Major Article Minimizing central line-associated bloodstream infections in a high-acuity liver transplant intensive care unit D1X X Tara A Russell D2X X MD, MPH, PhD a,b , D3X X Elyse Fritschel D4X X MPH, CIC c , D5X X Jennifer Do D6X X MSN, RN, ACNP d , D7X X Melanie Donovan D8X X RN, BSN d , D9X X Maureen Keckeisen D10X X RN, MN d , D11X X Vatche G. Agopian D12X X MD d , D13X X Douglas G. Farmer D14X X MD d , D15X X Tisha Wang D16X X MD e , D17X X Zachary Rubin D18X X MD f , D19X X Ronald W. Busuttil D20X X MD, PhD d , D21X X Fady M. Kaldas D22X X MD d, * a Department of General Surgery, University of California Los Angeles, Los Angeles, CA b Veterans Affairs Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, Department of Veterans Affairs, Los Angeles, CA c Clinical Epidemiology and Infection Prevention, UCLA Ronald Reagan Medical Center, Los Angeles, CA d Division of Liver and Pancreas Transplantation, Department of General Surgery, University of California Los Angeles, Los Angeles, CA e Division of Pulmonary and Critical Care Medicine, Department of General Internal Medicine, University of California Los Angeles, Los Angeles, CA f Division of Infectious Diseases, Department of General Internal Medicine, University of California Los Angeles, Los Angeles, CA Background: Increases in liver transplant patient perioperative acuity have resulted in frail immunosup- pressed patients at elevated risk for nosocomial infections. Avoiding central line-associated bloodstream infections (CLABSIs) is paramount to facilitate transplantation and post-transplant recovery. In 2015, our liver transplant intensive care unit (ICU) CLABSIs accounted for more than 25% of all CLABSI at our institution. We therefore undertook a multidisciplinary collaborative among clinical epidemiology, nursing, transplant surgery, and critical care to eliminate CLABSI events. Methods: From 2014-2016, using Lean methodology and plan-do-study-act (PDSA) cycles, 14 interventions were implemented in the liver transplant ICU. Interventions were aimed at infection prevention, care stan- dardization, and team-based monitoring. Implementation used quality improvement methodology including audit and feedback, education, standardization, multidisciplinary stakeholder involvement, and PDSA cycles. Process measures were monitored and audited. CLABSI rates per 1,000 central venous catheter (CVC) days were tracked by clinical epidemiology. Results: During the intervention, 901 CVC catheter audits were completed. Improvements were seen on all process measures, and complete compliance increased from 25%-67%. CLABSI infection rates dropped from 4.2 to 1.8 in 1,000 CVC days, with an average of less than 1 CLABSI per month. This marked a 61.2% annual reduction, which correlated with an estimated $935,000 annual savings. Conclusion: Concerted ongoing multidisciplinary collaboratives are essential to minimize CLABSI and opti- mize value and quality in a challenging, high-acuity patient population. © 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. Key Words: Central line-associated bloodstream infection Intensive care unit Liver transplant Transplantation Lean methodology PDSA Over the past decade, liver transplantation has been faced with increasing acuity due to continued organ shortages paired with sick- est-first allocation policies. Such dramatic increases in perioperative acuity have rendered frail immunosuppressed liver transplant patients at elevated risk for nosocomial infections, particularly central line-associated bloodstream infections (CLABSIs). In a variety of pub- lications evaluating infections after abdominal organ transplantation, liver transplant recipients have been noted to have the greatest inci- dence of post-transplant bloodstream infections and to have worse overall outcomes. 1-4 In studies that have evaluated the source of bloodstream infections among liver transplant patients, catheter- associated infections are among the most common. 2,5,6 Furthermore, infectious complications have been strongly associated with increased morbidity and mortality, especially in the early post-trans- plant period. 2 Therefore, preventing infections, particularly after * Address correspondence to Fady M. Kaldas, MD, 757 Westwood Plaza, Suite 8501, Los Angeles, CA 90095. E-mail address: FKaldas@mednet.ucla.edu (F.M. Kaldas). Previous presentation: Presented at the American College of Surgeons Annual Con- gress, San Diego, California, October 22-26, 2017. Funding/support: T.A.R. was supported by the VA Office of Academic Affiliation through the Veterans Affairs Robert Wood Johnson Clinical Scholars Program. Conflicts of interest: None to report. https://doi.org/10.1016/j.ajic.2018.08.006 0196-6553/© 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. ARTICLE IN PRESS American Journal of Infection Control 000 (2018) 1-8 Contents lists available at ScienceDirect American Journal of Infection Control journal homepage: www.ajicjournal.org