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o r i g i n a l a r t i c l e
Preventing Central Line–Associated Bloodstream Infections: A
Qualitative Study of Management Practices
Ann Scheck McAlearney, ScD, MS;1,2 Jennifer L. Hefner, PhD,
MPH;1 Julie Robbins, PhD, MHA;1 Michael I. Harrison, PhD;3
Andrew Garman, PsyD, MS4,5
objective. To identify factors that may explain hospital-level
differences in outcomes of programs to prevent central line–
associated
bloodstream infections.
design. Extensive qualitative case study comparing higher- and
lower-performing hospitals on the basis of reduction in the rate
of central
line–associated bloodstream infections. In-depth interviews

were transcribed verbatim and analyzed to determine whether
emergent themes
differentiated higher- from lower-performing hospitals.
setting. Eight US hospitals that had participated in the federally
funded On the CUSP—Stop BSI initiative.
participants. One hundred ninety-four interviewees including
administrative leaders, clinical leaders, professional staff, and
frontline
physicians and nurses.
results. A main theme that differentiated higher- from lower-
performing hospitals was a distinctive framing of the goal of
“getting
to zero” infections. Although all sites reported this goal, at the
higher-performing sites the goal was explicitly stated, widely
embraced, and
aggressively pursued; in contrast, at the lower-performing
hospitals the goal was more of an aspiration and not embraced
as part of the strategy
to prevent infections. Five additional management practices
were nearly exclusively present in the higher-performing
hospitals: (1) top-level
commitment, (2) physician-nurse alignment, (3) systematic
education, (4) meaningful use of data, and (5) rewards and
recognition.
We present these strategies for prevention of healthcare-
associated infection as a management “bundle” with
corresponding suggestions for
implementation.
conclusions. Some of the variance associated with CLABSI
prevention program outcomes may relate to specific
management practices.
Adding a management practice bundle may provide critical

guidance to physicians, clinical managers, and hospital leaders
as they work to
prevent healthcare-associated infections.
Infect Control Hosp Epidemiol 2015;36(5):557–563
Central line–associated bloodstream infections (CLABSIs)
increase risk of prolonged hospitalization, morbidity, and
death, and result in substantial financial and nonfinancial
costs to health systems and society.1–3 CLABSI rates can be
significantly reduced by implementing a “bundle” of 5 clinical
practices: full-barrier precautions, chlorhexidine antiseptic
and sterile dressing, optimal vein selection, improved hand
hygiene, and prompt removal of unnecessary central line
catheters.2,4,5 This bundle, combined with dedicated line
insertion and maintenance teams, checklists to ensure practice
consistency, and practitioner education, has led hospital
intensive care units (ICUs) to see significant and sustained
CLABSI rate reductions.6–9
Given strong evidence supporting the effectiveness of these
programs, the Joint Commission and the Department of
Health and Human Services set the goal of “zero CLABSIs”
as a policy tool to mobilize hospital stakeholders, resulting
in a proliferation of coordinated state and local quality
improvement initiatives and widespread implementation of
CLABSI reduction programs.9–13 These efforts contributed to
an estimated 58% CLABSI rate decrease in US ICUs between
2001 and 2009.13 However, while some hospitals have virtually
eliminated CLABSIs in their ICUs, others continue to struggle
to attain and/or sustain near-zero rates.6
Organizational differences in achieving successful reduc-
tions are evident within one of the largest and most successful
Affiliations: 1. Department of Family Medicine, College of

Medicine, Ohio State University, Columbus, Ohio; 2. Division
of Health Services Management
and Policy, College of Public Health, Ohio State University,
Columbus, Ohio; 3. Center for Delivery, Organization, and
Markets, Agency for Healthcare
Research and Quality, Rockville, Maryland; 4. Department of
Health Systems Management, Rush University, Chicago,
Illinois; 5. National Center for Health-
care Leadership, Chicago, Illinois.
© 2015 by The Society for Healthcare Epidemiology of
America. All rights reserved. 0899-823X/2015/3605-0008. DOI:
10.1017/ice.2015.27
Received October 16, 2014; accepted January 29, 2015;
electronically published February 23, 2015
infection control & hospital epidemiology may 2015, vol. 36,
no. 5
initiatives: the Comprehensive Unit-based Safety Program
(CUSP)—a formal model for translating CLABSI reduction
evidence into practice—developed at Johns Hopkins University
and disseminated by the Agency for Healthcare Research and
Quality (AHRQ).4,7 By 2013 there was a decrease of 41% in
the
overall rate of CLABSI infections among hospitals implement-
ing this program.14 Additionally, 68% of units reported zero
CLABSIs for at least one quarter, up from 30% at baseline.
Although these statistics demonstrate program efficacy and the
feasibility of achieving “zero,” variability across participating
ICUs was evident, and not all hospitals achieved or maintained
zero infections, possibly owing to inconsistency in protocol
implementation within and across hospitals.

Evaluations of CLABSI prevention programs proposed orga-
nizational factors—leadership and management practices—as
potential explanations for program success, including the CUSP
final report and a post hoc analysis of the Michigan Keystone
project by Dixon-Woods et al.14,15 However, as Dixon-Woods
et al state, “we did not try to describe the contextual factors that
might have modified the effectiveness of the program in
different
settings.”15 To help fill this gap in the literature, we conducted
an
extensive qualitative exploratory study of 8 sites that
participated
in the first wave of AHRQ’s CUSP program and compared
management strategies present at higher- vs lower-performing
hospitals. We propose a “management bundle” to incorporate
identified best practice strategies and provide corresponding
implementation suggestions.
methods
Site Selection
Site selection was a multi-step process. First, we reviewed base-
line and post intervention hospital-level CLABSI outcome data
for the first 2 cohorts of the AHRQ’s CUSP CLABSI prevention
initiative. Although nearly all of the participating hospitals
showed notable improvements after the intervention, some
hospitals had virtually eliminated CLABSIs and maintained
those results for 6 months or longer. We classified these
hospitals
as higher performers, and we designated as lower performers the
hospitals that demonstrated less consistent results—for
example,
variation between units or occasional sharp upticks in their
infection rate trends. Next, we paired higher- and lower-
performing hospitals according to key organizational character-

istics (ie, size, number, and size of ICUs, teaching status, and
geography). We then presented short lists of potential sites to
CUSP project staff to obtain their perspective about the sites as
comparators and as candidates for extensive study. We worked
through CUSP staff at the national and state levels to invite
sites to participate in our study; all sites we approached agreed
to participate. Because one site originally identified as lower-
performing had substantially improved by the time of our
analysis, we reclassified this site as higher-performing.
Therefore
our final, purposive sample included five higher-performing and
three lower-performing hospitals.
Study Sites
The 8 study sites ranged in size from 300-bed single hospitals
to 1,000-plus-bed health systems and included community
hospitals, teaching hospitals, academic medical centers, and
health systems. The sites were located throughout the East
Coast and Midwest and there were no differences by type
between pairs of higher- and lower-performing hospitals
(Table 1).
Data Collection
During 2-day visits between June 2011 and October 2012 to
each of the 8 hospitals, 3 research team members conducted a
total of 194 in-person interviews lasting 30 to 60 minutes each.
Interviewees included administrative leaders, clinical leaders,
professional staff, and frontline physicians and nurses. We
interviewed a similar mix of key informants at each site, using
2 versions (ie, clinical and nonclinical) of a semi-structured
interview guide. Questions were about organizational change
related to healthcare-associated infection initiatives as well as
facilitators and barriers to that change. To ensure consistency
and accuracy of our data, interviews were audio-recorded with

participant consent and then transcribed verbatim.
Analysis
We used a constant comparative analytic approach involving
both inductive and deductive methods16 to analyze 1,236 pages
of interview transcripts and determine what distinguished
higher- and lower-performing sites. First, a coding team
overseen by the lead investigator identified broad themes on
the basis of the interview guide and developed a preliminary
coding dictionary. Data were then classified into categories of
findings following the methods described by Constas.17 The
team next developed code lists and a coding frame. A doctoral
student who had been involved in the research from its
inception coded the transcripts, working closely with the
principal investigator to ensure consistency and accuracy. We
used the Atlas.ti, version 6.0, qualitative data analysis software
to support our analysis.18
results
Strategies for Prevention of Healthcare-Associated Infection
Evident at Higher-Performing Hospitals
We identified 6 management strategies that distinguished
higher- from lower-performing hospitals. These factors
are briefly described below and summarized in Table 2. Unless
otherwise noted, we considered strategies in higher-performing
hospitals to be distinctive when there was evidence the strategy
was in place in at least 4 of the higher-performing hospitals and
in no more than 1 lower-performing hospital.
1. Aggressive goal setting and commitment to “zero”
CLABSIs. All of the hospitals in our study stated a goal of
558 infection control & hospital epidemiology may 2015, vol.

