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Learning Session Abstract

Leveraging High Reliability to Identify Special Cause Factors and Reduce Central Line-Associated Bloodstream Infections

Srinivasan, Lakshmi MBBS, MTR*,†; Morris, Kelly MSN, RN, ACCNS-P; Shanahan, Amanda BSN, RN, CPHQ; Bezpalko, Orysia MPH, LSSGB§; Frye, Anna BS, LSSGB§; Powell, Stephanie MSN, PCNS-BC; Sammons, Julia S. MD, MSCE¶,†,**

Author Information
Pediatric Quality and Safety: March/April 2019 - Volume 4 - Issue - p e150
doi: 10.1097/pq9.0000000000000150
  • Open


Central line-associated bloodstream infections (CLABSIs) are the most common healthcare-associated infection in hospitalized children, often leading to increased morbidity, mortality, and healthcare costs. At our institution, we focused CLABSI prevention efforts on achieving high reliability with each element of the CLABSI maintenance bundle. We describe how this high reliability approach helped to identify extraneous factors implicated in special cause variation in our CLABSI rate.

Hypothesis and objectives:

We hypothesized that improved bundle compliance would reduce the hospital CLABSI rate. We sought to improve overall bundle compliance to >90%.


The CLABSI prevention team implemented a standard CLABSI maintenance bundle hospital wide. An electronic dashboard was developed to monitor the CLABSI rate (outcome metric) and bundle compliance (process metric), including both overall compliance and with individual elements. Using these data, daily chlorhexidine gluconate (CHG) treatment was identified as the lowest compliant bundle element, and the targeted Plan, Do, Study, Act (PDSA) cycles were implemented to increase compliance.


In fiscal year (FY) 2016, overall bundle compliance was 85%. Targeted interventions over the course of FY17 were successful in raising overall compliance to 90%. In FY18, these efforts were sustained, with overall compliance at 92% and CHG compliance at 97% (Fig. 1). In September 2017, the hospital achieved 8 consecutive months below the CLABSI rate centerline, indicating a statistically meaningful reduction in the overall CLABSI rate and resulting in a centerline shift (Fig. 2). In October 2017, CLABSI rates increased and were consistently above the new centerline. Upon review, bundle compliance remained high, and no clear process deviations were apparent. Simultaneously, an increase in reported disconnections of IV tubing was identified in the safety reporting system; the timing of increased tubing disconnections correlated with the higher occurrence of CLABSIs. A multidisciplinary group was assembled to investigate, and escalated the concern to the manufacturer of the implicated products. Following the confirmation of a product defect, an appropriate alternative product was identified and defective product was replaced hospital wide as soon as supply was available. Following product replacement, CLABSI rates returned to levels comparable to earlier months.

Fig. 1.
Fig. 1.:
CLABSI bundle compliance over time. CDI, Clean, dry, intact; CHG, Chlorhexidine Gluconate; CVL, central venous line.
Fig. 2.
Fig. 2.:
CLABSI control chart and bundle compliance, annotated with product issue timeline.


Due to highly reliable process metric performance, a reluctance to simplify, and a high degree of situational awareness across all units, a potential product issue was quickly identified and investigated. This product issue was confirmed by the manufacturer, and steps were taken to mitigate the issue and convert the product. The temporal association of the increased CLABSI rates with increased reporting of product issues, followed by a decrease in CLABSI rates once defective product was replaced, strongly suggests that the defective product contributed to the increased CLABSI rate. The focus of the institution on high reliability to the CLABSI bundle enabled this patient safety issue to be quickly identified and mitigated. Without sustained bundle reliability, the ability to confidently implicate this extraneous special cause factor would have been more challenging, and increased CLABSI rates might have then persisted for a longer period of time before the issue was identified. Highly reliable processes, attention to detail, and situational awareness led to timely identification and response, thereby attenuating resultant patient harm.

Copyright © 2019 the Author(s). Published by Wolters Kluwer Health, Inc.