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American Association for Physician Leadership
American Association for Physician Leadership

Central Line Associated Blood Stream Infection Reduction at an Academic Community Hospital During the COVID-19 Pandemic to Achieve Patient Safety

James Hill, Jr., MD, MBA, CPE, FASA, FACHE

Julia Manzo, DO

Meghan Ramic, MSN, RN, CPHQ

Maria Scheutzow, BSN, RN, CIC

Gail Colgrove, BSN, RN, CIC

Kim Monaco, BSN, RN

Kimberly Togliatti-Trickett, MD, MBA

May 8, 2023

Physician Leadership Journal

Volume 10, Issue 3, Pages 16-23



During the COVID-19 pandemic, many institutions saw an overall increase in central line associated blood stream infection (CLABSI) events. CLABSI events can be prevented by decreasing central line utilization, improving practices during central line insertion and maintenance phases, and daily surveillance for necessity. A belief that zero harm to patients is possible and development of a supportive organizational culture with visible leadership were key to reducing CLABSI events and creating long-lasting change, even during the pandemic.

The COVID-19 pandemic strained hospitals in the United States, negatively impacting nurse-to-patient ratios, inpatient hospital resource utilization, and overall staffing conditions.(1) Patient acuity led to a rise in central line utilization and central line associated blood stream infection (CLABSI) events(2) and a renewed focus on CLABSI prevention, which continues to be of critical importance amid challenges posed by the pandemic.(3)

CLABSI is a key quality and safety indicator, monitored by the Centers for Medicare and Medicaid Services (CMS) and carrying significant reputation and reimbursement implications in addition to the noted patient safety concerns.(1) CLABSI events have profound effects on the morbidity and mortality of patients. During the COVID-19 pandemic, the mortality for COVID-positive patients with a CLABSI event was 53.8% as compared to 24.0% in non-COVID patients.(3) The average cost of a CLABSI was $48,108 ($27,232 – $68,983) in 2017 and is likely higher now when adjusting for 2023 dollars.(4)


The study hospital, serving a six-city suburban area in Ohio, is an adult academic suburban hospital that is licensed for 247 beds, supporting an internal medicine residency program, medical students, and nursing students, among other staff. The hospital is part of a multi-hospital system and offers a wide spectrum of care, including trauma emergency department, acute inpatient care, two critical care units, an acute rehabilitation center, and (at the time of this intervention) a gero-psychiatric unit.

The hospital infection control department publicly reports to the National Healthcare Safety Network (NHSN) and has been on a journey to avoid hospital-acquired infections (HAIs) for many years. The hospital had five reported CLABSI events in 2018 and four in 2019. In December 2019, two CLABSI events in the critical care units prompted a renewed focus and energy on CLABSI reduction; these events were determined to not be acceptable in the context of a hospital system pursuing “zero harm.”

Interventions have proven to be effective in reducing CLABSI events in the pre-pandemic environment. Previous effective interventions included implementation of central line insertion checklists, reduction of central line utilization rates, and improved central line maintenance techniques. Few studies exist on the implementation and efficacy of CLABSI reduction efforts in the setting of the COVID pandemic.

A multidisciplinary team worked to build a surveillance program and hardwire CLABSI reduction efforts. A key focus of the intervention was the peer-to-peer interactions with nursing, quality team members, physicians, and hospital administration. The goal was to reduce CLABSI events and avoid patient harm, even in the midst of the COVID-19 pandemic.

Implementation of evidenced-based practices, peer-to-peer communication and a “Stop the Line” culture were critical to successful change. As CLABSI reduction efforts were implemented, the COVID-19 pandemic began to take hold in early 2020 (see Figure 1). Even in the midst of the challenges that the pandemic posed, CLABSI events were reduced to zero in 2020 and one in 2021.

Figure 1. CLABSI Reduction Efforts


The interventions employed to avoid CLABSI were multi-pronged and hinged on the cooperation of a multidisciplinary team. The team was led by the chief medical officer (CMO), chief operating officer, chief nursing officer (CNO), quality manager, critical care intensivists, nurse managers and assistant managers, resident physicians, and infection preventionists.

The interactions among these team members can be characterized as cooperative and open, with an emphasis on maintaining healthy relationships and meeting shared goals rather than targeting rank or reporting structure.

1. Removing Unneeded Central Lines

The primary intervention was a push to remove central lines when no longer indicated. This was accomplished by an interdisciplinary healthcare team. ICU night shift nurses provided the day shift nurses with a morning sign out, which included presence of central venous catheters. The day shift nurses then notified the unit charge nurse of the patients with central venous catheters.