36, no. 5
eliminating CLABSIs, referring frequently to their desire to
“get to zero.” However, at higher-performing sites this goal
was more explicitly stated, widely embraced, and aggressively
pursued. In contrast, staff at lower-performing hospitals
regarded “getting to zero” as aspirational, with many inter-
viewees suggesting they did not actually believe it was “realis-
tic” to completely eliminate CLABSIs.
Notably, many of the interviewees at the higher-performing
hospitals indicated that they had also started out thinking that
CLABSIs were an unavoidable “cost of doing business,” but
now believed these infections could be eliminated. This shift
was attributed to mounting evidence from other organizations
and care units that had successfully eliminated CLABSIs. One
interviewee described this cognitive shift from the physicians’
perspective.
“I think our doctors, like doctors around the country,
have finally bought in to the fact that you can get to zero.
I think they didn’t agree with that [previously], and we
would hear ‘our patients are sicker.’ But as the data
has shown around the country, it is possible to get to
zero.” —infection preventionist
Many ICU clinicians and staff identified this aggressive goal
as a clear motivator for consistently focusing on CLABSI
reduction, continually pushing themselves to go longer and
longer between infections. In contrast, interviewees from
lower-performing hospitals were satisfied with continual
decreases in rates and/or adequate performance relative to
benchmark institutions. This acceptance of lower standards

was reflected by one executive who noted, “I understand
that we will never be at zero; I am impressed that we are low as
we are.”
2. Top-level commitment. One of the hallmarks of higher-
performing organizations was visible top-level leadership
commitment to CLABSI prevention as an organizational
goal. In all of these hospitals, CLABSI prevention had been
adopted as a board-level initiative and/or a priority for the
overall organizational performance “scorecard.” One inter-
viewee, for example, said that success “starts with the CEO,”
and requires “100% commitment” from top leaders. Others
noted the importance of having leaders who “walked the
talk” by providing resources and/or other support to CLABSI
prevention. Within the lower-performing sites, CLABSI
prevention appeared to be more a unit-based effort than
an organization-wide initiative, with few interviewees even
mentioning a role for top leaders.
3. Physician-nurse alignment. Higher-performing hospi-
tals also showed strong alignment and collaboration between
physician and nurse leaders at all organizational levels. Infor-
mants indicated that having cross-disciplinary leaders who
table 1. Case Study Sites and Key Informants Interviewed
Site (pair no.)
CLABSI- reduction
record
Key informants
interviewed (n = 194) Site characteristics
Site 1 (1) Higher-performing ∙ Administrators (14)
∙ Clinicians (14)

∙ Large, teaching hospital
∙ Urban region
∙ More than one ICU
Site 2 (1) Lower-performing ∙ Administrators (16)
∙ Clinicians (14)
∙ Large, teaching hospital
∙ Suburban area adjacent to urban area
∙ Clinicians (11)
∙ Large academic medical center, multiple hospitals
∙ Urban region
∙ Multiple ICUs
Site 4 (2) Higher-performinga ∙ Administrators (21)
∙ Clinicians (17)
∙ Large academic medical center, multiple hospitals
∙ Urban region
∙ Multiple ICUs
∙ Clinicians (12)
∙ Midsize, nonteaching hospital
∙ Small urban area
∙ Clinicians (10)
∙ Midsize, nonteaching hospital

∙ Small urban area
∙ Clinicians (10)
∙ Small, nonteaching hospital
∙ Part of rural hospital system
∙ Clinicians (8)
∙ Small, nonteaching hospital
∙ Part of rural hospital system
NOTE. CLABSI, central line–associated bloodstream infection;
ICU, intensive care unit.
aSite 4 was selected initially as “lower-performing” based on
CLABSI data and input from the project liaison. However,
because this site had
made a successful turnaround since the Comprehensive Unit-
based Safety Program concluded, we categorized this hospital as
“higher-
performing” for the purposes of our study.
management practices to prevent clabsis 559
were “on the same page” about CLABSI goals and approach
was an important success factor. In some of the hospitals,
alignment occurred through formal organizational structure—
for example, a shared nurse/physician leadership model; in
others, it was simply reflected in positive relationships and

effective communication. The pair of quotes below, from the
chief medical and chief nursing officers at one higher-
performing
hospital, illustrate the importance of physician-nurse collabora-
tion from both perspectives.
“Leadership is important, [as is] the ability of leaders to
work together and be candid with each other. It’s a hard
job… and my relationship with [the chief nursing
officer] and the entire nursing team is good…. It is a
pleasure to work with that group.” —chief medical officer
“We do not draw a clear line in the sand with me on
the nursing side and [the chief medical officer] on the
physician side. I probably spend as much time with
physician issues, and she probably spends as much time
with nursing care. At the end of the day, it’s really a
patient care issue. We are not afraid to be in each other’s
peer group.” —chief nursing officer
Among the lower-performing sites, interviewees did not
mention positive physician-nurse relations as a component of
CLABSI prevention efforts.
4. Systematic approach to education. Education in the
higher-performing hospitals was described as systematic,
comprehensive, and repetitive. Whereas all hospitals had
education programs for clinicians, only the high-performers
indicated CLABSI prevention topics were included as part of
physician orientation and resident education, as well as being
reintroduced through in-service programs and communications
when protocol changes occurred or reminders were needed.
Higher-performing hospitals also systematically assessed and
addressed unit-level educational needs, ensuring that new hires
were properly oriented and gaps in practice were addressed.
5. Meaningful use of data. One of the most noteworthy

characteristics of the higher-performing hospitals was that
nearly everyone involved in CLABSI prevention clearly knew
the CLABSI rates and trends on their units. Leaders recognized
that sharing data in multiple venues—at staff meetings, via
emails, and by posting in break rooms and other common
spaces—was important to fostering a shared sense of respon-
sibility among frontline clinicians and staff. One unit manager
summarized these efforts: “We usually do four or five different
modes of information sharing. We’ll do emails. There’s a
Friday communication from our manager. There’s a commu-
nication that I’ll do weekly. We have an educator newsletter
that goes out.”
As a result of these efforts, frontline clinicians and staff at
the higher-performing hospitals were well aware of their
table 2. Factors Differentiating Higher- and Lower-Performing
Hospitals
Factors Evidence
No. of sites
with higher
performance
(n = 5)
No. of sites
with lower
performance
(n = 3)
Aggressive goal setting and support Recognized shift from goal
of reducing to that of eliminating

CLABSIs
4 0
Goal of “zero” CLABSIs is clearly articulated and well
recognized
Widespread belief that “zero” is achievable
Top-level organizational
commitment
CLABSI prevention identified as high-level organizational
priority, eg, board, organizational scorecard
5 0
Top-level executives visibly support CLABSI prevention efforts
by “walking the talk,” eg, supporting staff, allocating resources
Physician-nurse alignment Physician and nurse leaders at both
the organizational and unit
levels perceived to be “on the same page” for CLABSI-
prevention
5 0
Systematic approach to education CLABSI prevention included
as part of physician orientation
and resident education
5 0
Unit-level educational needs systematically assessed and
addressed
Meaningful use of data Management routinely shares CLABSI

rates 4 0
Efforts to make CLABSI data meaningful to, and motivating
for,
ICU physicians and staff
Rewards and recognition Public celebrations for unit-level
success, eg, pizza parties 5 1
Individual contributions to CLABSI prevention efforts and
goals
are routinely recognized
NOTE. CLABSI, central line–associated bloodstream infection;
ICU, intensive care unit.
36, no. 5
current CLABSI rates, understood the reports, and enjoyed
seeing improvement in the data. Management and staff-level
interviewees talked about both a “sense of pride” that they
felt when they saw their rates improve and, in contrast,
disappointment when infections occurred. Although some of
the lower-performing hospitals had posted and/or shared data,
staff often did not know about the data and/or did not
understand the data or its relevance to their clinical work.
6. Rewards and recognition. In addition to more system-
atically sharing CLABSI data, higher-performing hospitals
more regularly provided recognition when goals and mile-
stones were met. Unit-level leaders in particular made a point
of publicizing and celebrating their units’ major CLABSI-
prevention accomplishments. These celebrations ranged from
simple recognition at staff meetings, to posters and newsletters
lauding the accomplishment, to larger celebrations, such as a

management-sponsored pizza party when the unit hit a major
milestone (eg, a CLABSI-free year). Many frontline staff indi-
cated these celebrations made them feel that management
understood and appreciated how hard they had worked to
make the practice changes that led to improved outcomes.
Beyond group celebrations, leaders also actively recognized
specific individuals for their contributions to the unit’s success.
Overall, this recognition both motivated and encouraged
continued commitment among staff. The lower-performing
hospitals, in contrast, tended to place less emphasis on recog-
nizing success. When they did so, the activities were less
visible
and meaningful to staff and, as interviewees in one hospital
indicated, the staff still felt underappreciated by management
in general.
discussion
In contrasting higher- and lower- performing hospitals on the
basis of success with CLABSI prevention, several management
practices stood out, including commitment to zero, leadership
support, physician-nurse alignment, systematic education,
meaningful use of data, and rewards and recognition. Many of
the factors distinguishing these higher-performing hospitals
are similar to those shown to be important elements of other
evidence-based quality improvement efforts19–21 and patient
safety interventions.22 In fact, a few months after the conclu-
sion of study data collection in 2012, the Johns Hopkins
CUSP program published a CUSP implementation framework
that includes several elements of the management practices
we identified in our study, specifically top-level support,
multidisciplinary teams, education, and the use of data.23
However, many of the CUSP framework elements presented

