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Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement
  1. Marta L Render1,4,
  2. Rachael Hasselbeck1,
  3. Ron W Freyberg1,
  4. Timothy P Hofer2,5,
  5. Anne E Sales2,
  6. Peter L Almenoff1,3,
  7. for the VA ICU Clinical Advisory Group
  1. 1VA Inpatient Evaluation Center, Cincinnati VAMC, Cincinnati, Ohio, USA
  2. 2VA Health Services Research Center of Excellence, Ann Arbor, Michigan, USA
  3. 3University of Kansas, Kansas City, Kansas, USA
  4. 4Division of Pulmonary/Critical Care/Sleep, University of Cincinnati, Cincinnati, Ohio USA
  5. 5Department of Internal Medicine, University of Michigan, Michigan, USA
  1. Correspondence to Marta L Render, VA Inpatient Evaluation Center at the Cincinnati VAMC, 205 W 4th St Suite 800 Cincinnati VAMC, Cincinnati, OH 45220, USA; marta.render{at}


Background Elimination of hospital-acquired infections is an important patient safety goal.

Setting All 174 medical, cardiac, surgical and mixed Veterans Administration (VA) intensive care units (ICUs).

Intervention A centralised infrastructure (Inpatient Evaluation Center (IPEC)) supported the practice bundle implementation (handwashing, maximal barriers, chlorhexidinegluconate site disinfection, avoidance of femoral catheterisation and timely removal) to reduce central line-associated bloodstream infections (CLABSI). Support included recruiting leadership, benchmarked feedback, learning tools and selective mentoring.

Data collection Sites recorded the number of CLABSI, line days and audit results of bundle compliance on a secure website.

Analysis CLABSI rates between years were compared with incidence rate ratios (IRRs) from a Poisson regression and with National Healthcare Safety Network referent rates (standardised infection ratio (SIR)). Pearson's correlation coefficient compared bundle adherence with CLABSI rates. Semi-structured interviews with teams struggling to reduce CLABSI identified common themes.

Results From 2006 to 2009, CLABSI rates fell (3.8–1.8/1000 line days; p<0.01); as did IRR (2007; 0.83 (95% CI 0.73 to 0.94), 2008; 0.65 (95% CI 0.56 to 0.76), 2009; 0.47 (95% CI 0.40 to 0.55)). Bundle adherence and CLABSI rates showed strong correlation (r=0.81). VA CLABSI SIR, January to June 2009, was 0.76 (95% CI 0.69 to 0.90), and for all FY2009 0.88 (95% CI 0.80 to 0.97). Struggling sites lacked a functional team, forcing functions and feedback systems.

Conclusion Capitalising on a large healthcare system, VA IPEC used strategies applicable to non-federal healthcare systems and communities. Such tactics included measurement through information technology, leadership, learning tools and mentoring.

  • Continuous quality improvement
  • evidence-based medicine
  • outcome
  • patient safety

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  • The manuscript authors include the VA ICU Clinical Advisory Group who organised regional efforts to reduce CLABSI at each of their medical centres' ICUs.

  • Funding This work was supported by the Veterans Health Administration as part of its quality improvement mission.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the University of Cincinnati.

  • Provenance and peer review Not commissioned; externally peer reviewed.