These nurse leaders subsequently presented each central line at a virtual morning leadership huddle with the CNO, quality manager, and infection prevention nurses when safety issues that needed to be addressed for that day were identified.

If a central line no longer met a proper indication or need, the quality manager and/or the infection prevention nurses notified the attending physician, resident physician, and nurse leaders through a secure text messaging system. For example, “Please consider central line removal for patient A.” The physician team then discussed central line necessity at daily bedside rounds and reviewed criteria, including length of treatment and vascular accessibility.

If the central line was deemed appropriate for removal, the bedside nurse was notified during rounds and an official communication order for removal was placed in the electronic medical record. If the physician team determined it was necessary to keep the central line in place, the CNO, quality manager, and infection prevention nurses were notified through the secure text messaging system, and rationale was explained.

If there was resistance, delay in taking action, or concern regarding the decision to maintain the central line, the quality manager informed the CMO. The CMO then contacted the attending physician for a peer-to-peer conversation enlisting their assistance to achieve timely removal or to help the team understand why the line was still needed (see Figure 2).

Figure 2. Protocol for Line Removal

2. Limiting Temporary Central Lines

An additional strategy to reduce CLABSI events was to limit, if not eliminate, any temporary central lines outside of the critical care units. While central line reduction was most prominent in the critical care units, there was additional opportunity in the inpatient wards.

Before the patient would be transferred from the critical care unit to the inpatient wards, a time out or “Stop the Line” at time of transfer was conducted. This important moment in the patient’s care allowed the team members to voice any concerns about the temporary central line, among other items.

The significance of allowing team members to voice concerns is similarly highlighted by the Agency for Healthcare Research and Quality (AHRQ) training program TeamSTEPPS, which empowers any team member to speak up and “Stop the Line” if necessary.(5) This was a time to stop and consider if the patient still required a temporary central line and whether the most appropriate intravenous access was in place before transfer to the inpatient nursing division.

If a temporary central line was not removed before the patient transfer, the plan for the central line removal was addressed during the morning leadership huddle. A similar intervention, as described earlier (see Figure 2), was used when personnel from quality and infection prevention would continue to determine whether the central line was removed in the inpatient wards, and address escalating issues with removal to the CMO.

3. Using Best Insertion Practices

Another key intervention was promoting best insertion practices. This was accomplished through a second observer who completed a central line insertion checklist during central line insertion.

Central lines are placed with ultrasound guidance. If a central line was placed in the femoral vein because of emergent need, the aim was to remove that central line within 24–48 hours, or sooner if the patient was more stable. This is secondary to the increased risk of infection and thrombosis associated with femoral venous catheterization.(6)

4. Strengthening Central Line Maintenance

Central line maintenance practices were also strengthened. During the pandemic, formal IV auditing practices were limited because of staffing constraints, especially during surges. The study protocol emphasized diligent use of alcohol disinfectant caps, particularly in critical care units where IV pumps were located outside of COVID-19 patient rooms to limit staff exposure, preserve personal protective equipment, and improve time efficiency.

Long lengths of extension tubing were extended outside of the patient room. Each port on the IV tubing was covered with the disinfection caps. Local educators, infection control nurses, and nurse leaders instructed bedside nurses, who quickly adopted use of alcohol disinfectant caps. In addition, a daily chlorhexidine bath was provided for all patients with central lines.

5. Promoting Culture Stewardship

Lastly, promoting culture stewardship was another critical element that contributed to overall success in reducing CLABSI events. An inpatient blood culture stewardship form was developed to guide clinicians with appropriate ordering of blood cultures. The form was completed by the nursing staff when blood cultures were ordered and indicated the type of central line ordered for the patient.

If the patient was symptomatic (fever >38.0, elevated WBC, chills, hypotension, or other signs of infection), the nursing staff was directed to draw the blood cultures and return the form to quality and infection prevention for tracking and monitoring. If the patient was asymptomatic or displayed no rationale for the cultures requested, the nurse advised the ordering provider that a peer-to-peer conversation was required before the blood cultures would be drawn.


Risk-adjusted data from the NHSN database was used to provide context for the raw CLABSI data. “The NHSN is the nation’s largest HAI surveillance system and is used by nearly all U.S. hospitals to fulfill local, state or federal HAI reporting requirements. NHSN data are used to measure progress toward prevention goals; this progress is assessed using an observed-to-predicted ratio called the Standardized Infection Ratio (SIR).”(7)

Faced with similar challenges as other hospitals during COVID, one would hypothesize that the study hospital would have comparable struggles with CLABSI events. The issues experienced globally included variables that are cited as risk factors for CLABSI such as prolonged duration of catheterization and reduced nurse-to-patient ratio in the critical care units.(8) While others saw increased CLABSI rates, however, a significant decrease was realized at the study site.