by Johns Hopkins did not emerge in our study as strategies
important to success, and others had a different focus. For
example, the CUSP framework listed education as an element,
described as the need to “train staff in the science of safety.”
Our findings revealed that successful education focused
more specifically on CLABSI prevention topics and clinical
table 3. Management “Bundle” for CLABSI Prevention
Interventions
Recommended management strategy Suggestions for
implementation
1. Aggressive goal setting and support ∙ Establish the goal of
zero CLABSIs and “walk the talk” in supporting actions that
help move
toward that goal.
∙ Establish a budget to support products, education, and
communication efforts required to
demonstrate CLABSI prevention is a priority.
2. Strategic alignment/ communication and
information sharing
∙ Include CLABSI rate information as part of organization level
scorecard to be reviewed
regularly with executives and the board.
∙ Communicate widely and regularly about CLABSI prevention
goals and progress
∙ Emphasize importance of patient safety and infection
prevention as part of everyone’s job
3. Systematic education ∙ Include education about CLABSIs as
part of broader patient safety education for new and

existing employees
∙ Develop structured education and in-service programs,
supporting adoption and imple-
mentation of new clinical products, practices, and technologies
that facilitate CLABSI
prevention
∙ Establish standards for line insertion, line maintenance, and
routine assessment of line
necessity; develop educational programs imparting knowledge
and skills required to meet
those standards
4. Interprofessional collaboration ∙ Include both physicians and
nurses in all committees and initiatives involving patient safety
and quality of care, rather than creating siloed committees or
initiatives
∙ Hold interdisciplinary rounds and safety huddles
∙ Support staff in “speaking up” when higher-status individuals
breach safety protocols.
5. Meaningful use of data ∙ Emphasize importance of data by
widely and regularly sharing data on CLABSI rates
∙ Prioritize development of automated reporting capabilities to
support CLABSI monitoring
and compliance with protocols
6. Recognition for success ∙ Provide rewards and recognition for
success with CLABSI reduction efforts and ongoing
CLABSI prevention
∙ If incentive compensation is used, tie a portion to CLABSI
prevention goals.

NOTE. CLABSI, central line–associated bloodstream infection.
techniques such as implementing infection prevention prac-
tices rather than general education about patient safety. Most
importantly, our finding that goal definition distinguished
higher-performing hospitals is new. We found that aiming for
general improvement seemed far less motivating than aiming
for an absolute standard of zero CLABSIs. This apparent
association mirrors anecdotal reports in the literature.24
However, ours is the first study to formally explore and high-
light this aspect of CLABSI program success and to identify
management strategies supporting the zero infections goal
specifically, as well as program success generally.
Our findings suggest an important fourth and final step in
CLABSI program implementation and evaluation.15 The first 2
steps were to (1) identify a clinical bundle capable of
eliminating
CLABSIs and (2) develop a set of clinical practice interventions
to implement the bundle.4 The third step was to spread the
CUSP program nationwide to demonstrate the program efficacy
and the ability to achieve “zero.”14 The persistent variability in
success rates across hospitals after this third step highlighted
the
need for a fourth step—identifying organizational and manage-
ment factors that are critical to successful implementation of the
CUSP program. In 2012 CUSP took this step by publishing the
CUSP framework discussed above. Our study expands this
work by comparing practice variation between higher- and
lower-performing hospitals and expands the evidence base for
this fourth step.

Management Bundle for CLABSI Prevention Interventions
Based on the 6 management strategies we identified as
common to high-performing hospitals, we developed a bundle
of management strategies and corresponding suggestions for
implementation of these management practices. We present
these strategies in Table 3 in the order they would be intro-
duced during a CLABSI prevention program.
Although our management bundle is based on evidence for
use of these specific management practices as mentioned by
interviewees at the higher-performing organizations, we do
not suggest that this set of strategies should be implemented
broadly in its current form. We instead propose this list of best
practices as a guide to future studies. The appropriate next
steps are to explore the presence of elements of this bundle in
larger-scale studies and compare the bundle elements with those
of the published CUSP framework to determine the relative
weights of the different strategies, edit this bundle accordingly,
and then experiment with implementing a revised CLABSI
CUSP framework that includes both a clinical practice bundle
and a management practice bundle. As the first step in this
process, the results of our study have important implications for
policy and practice within hospitals and their ICUs because they
highlight the importance of specific managerial practices in
support of the typical clinical bundle. Without attention to these
management practices, significant variation in CLABSI rates
may
persist, even within defined programs for prevention of
healthcare-associated infection.
Limitations
Several study limitations are important to note. One relates to
the small number of hospitals involved. The substantial

resources required to conduct systematic qualitative studies
pose a significant barrier to conducting larger-scale studies.
Future work can include the development of surveys based on
this research to explore and validate our findings in larger
samples, including assessing whether implementation of our
proposed best practices is associated in quantitative models
with greater reductions in CLABSI rates. An additional limi-
tation concerns external generalizability. All of the hospitals in
this sample participated in the CUSP project; a study using a
broader sample of hospitals might find additional or stronger
differences in management and organizational factors asso-
ciated with higher performance. A third limitation is that
despite the strength of the qualitative evidence presented,
causation may run in a different direction—for example, as
CLABSI rates decline, group beliefs and behaviors may also
change. If this were the case, retrospective accounts of how
the teams reduced CLABSIs might mention practices that
were more a product of success in reducing CLABSIs than
contributors to their success.
conclusions
Results of this research suggest that some of the between-
hospital variability in success when implementing a defined
CLABSI prevention program may relate to specific manage-
ment practices focused on “getting to zero” infections.
Hospitals currently vary widely with respect to the strategies
they use to support implementation and use of clinical CLABSI
prevention bundles. If the management bundle proposed in
this study is verified through larger-scale work, it may benefit
the field to expand the concept of clinical practice bundles to
include a management practice bundle as well.
acknowledgments
We are grateful to the hospitals and individuals who

participated in this study.
Financial support. AHRQ (contract #HHSA290200600022).
Potential conflicts of interest. All authors report no conflicts of
interest
relevant to this article.
Disclaimer. The views expressed in this paper are solely those
of the authors
and do not represent any US government agency or any
institutions with which
the authors are affiliated. AHRQ solicited the research through
a competitive
task order awarded under its pre-competed ACTION II contract.
To ensure
fulfillment of the terms of the task order, the Agency’s
representative reviewed
deliverables from the study describing study design, conduct;
collection,
management, analysis, and interpretation of the data; and the
resulting
manuscript. However, this review allowed the research team
autonomy to
exercise its scientific judgment in all of the above project
phases. Conduct of
this research was reviewed and approved by the institutional
review board of
the Ohio State University.
Address correspondence to Ann Scheck McAlearney, ScD, MS,
Depart-
ment of Family Medicine, College of Medicine, Ohio State
University, 2231
North High Street, 273 Northwood and High, Columbus, Ohio,
43201 (Ann.
[email protected]).

36, no. 5
mailto:[email protected]
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PJ. Explaining Michigan: developing an ex post theory of a
quality
improvement program. Milbank Q 2011;89:167–205.
16. Glaser B, Strauss A. The constant comparative method of
qualitative analysis. In: The Discovery of Grounded Theory:
Strategies for Qualitative Research. New York: Aldine de
Gruyter;
1967:101–115.
17. Constas MA. Qualitative analysis as a public event: the
docu-
mentation of category development procedures. Am Educ Res J
1992;29:253–266.
18. Scientific Software Development. Atlas.ti. 2008.
19. Kaplan HC, Brady PW, Dritz MC, et al. The influence of
context
on quality improvement success in health care: a systematic
review of the literature. Milbank Q 2010;88:500–559.
20. Leonard M, Graham S, Bonacum D. The human factor: the
critical importance of effective teamwork and communication in
providing safe care. Qual Saf Health Care 2004;13:i85–i90.

