sheng, W. H., … & Chang, S. C. (2017). Central line-associated bloodstream infections among critically-ill patients in the era of bundle care. Journal of microbiology, immunology and infection, 50(3), 339-348. https://doi.org/10.1016/j.jmii.2015.07.001

Marang-van de Mheen, P. J., & van Bodegom-Vos, L. (2016). Meta-analysis of the central line bundle for preventing catheter-related infections: a case study in appraising the evidence in quality improvement. BMJ Qual Saf, 25(2), 118-129. http://dx.doi.org/10.1136/bmjqs-2014-003787

McAlearney, A. S., Hefner, J. L., Robbins, J., Harrison, M. I., & Garman, A. (2015). Preventing Central Line–Associated Bloodstream Infections: A Qualitative Study of Management Practices. infection control & hospital epidemiology, 36(5), 557-563. DOI: https://doi.org/10.1017/ice.2015.27

Moss, E., Seifert, P. C., & O’Sullivan, A. (2016). Registered nurses as interprofessional collaborative partners: Creating value-based outcomes. OJIN: The Online Journal of Issues in Nursing, 21(3). DOI: 10.3912/ojin.vol21no03man04

Office of Disease Prevention and health Promotion (ODPHP). (2020). Healthy people 2020: Healthcare-Associated Infections. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/healthcare-associated-infections

Padilla Fortunatti, C. F. (2017). Impact of two bundles on central catheter-related bloodstream infection in critically ill patients. Revista latino-americana de enfermagem25. doi: 10.1590/1518-8345.2190.2951

Patel, P. K., Gupta, A., Vaughn, V. M., Mann, J. D., Ameling, J. M., & Meddings, J. (2018). Review of Strategies to Reduce Central Line-Associated Bloodstream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI) in Adult ICUs. Journal of hospital medicine, 13(2), 105-116. DOI: 10.12788/jhm.2856

Patient Safety Movement Foundation (PSMF). (2016). Actionable Patient Safety Solution: Central Line-Associated Bloodstream Infections. Retrieved from https://patientsafetymovement.org/wp-content/uploads/2016/02/APSS-2F_-Central-Line-associated-Blood-Stream-Infections-CLABSI.pdf

Reyes, D. C. V., Bloomer, M., & Morphet, J. (2017). Prevention of central venous line associated bloodstream infections in adult intensive care units: a systematic review. Intensive and Critical Care Nursing43, 12-22. https://doi.org/10.1016/j.iccn.2017.05.006

Saint, S., Meddings, J., Fowler, K. E., Vaughn, V. M., Ameling, J. M., Rohde, J. M., … & Chopra, V. (2019). The guide to patient safety for health care–associated infections. Annals of Internal Medicine, 171(7_Supplement), S7-S9. Retrieved from https://annals.org/aim/fullarticle/2752401

Salama, M. F., Jamal, W., Al Mousa, H., & Rotimi, V. (2016). Implementation of central venous catheter bundle in an intensive care unit in Kuwait: Effect on central line-associated bloodstream infections. Journal of infection and public health, 9(1), 34-41. https://doi.org/10.1016/j.jiph.2015.05.001

Scatliffe, K., Davis, A., Wang-Kocik, C., Villanueva, N. M., Espiritu-fuller, M., Larang, R., … & Engell, C. A. (2015). The Reduction of Catheter-Related Blood Stream Infections through the Implementation of an Interdisciplinary Healthcare Team. Journal of Critical Care Medicine, 2015. https://doi.org/10.1155/2015/635939

Valencia, C., Hammami, N., Agodi, A., Lepape, A., Herrejon, E. P., Blot, S., … & Lambert, M. L. (2016). Poor adherence to guidelines for preventing central line-associated bloodstream infections (CLABSI): results of a worldwide survey. Antimicrobial Resistance & Infection Control, 5(1), 49. doi: 10.1186/s13756-016-0139-y

van der Kooi, T., Sax, H., Pittet, D., van Dissel, J., van Benthem, B., Walder, B., … & Hieke, S. (2018). Prevention of hospital infections by intervention and training (PROHIBIT): results of a pan-European cluster-randomized multicentre study to reduce central venous catheter-related bloodstream infections. Intensive care medicine, 44(1), 48-60.  https://doi.org/10.1007/s00134-017-5007-6

Walz, J. M., Ellison III, R. T., Mack, D. A., Flaherty, H. M., McIlwaine, J. K., Whyte, K. G., … & CCOC Research Group. (2015). The bundle “plus”: the effect of a multidisciplinary team approach to eradicate central line-associated bloodstream infections. Anesthesia & Analgesia, 120(4), 868-876. DOI: 10.1213/ANE.0b013e3182a8b01b

Wichmann, D., Belmar Campos, C. E., Ehrhardt, S., Kock, T., Weber, C., Rohde, H., & Kluge, S. (2018). Efficacy of introducing a checklist to reduce central venous line associated bloodstream infections in the ICU caring for adult patients. BMC infectious diseases, 18(1), 267. doi: 10.1186/s12879-018-3178-6

Yaseen, M., Al-Hameed, F., Osman, K., Al-Janadi, M., Al-Shamrani, M., Al-Saedi, A., & Al-Thaqafi, A. (2016). A project to reduce the rate of central line associated bloodstream infection in ICU patients to a target of zero. BMJ Open Quality, 5(1), u212545-w4986. http://dx.doi.org/10.1136/bmjquality.u212545.w4986

Zingg, W., Cartier, V., Inan, C., Touveneau, S., Theriault, M., Gayet-Ageron, A., … & Walder, B. (2014). Hospital-wide multidisciplinary, multimodal intervention programme to reduce central venous catheter-associated bloodstream infection. PloS one, 9(4), e93898. doi: 10.1371/journal.pone.0093898