The authors believe accessible leaders made the difference by creating a culture of cooperation and passion for patient safety in the midst of what often felt like an impossible situation during COVID-19 surges. There was a true sense of “the team is in this together,” and, while a hospital cannot control COVID-19 patient volume or always provide ideal staffing, leaders and their teams can keep patients from harm during care by employing simple CLABSI avoidance strategies.

Since the project began in January 2020, the organization has undergone several changes that could contribute to an increase in CLABSI events, including receiving level 3 trauma designation, increasing the volume of cardiac surgery (from about 60 cases in 2019 to more than 100 in 2020), and many COVID surges. The hospital has subsequently seen an appropriate increase in central line utilization. With the increase in patient acuity, there was also an expected increase in central line days from an average rate of 88.96 per 1,000 patient days in 2018 and 2019 before the pandemic to 103.18 in 2020 and 2021 (see Figure 3). Additionally, there was an improvement in Case Mix Index in 2020 (see Figure 4).

Figure 3. Monthly COVID-19 Volume, Patient Days, Central Line Days

Figure 4. Case Mix Index

However, despite all of these challenges, the facility has seen a significant decrease in CLABSI events. The culture change of removing the central lines as soon they are no longer necessary, adhering to central line maintenance bundles, and focusing on culture stewardship have resulted in the number of CLABSI events to be significantly below the predicted SIR.

The NHSN surveillance definition determined CLABSI events, and the SIR was used to review risk adjusted data. The facility had five CLABSI events in 2018 (SIR 1.555, number predicted 3.215), four CLABSI events in 2019 (SIR 1.545, number predicted 2.588), zero CLABSI events in 2020 (SIR 0, number predicted 2.589), and one CLABSI event in 2021 (SIR 0, predicted value 2.774).

The one CLABSI event in 2021 was attributed to a telemetry step down unit which is excluded from the NHSN SIR data. The team was able to significantly decrease the CLABSI rate in the midst of the COVID pandemic. This is in contrast to the national CLABSI SIR during the COVID-19 pandemic, which increased significantly in 2020-Q2–2020-Q4.(7)

The passion of executive leadership to drive a hospital-wide culture change of “zero harm” proved successful with additional improvements, including reductions in CAUTI,(9) PSI 11, PSI 12, as well as with blood utilization. These results motivated caregivers by demonstrating that it is possible to prevent exposure to potential harm or injury and that caregivers directly played a key part in creating this “zero harm” culture.


The health of patients is greatly affected by CLABSI, which causes thousands of deaths annually and costs billions of dollars globally. Data reported to the NHSN show a significantly higher incidence of CLABSI events in 2021 compared to 2019 with a 47% increase in 2020 Q4 versus 2019 Q4, predominantly in the critical care units.(10)

Recent studies have reported large increases in CLABSI events in COVID-19 patients and predict CLABSI to be the most adversely impacted HAI because of the pandemic.(3,11,12) These findings highlight a substantial increase in CLABSI events in hospitals throughout the United States, coinciding with hospitals being faced with managing the COVID-19 pandemic.

During the pandemic, institutional infection control practices changed in many healthcare settings to accommodate increasing numbers of patients and to mitigate shortages of personal protective equipment, supplies, and staffing.(11) One strategy to reduce healthcare worker exposure to patients was a reduction in patient contact time with increased batching of tasks during each visit into the room. This decreased compliance with routine maintenance activities for central venous catheters may include critical aspects of the central line bundle, specifically hand hygiene, chlorhexidine gluconate bathing, scrubbing the hub, and site examinations.

Moving intravenous medication pumps into hallways and difficulties associated with pronation of patients were also challenges that presented from clinical practices during the pandemic.(3,12,13,14)

Furthermore, patients admitted during the pandemic had increased acuity and longer lengths of stay, putting them at greater risk for a CLABSI event. Device use increased, and there was reluctance in use of lower risk venous access devices (midlines, peripheral catheters) to manage critically ill patients.(13)

The most common reason staff cited for deviations from best practices was limited time secondary to staffing shortages.(12) The need to pull support from noncritical care units and the increase in hiring contract nurses also likely contributed to decreased safety measures.

Lastly, and possibly most important, formal central line audits decreased or stopped during the COVID-19 pandemic because of competing priorities.