21. Poon EG, Blumenthal D, Jaggi T, Honour MM, Bates DW,
Kaushal R. Overcoming barriers to adopting and implementing
computerized physician order entry systems in US hospitals.
Health Aff 2004;23:184–190.
22. Taylor SL, Dy S, Foy R, et al. What context features might
be
important determinants of the effectiveness of patient safety
practice interventions? BMJ Qual Saf 2011;20:611–617.
23. The five steps of CUSP. Johns Hopkins Medicine website.
2012. Available from:
http://www.hopkinsmedicine.org/innovation_
quality_patient_care/areas_expertise/improve_patient_safety/
cusp/five_steps_cusp.html.
24. Kuehn BM. Hospitals slash central line infections with
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http://www.hopkinsmedicine.org/innovation_quality_patient_car
e/areas_expertise/improve_patient_safety/cusp/five_steps_cusp.
html
html
htmlOutline placeholderMETHODSSite SelectionStudy
SitesData CollectionAnalysisRESULTSStrategies for Prevention
of Healthcare-Associated Infection Evident at Higher-
Performing HospitalsTable 1Case Study Sites and Key
Informants InterviewedTable 2Factors Differentiating Higher-
and Lower-Performing HospitalsDISCUSSIONTable

3Management “Bundle” for CLABSI
Prevention InterventionsManagement Bundle for CLABSI
Prevention
InterventionsLimitationsCONCLUSIONSAcknowledgmentsACK
NOWLEDGEMENTS
Major article
Effect of chlorhexidine bathing in preventing infections and
reducing skin burden and environmental contamination:
A review of the literature
Curtis J. Donskey MD a,b,*, Abhishek Deshpande MD, PhD c,d
a Geriatric Research, Education, and Clinical Center, Cleveland
Veterans Affairs Medical Center, Cleveland, OH
b Case Western Reserve University School of Medicine,
Cleveland, OH
c Department of Infectious Diseases, Cleveland Clinic,
Cleveland, OH
dMedicine Institute Center for Value-Based Care Research,
Cleveland Clinic, Cleveland, OH
Key Words:
Staphylococcus aureus
Vancomycin-resistant
Enterococcus
Chlorhexidine bathing is effective in reducing levels of
pathogens on skin. In this review, we examine the
evidence that chlorhexidine bathing can prevent colonization
and infection with health care-associated
pathogens and reduce dissemination to the environment and the
hands of personnel. The importance of

education and monitoring of compliance with bathing
procedures is emphasized in order to optimize
chlorhexidine bathing in clinical practice.
Published by Elsevier Inc. on behalf of Association for
Professionals in Infection Control and
Epidemiology, Inc. This is an open access article under the CC
BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Patients colonized or infected with health care-associated patho-
gens often carry the organisms on their skin.1-3 Such
contamination
may lead to infection when factors such as devices, catheters,
and
wounds provide a route for pathogens on skin to reach normally
sterile sites. Skin contamination may also contribute to
transmis-
sion due to environmental shedding and transfer to the hands of
personnel.1-3 Thus, there is a strong rationale for efforts to
reduce
the burden of pathogens on skin.
During the past decade, a number of studies have examined
the use of chlorhexidine bathing as an infection prevention
strat-
egy. This review examines the evidence that chlorhexidine
bathing
can prevent colonization and infection with health care-
associated
pathogens and reduce dissemination to the environment and the
hands of personnel. We also consider recent evidence that
chlorhexidine bathing is often suboptimal in clinical practice.
The

importance of education and monitoring and feedback on
compli-
ance with bathing procedures to optimize chlorhexidine bathing
is emphasized. The review was not conducted as a systematic
review, but the MEDLINE electronic database was searched
using
broad search terminologies and recent review articles and their
references were searched.
CHLORHEXIDINE SPECTRUM OF ACTIVITY AND USE FOR
SKIN ANTISEPSIS
Chlorhexidine is a cationic bisbiguanide antiseptic that alters
mi-
crobial membrane integrity.4 A variety of formulations are
available,
with chlorhexidine gluconate being most commonly used in
health
care settings. Chlorhexidine has broad-spectrum activity against
gram-positive and gram-negative bacteria, yeasts, and some
lipid-
enveloped viruses. Potent sporicidal activity can be induced in
chlorhexidine under altered physical and chemical conditions
(eg,
elevated temperature, altered pH, and addition of ethanol).5
However,
chlorhexidine does not have activity against bacterial spores
under
the conditions present on skin.
Due to its broad-spectrum antimicrobial activity and excellent
safety profile, chlorhexidine is used in a wide variety of
disinfec-
tant, antiseptic, and preservative applications.5 In health care
settings,
chlorhexidine has been used for several decades for hand

hygiene
and for disinfection of the skin of patients before surgical
proce-
dures and catheter insertion.4 Chlorhexidine significantly
reduces
levels of resident and transient skin microbiota and has
persistent
activity for several hours after application.6 Chlorhexidine
* Address correspondence to Curtis J. Donskey, MD, Geriatric
Research Education
and Clinical Center, Cleveland VA Medical Center, 10701 East
Blvd, Cleveland, OH
44106.
E-mail address: [email protected] (C.J. Donskey).
This work was supported by a Merit Review grant from the
Department of Vet-
erans Affairs to CJD.
Publication of this article was supported by an educational grant
from Clorox
Healthcare, Sealed Air, and Tru-D. Content of this article was
initiated and written
by the authors with no input or financial support to the authors
from Clorox Health-
care, Sealed Air, or Tru-D.
Conflicts of Interest: CJD has received research grants from
Clorox, GOJO, Steris,
and EcoLab and has served on an advisory board for Clorox. AD
has received re-
search funding from Clorox, Steris, and 3M.
0196-6553/Published by Elsevier Inc. on behalf of Association

for Professionals in Infection Control and Epidemiology, Inc.
This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).
http://dx.doi.org/10.1016/j.ajic.2016.02.024
American Journal of Infection Control 44 (2016) e17-e21
Contents lists available at ScienceDirect
American Journal of Infection Control
journal homepage: www.aj ic journal .org
American Journal of
Infection Control
http://www.sciencedirect.com/science/journal/01966553
http://www.ajicjournal.org
http://crossmark.crossref.org/dialog/?doi=10.1016/j.ajic.2016.0
2.024&domain=pdf
occasionally is associated with contact dermatitis, and rarely
has
been associated with anaphylaxis and hypersensitivity
reactions.4
EFFECT OF DAILY CHLORHEXIDINE BATHING
ON SHEDDING OF PATHOGENS
Skin contamination can be an important source of transmission
of health care-associated pathogens through transfer to the

hands
of personnel and shedding into the environment.1-3 To test the
po-
tential for skin decontamination to reduce transmission, Vernon
et
al7 conducted a quasiexperimental study of daily
chlorhexidinewhole-
body bathing in an intensive care unit (ICU). Vancomycin-
resistant
Enterococcus (VRE) was chosen for study as it is often present
on the
skin of colonized patients and it is a common cause of central
line-
associated bloodstream infections (CLABSIs). Patients were
bathed
daily with 2% chlorhexidine cloths during the intervention
period and
standard soap-and-water baths or cloths cleansing without
chlorhexidine was performed during control periods.
As shown in Figure 1, chlorhexidine bathing was associated
with
a reduction in detection of VRE on skin. For inguinal skin, there
was
a 2.5-log reduction in VRE concentrations in the chlorhexidine
bathing group that persisted for at least 6-8 hours. The
reduction
in VRE on skin was associated with significantly reduced VRE
con-
tamination in the environment and on the hands of personnel.
Moreover, there was a significant reduction in VRE acquisition
in
the ICU. The findings of Vernon et al7 provide strong support
for the
concept of source control as a strategy to reduce dissemination

of
health care-associated pathogens (ie, reducing the burden of
patho-
gens on the skin as a means to reduce dissemination to the
environment or hands). Given its broad spectrum of activity,
chlorhexidine bathing represents a horizontal infection preven-
tion approach that can potentially reduce dissemination of
multiple
pathogens. In addition, it is in theory a very simple and easy to
im-
plement intervention because it involves substitution of
chlorhexidine bathing for standard soap-and-water bathing.
EFFECT OF DAILY CHLORHEXIDINE BATHING ON
COLONIZATION
AND INFECTION WITH PATHOGENS
Table 1 provides an overview of 14 studies that have evaluated
the effect of chlorhexidine bathing using quasiexperimental,
ward-
level crossover, or stepped wedge design.7-22 Several of the
studies
demonstrated reductions in levels of pathogens, including gram-
negative bacilli, on skin.7,11,18 For example, Popovich et al18
reported
significant reductions in gram-positive and gram-negative
bacte-
ria and Candida spp on skin. In 12 of the 14 (86%) studies,
chlorhexidine bathing was associated with a significant
reduction
Fig 1. Effect of daily chlorhexidine bathing on skin and
environmental contamina-
tion and acquisition of vancomycin-resistant enterococci (VRE).
Table 1

