Crit Care Med 2012 Vol. 40, No. 11 2933
N
early 250,000 healthcare-
associated infections occur
annually in patients with
central lines placed to deliver
life-saving medical care (1). Furthermore,
25% of patients contracting a central
line-associated bloodstream infection
(CLABSI) in the intensive care unit (ICU)
die, totaling 31,000 deaths annually in the
United States (2). A recent review esti-
mated an added annual cost of $9 billion
to the U.S. healthcare system (3).
Previous quality improvement studies
suggest that these infections are largely
preventable (4–8). However, these studies
were based on nonrandomized trials with
historical or contemporaneous controls.
These designs might overestimate the
effect of the intervention and may not be
sufficient to establish a causal relationship
between the interventions and the
reduced infections (9, 10), especially when
a consistent national decline in CLABSIs
was found in all types of ICUs in the United
States over the same period (11). The
Keystone ICU collaborative in Michigan
(12) used a bundle of evidence-based
bloodstream infection prevention practices
coupled with a program to improve patient
safety, communication, and teamwork,
known as the Comprehensive Unit–based
Safety Program (CUSP) (13). Together
these interventions reduced the overall
CLABSI rate by 66% in a cohort of ICUs
(7). Nevertheless, this cohort study, with
no concurrent control group, was not able
to establish a causal relationship between
the intervention and the reduced CLABSI
rate. The rational next scientific step was
to test a causal relationship between this
multifaceted intervention and reduced
CLABSI rates in a randomized controlled
trial (RCT) to evaluate the magnitude of
the effectiveness of the intervention. This
article reports our findings.
METHODS
Design and Setting. We used a multicenter,
phased, cluster RCT to implement and test the
multifaceted intervention designed to improve
safety, safety climate, and the use of evidence-
based practices to prevent bloodstream infec-
tions. Two faith-based, affiliated health systems
with hospitals in the West (Adventist Health)
and in the Midwest and Southeast regions
(Adventist Health System) of the country were
Copyright © 2012 by the Society of Critical Care
Medicine and Lippincott Williams and Wilkins
DOI: 10.1097/CCM.0b013e31825fd4d8
Objectives: To determine the causal effects of an intervention
proven effective in pre-post studies in reducing central line-asso-
ciated bloodstream infections in the intensive care unit.
Design: We conducted a multicenter, phased, cluster-random-
ized controlled trial in which hospitals were randomized into two
groups. The intervention group started in March 2007 and the con-
trol group started in October 2007; the study period ended Septem-
ber 2008. Baseline data for both groups are from 2006.
Setting: Forty-five intensive care units from 35 hospitals in two
Adventist healthcare systems.
Interventions: A multifaceted intervention involving evidence-
based practices to prevent central line-associated bloodstream
infections and the Comprehensive Unit–based Safety Program to
improve safety, teamwork, and communication.
Measurements and Results: We measured central line-associ-
ated bloodstream infections per 1,000 central line days and reported
quarterly rates. Baseline average central line-associated blood-
stream infections per 1,000 central line days was 4.48 and 2.71, for
the intervention and control groups (p = .28), respectively. By October
to December 2007, the infection rate declined to 1.33 in the interven-
tion group compared to 2.16 in the control group (adjusted incidence
rate ratio 0.19; p = .003; 95% confidence interval 0.06–0.57). The
intervention group sustained rates <1/1,000 central line days at 19
months (an 81% reduction). The control group also reduced infection
rates to <1/1,000 central line days (a 69% reduction) at 12 months.
Conclusions: This study demonstrated a causal relationship
between the multifaceted intervention and the reduced central
line-associated bloodstream infections. Both groups decreased
infection rates after implementation and sustained these results
over time, replicating the results found in previous, pre-post stud-
ies of this multifaceted intervention and providing further evidence
that most central line-associated bloodstream infections are pre-
ventable. (Crit Care Med 2012; 40:2933–2939)
KEY WORDS: catheter-related infections; evidence-based prac-
tice; intensive care units; prevention and control; quality improve-
ment; randomized controlled trial
A multicenter, phased, cluster-randomized controlled trial to
reduce central line-associated bloodstream infections in intensive
care units*
Jill A. Marsteller, PhD, MPP; J. Bryan Sexton, PhD; Yea-Jen Hsu, PhD, MHA; Chun-Ju Hsiao, PhD, MHS;
Christine G. Holzmueller, BLA; Peter J. Pronovost, MD, PhD, FCCM; David A. Thompson, DNSc, MS, RN
Feature Articles
*See also p. 3083.
From the Department of Health Policy and
Management (JAM, JBS, Y-JH, C-JH, PJP), Johns
Hopkins Bloomberg School of Public Health, Baltimore,
MD; and Department of Anesthesiology and Critical
Care Medicine (JAM, JBS, CGH, PJP, DAT), Johns
Hopkins School of Medicine, Baltimore, MD.
The work was performed at Adventist Health and
the Adventist Health System.
Supported by a grant from the Robert Wood
Johnson Foundation’s Interdisciplinary Nursing Quality
Research Initiative.
Dr. Sexton received honoraria from Michigan
Hospital Association & Trinity. Dr. Pronovost is a consul-
tant for Leigh Bureau Association for Professionals in
Infection Control and Epidemiology. He receives grant
support from AHRQ, NIH, RAND, Common Wealth Fund,
and receives royalties from his book, Safe Patients,
Smart Hospitals. The remaining authors have not dis-
closed any potential conflicts of interest.
For information regarding this article, E-mail:
jmarstel@jhsph.edu