However, while the majority of studies reported increases in CLABSI events during the COVID-19 pandemic, the authors’ data showed a significant decrease in CLABSI rate. This decrease in CLABSI rate is believed to be directly related to the continued engagement of executive leadership at the hospital during the pandemic and their ongoing dedication to support initiatives designed to promote organizational patient safety improvement efforts, even in times of crisis.

Studies have shown that the degree of leadership involvement in performance improvement initiatives determines their success and, similarly, plays an important role in the successful implementation of HAI prevention interventions.(15,16) In the healthcare setting, leadership rounding demonstrates commitment to a culture of performance improvement. Multidisciplinary rounds provide leaders, managers, frontline staff, patients, and their caregivers a platform for direct interaction and sharing of a common vision of patient safety.(15)

The findings are consistent with those from several studies which identified factors leading to successful HAI prevention efforts.(16,17,18,19) These include visible executive leadership engagement, a supportive organizational culture, feedback, efficient communication, and the belief that a rate of zero CLABSI events was attainable.

The steadfast initiative of hospital executive leadership to focus on CLABSI prevention by revamping a surveillance program and developing a multidisciplinary team to ensure compliance was a critical component in CLABSI reduction efforts during the pandemic. It was this unique approach that separates the authors’ intervention from that of other institutions. This was accomplished through a high level of peer-to-peer interactions with approachable and accessible leaders and hospital administrators throughout the intensive care units and inpatient wards.

The importance of maintaining leadership engagement during pandemics cannot be underplayed. Unfortunately, in the context of COVID-19, executive leaders at hospitals were facing the need to adjust their practices to accommodate changes in infrastructure and shortages of resources while also maintaining physical distance. Facing similar challenges as other hospitals during the COVID-19 pandemic, however, the hospital executive leadership maintained consistent visibility and ensured leadership rounds continued, which played an essential role in improving the overall safety culture and made evident that CLABSI prevention remained an institutional priority. With concerted effort, as demonstrated during the COVID-19 pandemic, patient harm can be reduced.(8,20,21)


In the aftermath of the pandemic, leadership and management practices should re-implement monitoring compliance with routine multidisciplinary central line rounds and re-establish the evidence-based practices that have been shown to be successful. These include good hand hygiene, utilization of bundles for insertion and maintenance, selection of the most appropriate line type, and discontinuation of the central lines when they are no longer needed.

The results confirm that engaged and visible leaders can significantly improve CLABSI prevention efforts by fostering a belief that a rate of zero CLABSI events is attainable, creating a supportive organizational culture, and providing effective feedback. Furthermore, the findings emphasize that hospitals should remain vigilant in management practices in the context of infection prevention and patient safety during pandemics and other periods of HAI burden.


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James Hill, Jr., MD, MBA, CPE, FASA, FACHE

James Hill, Jr., MD, MBA, CPE, FASA, FACHE, is the chief operating officer and critical care anesthesiologist at University Hospitals Parma Medical Center and an assistant professor for the school of medicine at Case Western Reserve. He previously was the chief medical officer of University Hospitals Parma Medical Center and the system medical director of transfusion services and blood management and division chief of trauma anesthesiology at University Hospitals Cleveland Medical Center in Cleveland, Ohio.

Julia Manzo, DO

Julia Manzo, DO, is an internal medicine resident physician (PGY-3) at University Hospitals Parma Medical Center in Cleveland, Ohio.

Meghan Ramic, MSN, RN, CPHQ

Meghan Ramic, MSN, RN, CPHQ, is the quality manager for University Hospitals Parma Medical Center and market manager for the West Market Quality Operations for University Hospitals Health System.

Maria Scheutzow, BSN, RN, CIC

Maria Scheutzow, BSN, RN, CIC, is a senior infection preventionist at University Hospitals Parma Medical Center.

Gail Colgrove, BSN, RN, CIC

Gail Colgrove, BSN, RN, CIC, is a senior infection preventionist at University Hospitals Parma Medical Center.

Kim Monaco, BSN, RN

Kim Monaco, BSN, RN, is the chief nursing officer for University Hospitals Parma Medical Center.

Kimberly Togliatti-Trickett, MD, MBA

Kimberly Togliatti-Trickett, MD, MBA, is the Western Region chief medical officer for the University Hospitals Health System and the Parma Medical Center Inpatient Rehabilitation Unit co-medical director. She is a practicing internal medicine and physical medicine and rehabilitation physician. She was previously the chief medical officer of University Hospitals Parma Medical Center in Parma, Ohio.

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