Effect of chlorhexidine gluconate (CHG) bathing on
colonization and infection with pathogens
Study Setting Chlorhexidine formulation Design Outcomes
7 Medical intensive care
unit
2% chlorhexidine gluconate
(CHG)-impregnated cloths
Quasiexperimental Decreased vancomycin-resistant enterococci
on patients’ skin,
health care workers’ hands, and environment
Reduced acquisition of vancomycin-resistant enterococci
colonization
unit
4% CHG solution Quasiexperimental Decreased Acinetobacter
baumannii skin colonization and
bloodstream infections
10 2 Medical intensive
care unit wards
2% CHG-impregnated cloths 2 arm crossover trial Decreased
primary bloodstream infections
unit
2% CHG-impregnated cloths Quasiexperimental Decreased
central line-associated bloodstream infections and

blood culture contamination
12 6 Intensive care units
in 4 hospitals
acquisition of methicillin-resistant Staphylococcus
aureus and vancomycin-resistant enterococci
Decreased vancomycin-resistant enterococci bacteremia
17 Long-term acute care
hospital
2% CHG solution Quasiexperimental Decreased central line-
associated bloodstream infection
No change in ventilator-associated pneumonia
9 2 Intensive care units 4% CHG solution plus chlorhexidine
acetate powder to groin, axilla, and
skin folds
Quasiexperimental Decreased acquisition of methicillin-
resistant S aureus
(non-qacA/B strains)
14 Trauma intensive care
unit
methicillin-resistant S aureus and Acinetobacter spp
colonization
Decreased central line-associated bloodstream infection
19 Surgical intensive care

unit
2% CHG-impregnated cloths Quasiexperimental No decrease in
central line-associated bloodstream infection
13 Trauma center
intensive care unit
central line-associated bloodstream infection
16 4 Medical wards 2% CHG-impregnated cloths
Quasiexperimental Decreased methicillin-resistant S aureus and
vancomycin-resistant
enterococci infections
No change in Clostridium difficile infections
21 Hospital-wide 4% CHG solution applied as bed bath or
shower daily or 3 times per week
Quasiexperimental Decreased C difficile infections
No change in other hospital-associated infections
8 Oncology patients 2% CHG-impregnated cloths
Quasiexperimental Decreased acquisition of vancomycin-
resistant enterococci
colonization
15 4 Long-term acute care
hospitals
2% CHG-impregnated cloths Stepped wedge
bundle
Decreased Klebsiella pneumoniae carbapenemase-producing
enterobacteriaceae colonization and infection, all-cause
bacteremia, and blood culture contamination

e18 C.J. Donskey, A. Deshpande / American Journal of
Infection Control 44 (2016) e17-e21
in colonization or infection with 1 or more of the pathogens
being
studied. Chlorhexidine was associated with beneficial effects
when
applied using 2% chlorhexidine-impregnated cloths and using
cotton
cloths with 2% or 4% chlorhexidine solution.
In 1 quasiexperimental study, hospital-wide chlorhexidine
patient
bathing was associated with a significant reduction in the inci-
dence of health care-associated Clostridium difficile infection
(CDI),
but not in other health care-associated infections.21 The
strength
of the observation was increased by the finding of an increase in
the incidence of CDI during a washout period in which standard
soap-and-water bathing was reinstituted. As noted previously,
chlorhexidine does not have sporicidal activity under the condi-
tions present on skin, and therefore the reduction in CDI was
unexpected. It was speculated that there may have been an in-
crease in physical removal of spores during the chlorhexidine
bathing
period or that chlorhexidine might be killing vegetative C
difficile
or inhibiting spore germination on skin. Based on these
findings,
further studies are needed to examine the effect of
chlorhexidine
bathing on levels of spores on skin of patients with CDI.

However,
others have not demonstrated reductions in health care-
associated
CDI during chlorhexidine bathing.16
The 1 quasiexperimental study that did not report a benefit of
chlorhexidine bathing was conducted in a surgical ICU.19 After
the
switch to chlorhexidine bathing, there was no significant reduc-
tion in CLABSIs or other nosocomial infections. It was
suggested that
the failure to achieve a reduction in CLABSIs might have been
related
to characteristics of surgical intensive care unit patients. Such
pa-
tients may have large, open abdominal wounds that may serve
as
a source of bacteremia that could be misidentified as CLABSIs.
RANDOMIZED TRIALS
Four randomized trials have evaluated the effect of
chlorhexidine
bathing on hospital-acquired infections.23-26 Climo et al24
con-
ducted amulticenter, cluster-randomized, nonblinded crossover
trial
to evaluate the effect of daily bathing with chlorhexidine-
impregnated washcloths on acquisition of multidrug-resistant
organisms (MDROs) and the incidence of hospital-acquired
blood-
stream infections. Nine ICUs and bonemarrow transplantation
units
in 6 hospitals were included. During the chlorhexidine bathing
periods, the rates of MDRO acquisition and hospital-acquired
blood-

stream infection were reduced by 23% and 28%, respectively.
Much
of the reduction in bloodstream infections was attributable to a
re-
duction in infections with coagulase-negative staphylococci.
The
benefit of chlorhexidine bathing in reducing bloodstream infec-
tions increased with longer length of stay in the unit.
Milstone et al25 conducted a multicenter, cluster-randomized,
crossover trial in critically ill children in 10 ICUs. Bathing was
per-
formed using 2% chlorhexidine-impregnated cloths.
Chlorhexidine
bathing resulted in a statistically significant reduction in
bacteremia.
Noto et al26 conducted a pragmatic cluster-randomized, cross-
over study in 5 adult intensive care units in a tertiary care
medical
center. Patients were bathed with 2% chlorhexidine-impregnated
cloths or nonantimicrobial cloths (controls). There was no
differ-
ence between the chlorhexidine and control groups in the
primary
outcome, which was a composite of nosocomial infections,
includ-
ing CLABSIs, catheter-associated urinary tract infection,
ventilator-
associated pneumonia, and CDI. In addition, chlorhexidine
bathing
was not associated with a reduction in secondary outcomes such
as hospital-acquired bloodstream infections, blood culture
contam-
ination, or clinical cultures yielding MDROs. One criticism of
the

study design is that the primary end point included infections
such
as CDI, catheter-associated urinary tract infection, and
ventilator-
associated pneumonia that would not be expected to be reduced
by chlorhexidine bathing. In addition, adherence to
chlorhexidine
bathing was not monitored.
Boonyasiri et al23 conducted a randomized, open-label con-
trolled trial in 4 medical ICUs in Thailand. Patients were bathed
with
2% chlorhexidine-impregnated cloths or with nonantimicrobial
soap.
Adherence to bathing procedures was reported to be >95%, but
the
method of monitoring was not reported. There were no differ-
ences in the 5 outcomes, including having all skin sites culture-
negative throughout admission or initial positives converted to
negative, colonization with MDROs, hospital-acquired
infection,
length of intensive care and hospital stay, and adverse skin
reac-
tions. The authors speculated that the failure to demonstrate a
benefit
of chlorhexidine bathing in this setting may have been related to
the fact that the major colonizing organisms in the ICUs were
gram-
negative bacilli. Other studies have demonstrated that gram-
negative pathogens often have higher minimum-inhibitory
concentrations for chlorhexidine than gram-positive
pathogens.27,28
In addition, most of the multidrug-resistant gram-negative
bacilli

recovered from skin were from the perianal area, suggesting
that
they may have been shed from the gastrointestinal tract.
Chlorhexidine bathing would not be expected to affect gastroin-
testinal colonization.
IMPORTANCE OF EDUCATION AND MONITORING
OF COMPLIANCE
One of the guiding principles of infection prevention is that ef-
fective implementation of interventions requires monitoring of
compliance of staff with regular feedback on performance. For
example, thoroughness of cleaning is often suboptimal and can
be
significantly improved by monitoring and feedback.29 However,
in
published studies, surprisingly little information has been re-
ported on compliance with chlorhexidine bathing procedures.
Those
studies that have included monitoring have suggested that com-
pliance may often be less than ideal even in the setting of a
research
study. For example, based on purchasing records, Kassakian et
al16
estimated that compliancewith chlorhexidine bathing among
general
medical patients was 77%. Similarly, Rupp et al21 estimated
com-
pliance based on inventory assessments and found that estimates
varied widely by ward, ranging from 45%-95%.
Although in theory chlorhexidine bathing should be easy to im-
plement, 2 recent studies have provided striking demonstrations
of the potential for suboptimal implementation of bathing inter-
ventions in real-world settings.17,30 In a long-term acute care

hospital,
Munoz-Price et al17 found that constant supervision of staff
was es-
sential to ensure that chlorhexidine baths were appropriately
given.
In the absence of regular evaluations of bathing, staff stopped
using
chlorhexidine and began bathing patients with baby shampoo.
Sim-
ilarly, in medical and surgical ICUs where daily bathing with
chlorhexidine 2% cloths had been implemented 2 years earlier,
Supple
et al30 found that none of the patients had detectable
chlorhexidine
on skin. It was determined that the nursing staff in both
intensive
care units had abandoned chlorhexidine bathing altogether
without
the knowledge of the infection control program. As shown in
Figure 2,
an intervention that included monitoring and feedback on
compli-
ance with chlorhexidine bathing was effective in increasing the
percentage of skin sites with detectable chlorhexidine to 70%-
88%.30
The experience of Supple et al30 suggests that measurement of
chlorhexidine on skin may be useful as a means to monitor
effec-
tiveness of bathing practices and provide feedback. A simple,
rapid
colorimetric assay that is commonly used in research studies
was
used tomeasure chlorhexidine on skin.31 The assay is easy to
perform
and includes reagents that are inexpensive and commercially

