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CLABSI Conversations: Lessons From Peer-to-Peer Assessments to Reduce Central Line-Associated Bloodstream Infections

Pham, Julius Cuong MD, PhD; Goeschel, Christine A. ScD, MPA, MPS, RN; Berenholtz, Sean M. MD, MHS; Demski, Renee MSW, MBA, RN; Lubomski, Lisa H. PhD; Rosen, Michael A. PhD; Sawyer, Melinda D. MSN, RN, CNS-BC; Thompson, David A. DNSc, MS, RN; Trexler, Polly MS, CIC; Weaver, Sallie J. PhD; Weeks, Kristina R. MHS; Pronovost, Peter J. MD, PhD

Quality Management in Health Care: April/June 2016 - Volume 25 - Issue 2 - p 67–78
doi: 10.1097/QMH.0000000000000091
Organizational Quality Management: Original Article

A national collaborative helped many hospitals dramatically reduce central line–associated bloodstream infections (CLABSIs), but some hospitals struggled to reduce infection rates. This article describes the development of a peer-to-peer assessment process (CLABSI Conversations) and the practical, actionable practices we discovered that helped intensive care unit teams achieve a CLABSI rate of less than 1 infection per 1000 catheter-days for at least 1 year. CLABSI Conversations was designed as a learning-oriented process, in which a team of peers visited hospitals to surface barriers to infection prevention and to share best practices and insights from successful intensive care units. Common practices led to 10 recommendations: executive and board leaders communicate the goal of zero CLABSI throughout the hospital; senior and unit-level leaders hold themselves accountable for CLABSI rates; unit physicians and nurse leaders own the problem; clinical leaders and infection preventionists build infection prevention training and simulation programs; infection preventionists participate in unit-based CLABSI reduction efforts; hospital managers make compliance with best practices easy; clinical leaders standardize the hospital's catheter insertion and maintenance practices and empower nurses to stop any potentially harmful acts; unit leaders and infection preventionists investigate CLABSIs to identify root causes; and unit nurses and staff audit catheter maintenance policies and practices.

Departments of Anesthesiology & Critical Care Medicine (Drs Pham, Berenholtz, Lubomski, Rosen, Thompson, Weaver, and Pronovost and Ms Weeks) and Surgery (Drs Berenholtz and Pronovost), Armstrong Institute for Patient Safety and Quality (Mss Demski, Sawyer, and Weeks and Drs Pham, Berenholtz, Lubomski, Rosen, Thompson, Weaver, and Pronovost), Johns Hopkins University School of Medicine, Baltimore, Maryland; MedStar Health, Washington, District of Columbia (Dr Goeschel); and Department of Hospital Epidemiology and Infection Control, The Johns Hopkins Hospital (Ms Trexler), and Johns Hopkins Health System (Mss Demski and Trexler), Baltimore, Maryland.

Correspondence: Julius Cuong Pham, MD, PhD, Department of Anesthesiology & Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, 750 E. Pratt St, Baltimore, MD 21202 (

The authors thank Christine G. Holzmueller, BLA, for her assistance in editing the submitted version of this article.

Dr Pronovost reports receiving grant or contract support from the Agency for Healthcare Research and Quality, the Gordon and Betty Moore Foundation (research related to patient safety and quality of care), the National Institutes of Health (acute lung injury research), and the American Medical Association Inc (improve blood pressure control); honoraria from various health care organizations for speaking on patient safety and quality (the Leigh Bureau manages these engagements); book royalties from the Penguin Group for his book Safe Patients, Smart Hospitals; and stock and fees to serve as a director for Cantel Medical. Dr Pronovost is a founder of Patient Doctor Technologies, a startup company that seeks to enhance the partnership between patients and clinicians with an application called Doctella. The following authors report no conflicts of interest: Drs Pham, Goeschel, Berenholtz, Lubomski, Rosen, Thompson, and Weaver; and Mss Demski, Sawyer, Trexler, and Weeks.

© 2016Wolters Kluwer Health | Lippincott Williams & Wilkins