available.31 In addition to the improvement in daily intensive
care
unit bathing, the assay identified deficiencies in preoperative
bathing
e19C.J. Donskey, A. Deshpande / American Journal of Infection
Control 44 (2016) e17-e21
that were significantly improved by an intervention. For
example,
many patients performing preoperative bathing did not have de-
tectable chlorhexidine on their neck because their understanding
of the instructions was that they should bathe below the neck.
This
deficiency was easily corrected through education of nurses and
modification of patient education sheets. Similarly, Popovich et
al6
found that patients admitted to ICUs often had low levels of
chlorhexidine on their neck and noted that this area received
less
thorough cleansing when bathing was directly observed.
Popovich
et al6 also suggested that measurement of chlorhexidine on skin
might be useful as a means to improve bathing performance.
Finally, it should be appreciated that suboptimal application of
chlorhexidine may be an issue in real-world settings even if
staff
and patients are motivated to comply with recommended bathing
procedures. In contrast to healthy volunteers and most patients
re-
ceiving preoperative bathing, patients in ICUs and ill patients
on

medical wards often have large surgical wounds and numerous
lines,
catheters, and devices that make it difficult to apply
chlorhexidine
effectively. These difficulties are akin to the challenges
involved in
performing effective daily environmental cleaning of a cluttered
patient room versus terminal cleaning after patient discharge. In
this regard, it is notable that the 1 quasiexperimental study that
did
not report a benefit of chlorhexidine bathing was conducted in a
surgical ICU.19 The authors noted that many of the patients in
the
unit had large, open abdominal wounds that could make
chlorhexidine application difficult. In addition to providing
feed-
back on compliance, measurement of chlorhexidine on skin in
such
real-world settings may shed light on some of the challenges in-
volved in providing effective bathing.
CONCLUSIONS
During the past decade, a growing body of evidence has accu-
mulated suggesting that chlorhexidine bathing may be beneficial
as a strategy to prevent colonization and infection with health
care-
associated pathogens. In addition, reduction in skin carriage
may
reduce dissemination of pathogens to the environment and the
hands
of personnel. Although reductions in gram-positive pathogens
have
been reported most frequently, reductions in gram-negative
patho-
gens have also been reported in some but not all studies. Given

the
evidence that chlorhexidine bathing may be beneficial, this
prac-
tice is now becoming routine in many facilities, particularly in
ICUs.
There is evidence that chlorhexidine bathing is not infrequently
sub-
optimal in clinical practice. To optimize bathing in real-world
settings,
there is a need to develop effective strategies to monitor
compli-
ance with bathing protocols and provide feedback to personnel.
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Suiwongsa B, Apiradeewajeset
N, et al. Effectiveness of chlorhexidine wipes for the prevention

of multidrug-
resistant bacterial colonization and hospital-acquired infections
in intensive care
Fig 2. Point-prevalence of medical and surgical intensive care
unit patients with de-
tectable chlorhexidine on 1 or more skin sites before and 1, 3,
and 6 months after
an intervention. Chlorhexidine was measured from 4 skin sites
(neck, arm and hand,
chest and abdomen, and groin).
e20 C.J. Donskey, A. Deshpande / American Journal of
Infection Control 44 (2016) e17-e21
http://refhub.elsevier.com/S0196-6553(16)00200-5/sr0010

unit patients: a randomized trial in Thailand. Infect Control
Hosp Epidemiol
2016;37:245-53.
24. Climo MW, Yokoe DS, Warren DK, Perl TM, Bolon M,
Herwaldt LA, et al. Effect
of daily chlorhexidine bathing on hospital-acquired infection. N
Engl J Med

2013;368:533-42.
25. Milstone AM, Elward A, Song X, Zerr DM, Orscheln R,
Speck K, et al. Daily
chlorhexidine bathing to reduce bacteraemia in critically ill
children:
a multicentre, cluster-randomised, crossover trial. Lancet
2013;381:1099-106.
26. Noto MJ, Domenico HJ, Byrne DW, Talbot T, Rice TW,
Bernard GR, et al.
Chlorhexidine bathing and health care-associated infections: a
randomized
clinical trial. JAMA 2015;313:369-78.
27. Hassan KA, Jackson SM, Penesyan A, Patching SG, Tetu
SG, Eijkelkamp BA, et al.
Transcriptomic and biochemical analyses identify a family of
chlorhexidine efflux
proteins. Proc Natl Acad Sci U S A 2013;110:20254-9.
28. McDonnell G, Russell AD. Antiseptics and disinfectants:
activity, action, and
resistance. Clin Microbiol Rev 1999;12:147-79.
29. Carling PC, Briggs JL, Perkins J, Highlander D. Improved
cleaning of patient rooms
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30. Supple L, Kumaraswami M, Kundrapu S, Sunkesula V,
Cadnum JL, Nerandzic
MM, et al. Chlorhexidine only works if applied correctly: use of
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2015;36:1095-
7.
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Control 44 (2016) e17-e21

Effect of chlorhexidine bathing in preventing infections and
reducing skin burden and environmental contamination: A
review of the literature Chlorhexidine spectrum of activity and
use for skin antisepsis Effect of daily chlorhexidine bathing on
shedding of pathogens Effect of daily chlorhexidine bathing on
colonization and infection with pathogens Randomized trials
Importance of education and monitoring of compliance
Conclusions References
lable at ScienceDirect
American Journal of Infection Control 42 (2014) S216-S222
Contents lists avai
American Journal of Infection Control
journal homepage: www.aj ic journal .org
American Journal of
Infection Control
Original article
Facilitating central lineeassociated bloodstream infection
prevention: A qualitative study comparing perspectives of
infection
control professionals and frontline staff
Ann Scheck McAlearney ScD, MS a,b,*, Jennifer L. Hefner
PhD, MPH a
aDepartment of Family Medicine, College of Medicine, The
Ohio State University, Columbus, OH

bDivision of Health Services Management and Policy, College
of Public Health, The Ohio State University, Columbus, OH
Keywords:
HAI prevention
Health services research
Quality improvement
* Address correspondence to Ann Scheck McAlear
Family Medicine, College of Medicine, The Ohio State
273 Northwood and High Building, Columbus, OH 43
E-mail address: [email protected] (A.S.
This research was supported by a grant from
Research and Quality (contract #HHSA290200600022
article are solely those of the authors and do not re
agency or any institutions with which the authors ar
Publication of this article was supported by the Ag
and Quality (AHRQ).
Conflicts of interest: None to report.
0196-6553/$36.00 - Copyright � 2014 by the Associa
Background: Infection control professionals (ICPs) play a
critical role in implementing and managing
healthcare-associated infection reduction interventions, whereas
frontline staff are responsible for
delivering direct and ongoing patient care. The objective of our
study was to determine if ICPs and
frontline staff have different perspectives about the facilitators
and challenges of central line-associated
bloodstream infection (CLABSI) prevention program success.
Methods: We conducted key informant interviews at 8 hospitals
that participated in the Agency for
Healthcare Research and Quality CLABSI prevention initiative

called “On the CUSP: Stop BSI.” We
analyzed interview data from 50 frontline nurses and 26 ICPs to
identify common themes related to
program facilitators and challenges.
Results: We identified 4 facilitators of CLABSI program
success: education, leadership, data, and con-
sistency. We also identified 3 common challenges: lack of
resources, competing priorities, and physician
resistance. However, the perspective of ICPs and frontline
nurses differed. Whereas ICPs tended to focus
on general descriptions, frontline staff noted program specifics
and often discussed concrete examples.
Conclusions: Our results suggest that ICPs need to take into
account the perspectives of staff nurses when
implementing infection control and broader quality
improvement initiatives. Further, the deliberate in-
clusion of frontline staff in the implementation of these
programs may be critical to program success.
Copyright � 2014 by the Association for Professionals in
Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.
A central line-associated bloodstream infection (CLABSI) can
occur when a central venous catheter, a procedure often asso-
ciated with intensive care unit (ICU) settings,1 is not inserted
correctly or not maintained properly. CLABSIs result in
significant
financial and nonfinancial costs to health systems and society
because such infections increase risk of prolonged hospitaliza-
tions, morbidity, and death.2,3 Fortunately, the implementation
of
standardized, evidence-based protocols can lead to dramatic and
sustained reductions of CLABSIs in hospital ICUs.4-8 However,
ney, ScD, MS, Department of
University, 2231 N High St,

201.
McAlearney).
the Agency for Healthcare
). The views expressed in this
present any US government
e affiliated.
ency for Healthcare Research
tion for Professionals in Infection
success rates vary between organizations.8,9 Some hospitals
have virtually eliminated CLABSIs, and have sustained a rate of
0 infections for more than 24 months, whereas others have had
less consistent results.10
Infection control in hospitals and their ICUs is extremely chal-
lenging. Many people are involved (nurses, physicians, adminis-
tration personnel, patients, and their families), and this
certainly
contributes to the problem of infection control. For example,
these
different individuals and groups of providers may have different
opinions about how to reduce healthcare-associated infection
(HAI)
rates. Infection control professionals (ICPs) play a critical role
in
leading HAI-reduction interventions, and are responsible for the
implementation and ongoing management of such interventions
across hospitals and their ICUs. At the same time, frontline
staff are
responsible for delivering direct and ongoing patient care, and
must determine how to incorporate infection control
interventions
within daily practice.
Single hospital case studies of CLABSI reduction programs

have
engaged frontline staff in intervention design and
implementation
Control and Epidemiology, Inc. Published by Elsevier Inc. All
rights reserved.
Delta:1_given name
Delta:1_surname
http://crossmark.crossref.org/dialog/?doi=10.1016/j.ajic.2014.0
4.006&domain=pdf
www.sciencedirect.com/science/journal/01966553
http://www.ajicjournal.org
Table 1
Interview questions about facilitators and challenges of
healthcare-associated
infection (HAI) initiatives
� Do you have any stories about barriers to introducing and
implementing
these HAI efforts at this organization?
B How were these barriers overcome?
� Were there new problems introduced with the implementation
of the HAI
initiative?
B How did these problems get resolved?
B Do any of problems or barriers remain?
B What could have been done differently to improve what
happened with

these changes?
� Were there things that occurred before implementation of
these HAI efforts
that needed to be addressed to facilitate implementation?
� What were the most important things that you think went well
with intro-
duction and use of the HAI initiative?
B What went right with this introduction of HAI efforts in this
organization?
� What suggestions do you have for improvements in the use of
these HAI
initiatives?
B Do you have ideas about how work roles could be changed to
improve
the process?
B Do you have other ideas about how the process could be
improved?
A.S. McAlearney, J.L. Hefner / American Journal of Infection
Control 42 (2014) S216-S222 S217
and reported this as a critical success factor.11,12 Further,
leader-
ship has been a frequently mentioned attribute of success, and
nonclinical factors such as leadership and management practices
have been posited as a potential explanation for between-
organization variability in program outcomes.8,13,14 For ICPs
to as-
sume their critical leadership role in CLABSI prevention
programs,

they must understand the perspective of frontline staff. Studies
have suggested that there is potential for disparity in
perspectives
between managers and their clinical staff with respect to the
implementation and effects of patient safety initiatives,15,16
but this
area is largely understudied in the infection prevention
literature.
To advance this line of research, our study explored the ques-
tion, do ICPs and frontline staff have different perspectives
about
the facilitators and barriers associated with implementation and
effects of a CLABSI prevention protocol? We analyzed
interviews
with ICPs and staff across 8 hospitals that participated in a
CLABSI
prevention program funded by the Agency for Healthcare
Research
and Quality (AHRQ) called “On the CUSP: Stop BSI.”
Comprehensive
unit-based safety program (CUSP), is a formal model for
translating
CLABSI reduction evidence into practice. We wanted to
examine if
and how the perspectives of ICPs and frontline nurses varied to
improve our understanding about the factors that may contribute
to successful CLABSI prevention efforts.
METHODS
Study data collection
We conducted a comprehensive qualitative study of 8 hospitals
that participated in the same cohort of the AHRQ CLABSI
prevention

initiative, “On the CUSP: Stop BSI.” Across the 8 sites in our
study,
we interviewed 194 key informants with different jobs and roles
in
the hospitals. Among these informants were 50 frontline nurses,
and 26 ICPs (including interviewees with job titles of infection
preventionist; hospital epidemiologist; infectious disease physi-
cian; coordinator of infection control; and directors, managers,
and
staff in infection control departments). We focused on the com-
ments from these 76 informants because their roles in the orga-
nizations are relevant to our research question focusing on the
perspectives of ICPs and frontline staff.
Interviews lasted 30-60 minutes, and the majority were con-
ducted with at least 2 interviewers. We used a standard
interview
guide to ensure consistency in our data collection.With
informants’
permission, all interviews were recorded and then transcribed
verbatim to ensure accuracy and reliability. We received
approval
from the Institutional Review Board of The Ohio State
University to
conduct this study. For the results we report here, we focused
on
questions related to facilitators of and barriers to CLABSI
prevention
efforts to compare the responses of ICPs and frontline staff.
These
interview questions are shown in Table 1.
Data analysis
We analyzed our data using a combination of inductive and
deductive methods.17 We reviewed notes and transcripts from

in-
terviews as the study progressed and discussed preliminary
find-
ings. Themes emerged from these ongoing discussions and
allowed
us to develop additional question probes to include in
subsequent
interviews. At the conclusion of data collection we developed a
coding dictionary with main coding themes and specific
subcodes
with detailed definitions specifying when to apply those codes.
The
lead study investigator and two research assistants coded the
transcribed interview data using this dictionary. Throughout the
coding process the research teammet periodically to discuss
issues,
resolve discrepancies, and develop new codes and definitions
for
emergent themes and subthemes. We used Atlas.ti qualitative
analysis software (Leicester, United Kingdom) to support all
parts of
our analysis.
RESULTS
Across sites and informants we found four facilitators of
CLABSI
prevention initiatives, with perspectives about these facilitators
varying between ICPs and frontline staff. We also identified 3
main
challenges of CLABSI prevention programs, characterized
differ-
ently by respondent group and 2 additional challenges identified
only by ICPs. Below we describe our results in greater detail.
We provide additional evidence supporting our characterization
of these facilitators and challenges with representative
verbatim comments presented by theme and by respondent type

in
Tables 2 and 3.
Facilitators of CLABSI prevention initiatives
We found 4 facilitators of CLABSI prevention commonly
mentioned across interviewee groups: education, leadership,
data
and technology, and consistent clinical processes. These
facilitators
were noted across sites, and their absencewas oftenmentioned as
a
barrier to CLABSI prevention. Interestingly, whereas both inter-
viewee groups identified these 4 facilitators, groups’
perspectives
about these facilitators differed. For 3 of these 4 facilitators, we
also
identified subcategories of facilitators within the larger theme
category, as we describe in further detail below. In Table 2 we
present verbatim quotations as additional evidence about the
salience of these facilitator themes and subthemes, by
interviewee
group.
Education
We found 2 main subthemes associated with education as a
facilitator of CLABSI prevention: the importance of staff
education
and reeducation, and the importance of an inclusive education
process. Both the ICPs and frontline staff emphasized the
impor-
tance of continuing education, but the focus differed between
the

Table 2
Representative comments characterizing facilitators of central
line-associated bloodstream infection (CLABSI) prevention
initiatives, by interviewee group
Theme Verbatim comments from infection control specialists
Verbatim comments from frontline staff
Subtheme
Education
Staff education and reeducation Emphasis on learning from
mistakes
“How dowemove forward so this doesn’t happen again? I
think that whole process of letting them know is really
key.”
“Definitely keep everyone in the loop. Don’t just report it
out and move on. Let the people involved know ahead
of time, so it wasn’t or maybe it was, maybe something
was going on.”
Emphasis on continuing education
“Continuous education.The proper way. Sometimes we
forget. Always a reminder of the proper way of
changing the dressing, when the dressing needs to be
changed. Scrubbing the hub. .Even the simple things
you think we would remember, but, you know.”
“Education definitely. And make it frequent..
Newsletters, they use newsletters, which are great
because you can pull those up on your own personal
time. You can’t always do things here and I knowwhen I
go home and I read an e-mail that has a link and then
you can get the update. So education is definitely

important.”
Inclusive education Multidisciplinary education process
“We also have noticed, going back to CLABSI, where there
was some education needed with anesthesia or the
operating room nurses as they accessed these lines. But
it kind of helped that we already had a relationship built
in with some of these operating room folks because we
have to address line access.”
“I think it’s a combination of all of the education, the
collaborative.”
Include patients in education process
“And we also tell the patients. I tell the patients after I’ve
put a line into them or if I’ve done a dressing, ‘Make sure
that anyone who touches you washes their hands
before they touch you.’ I tell them all the time, ‘Make
sure that whoever’s taking care of you washes their
hands.’ They can use the alcohol if they want.”
“I think the most important is involving everyone and the
patient.”
Leadership
Attention from administration Engagement with supportive
leadership
“We’ve gotten more administrative support for making
our recommendations actually happen and go through
the entire system as part of it. . Now we can deal with
people at an administrative level, who understand the
importance of our intervention, and they put up policy
to make sure it continues. That’s part of it.”

“[One success factor is] strong support from
administration, including [our chief nursing officer],
who actually goes down when there’s a problem. She
goes down there. Everybody knows automatically this
is a big deal. People pay attention.”
Emphasis on audits and monitoring
“And usually there’s people going around, just, you
know.[They are checking.] That’s our quality, one of
our quality improvement control.. someone will go in
there, randomly pick a room, and look at the central line
and peripheral lines. See if they’re dated, time, and if
they’re expired or not.”
“Policing.”
“We call them the infection control Nazis who secretly
like to walk around to check and see if everybodydthe
nursesdare being good about checking; you know, are
we garbed appropriately wearing our stuff while we’re
in an isolation room and are we wiping off equipment
and all that sort of thing.”
Support from clinical infection
control champions
Importance of having an infection control champion
“. having somebody like Dr XX, both as a champion for
our CLABSI project and also as a constant presence in
the intensive care unit.”
“The infection control prevention nurse down in [the unit]
because she is very passionate about what she does and

she is very good at what she does.”
“We have a very good advocate with Dr XX . And we
have really been able to work well together as a team.”
Value of approachable, hands-on champions
“You want someone who can keep the group cohesive in
terms of going in the right direction. Yes, we
understand your frustration. However, how about if you
try? You put that initiative out there and you’re still
going to have someone say, ‘Why are we doing this? It’s
not going to work.’”
“It makes quite a bit of difference when you have
somebody who worked in the unit for so many years
step up into that position. She knows exactly how
things are done in this unit and is not afraid to come out
and lead by example.”
Data and technology
Importance of data on infection rates Importance of timely
access to data
“Data mining, which helps us get our information quicker,
so we can address any issue.”
“I think the fact that they can get that data relatively
quickly, rather than 3 months after the patient is
discharged.. So it’s a little bit better that they’re able to
get it in real time and see that.”
Using data to make the case for infection control
“I think nurses respond better to facts than just saying, ‘Oh
well we’re just going to rule this out and try it out.’ .if

they say with the [name] dressing, ‘Oh you knowwhat?
Evidence shows that by applying this we have like 50%
less infections.’ But yeah, come with the facts. If you
have the facts then I think nurses will respond more.”
“Having some kind of a place where you are counting it on
the days without infection or something that you’re
really going to get the staff on board with it.”
Value of new products and technologies New technologies help
reduce infection rates
“One of my faculty members, Dr XX who’s also in
pulmonary critical care, I made himmy simulation czar.
So he and I have met with the School of Nursing. They
have simulation equipment and they have a wonderful
simulation lab. That’s some of it.”
“A good example would be the use of the ultraviolet
machine. That machine cost over $100,000. We had to
convince them. . We were kind of in a bad zone. .I
think it’s made a real difference.”
New products involve changes in practice
“I love the biopatch because then you don’t have to do as
much dressing. With biopatch, it has antibiotics on it
and it usually protects.I guess that’s why we didn’t
have as many infections.”
“That was one of our biggest struggles in the neonatal
intensive care unit was getting nurses to switch over to
chlorhexidine . That for us was a huge change that
they were not happy about in the beginning.”
(continued on next page)

Control 42 (2014) S216-S222S218
Table 2
Continued
Theme Verbatim comments from infection control specialists
Verbatim comments from frontline staff
Consistent clinical processes
Standardization of processes Standardize practice around the
right thing
“Consistency with the protocols for preventing central
line, for preventing infection. People need to know
what they need to do and they need to be consistent in
doing that every time.”
“Looking at what’s best practice and having evidence-
based guidelines, and you know catheter insertion
guidelines really do prevent infections and save lives.”
Make it easy to do the right thing
“The fact that it comes in kit, we don’t have to look for it.
There’s less room for error. There’s no excuse that
there’s no biopatch because it’s in the kit.”
“We get a central line cart that assists us and we have all
of our lines typically on top and then drawers of all the
things that we need so I think that helps. Also where
you push it to outside the room so you have everything
necessary so you don’t skip a step.”

Control 42 (2014) S216-S222 S219
groups. Themajority of ICPs’ comments in this subtheme
focused on
the importance of education in the context of quality
improvement
processes, specifically learning from mistakes. At 1 site an
inter-
viewee noted, “Whenwe have an infection, we will go through
and
have staff come in and say, do you remember this case? How do
you
think we could have avoided this infection?” This sentiment was
echoed by a director of infection control who said, “Instead of
being
punitive, .we brought them (the staff) into the process and had
them look at what their processes are that could have broken
down.”
The majority of staff members, on the other hand, mentioned
the need for continuous education on the clinical processes of
CLABSI prevention. As 1 ICU nurse noted, a main facilitator
was “.
teaching, education, continuing education, just to staff.”
Another
staff nurse highlighted the need for “repetition of the procedure,
the goals, what we’re supposed to do, how we’re supposed to do
it,
whywe’re doing it.” Staff nurses across sites also noted that the
lack
of continuing education was a barrier to success. One
interviewee
explained this need as wanting “maybe a little more frequency
in
education. Maybe instead of once or twice a year maybe a little

bit
more repetitive with that.”.
Another element of education mentioned by both interviewee
groups was an inclusive education process that included people
beyond the frontline staff. However, the definition of inclusive
education differed, with frontline staff exclusively discussing
pa-
tient education and ICPs focusing on including a
multidisciplinary
team in the education process. ICPs discussed the need to
develop
multidisciplinary infection prevention programs. An ICP from 1
site,
for instance, remarked that a facilitator of CLABSI prevention
was
“just involving everybody, from the bedside nurse,
environmental
services, administration, they all work together.” ICPs
mentioned
this repeatedly across the sites; a few interviewees
evenmentioned
the inclusion of dietary services. ICPs also noted the lack of a
consistent, multidisciplinary team, including ICPs, nurses, and
physicians, as a barrier to successful CLABSI prevention. In
contrast,
the staff nurse focus on including patients as part of the
infection
prevention team was evident across sites. As a staff nurse at 1
site
said, “We spend a lot of time patient educating,” a staff nurse at
another site similarly reported, “We recently also had a letter
about
preventing infections that we started to give to families so that
they
too are a part of the team.”

Leadership
We also found 2 subthemes associated with leadership as a
facilitator of CLABSI prevention efforts: attention from
adminis-
tration and importance of clinical infection control champions.
First, although attention from hospital administration to
CLABSI
prevention was another commonly noted facilitator for both
interviewee groups, the focus differed. The ICPs typically noted
the
importance of engagement with supportive hospital
management.
As 1 ICP interviewee said, “I think the support of the
administration,
obviously that’s critical. And then you really need the buy-in
and
the support in particular of the physician leadership, the various
department chairs, the executive committee, the president of the
medical staff. You need those individuals to be behind you and
support the program.” Additionally, the chair of the Infection
Pre-
vention Committee at 1 study site commented that the role of
management in supporting infection control is: “to recognize
the
importance of the infection control activities across the board
not
just for the patients but for everyone in the institution. They
need to
not only recognize it, but they really need to be fully
supportive,
especially when we can show them issues and opportunities for
improvement that are not just a whim but that are based on good
science; that if there is a problem, there is a solution. It may
take

some dollars and it may take their support, that’s what we really
need.”.
Frontline staff often mentioned a more punitive aspect of
attention from administration, audit, and monitoring policies. A
staff nurse at 1 site commented, “We know that if somebody de-
velops a CLABSI [our clinical nurse specialist] is going to hunt
through that chart and find out what nurses took care of her.”
One
staff nurse at another site noted that facilitators of success were
“education and policing,” summing up this sentiment. Both staff
nurse and ICP interviewees commented that when supportive
leadership was lacking, this was a barrier to CLABSI program
suc-
cess. For instance, as 1 staff nurse noted when leadership was
not a
facilitator, “I feel like it’s more of a threat. It’s kind of like,
‘You
should be happy to have a job right now.’”
The second leadership subtheme was support from infection
control champions. Both the frontline staff and the ICPs
frequently
mentioned the importance of infection control champions among
the clinical staff, but whereas ICPs emphasized the champion
role
itself, frontline staff also noted the importance of having an
infection
control champion who was approachable and hands-on. When
asked about the role of a specific infection control champion an
interviewee was describing at 1 site, an ICP explained, “She
was just
on everybody all the time. All the time She’s tenacious.” An
ICP at
another site described how the infection control champion “has
been able to help the nursing staff focus on the importance of

this.”
In contrast, frontline staff tended to mention that
approachability
and good interpersonal skills were important in a champion, a
sentiment not mentioned by ICPs. One staff nurse said, “I think
that
helps when you have had somebody who’s worked in this unit
as a
nurse and who will come in and help you turn and things like
that. I
think that makes them good mentors in their positions so people
do
listen.” A staff nurse from another site expressed the same
senti-
ment, “Dr XX, I think he’s head of the infection. He’s a real
nice guy,
you know, and does stuff, you know? Imeanyou can have a
question,
call him anytime, and he’ll tell you, you know? Things like
that.”
Data and technology
We identified 2 facilitators associated with the use of data and
technology across sites: the importance of data on infection
rates
and the value of new products and technologies. Within these
Table 3
Representative comments characterizing challenges of central
line-associated bloodstream infection prevention initiatives, by
interviewee group
Theme Verbatim comments from infection control professionals

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