Prevention of central line-associated bloodstream infections through quality improvement interventions: a systematic review and meta-analysis

Abstract

This systematic review and meta-analysis examines the impact of quality improvement interventions on central line-associated bloodstream infections in adult intensive care units. Studies were identified through Medline and manual searches (1995-June 2012). Random-effects meta-analysis obtained pooled odds ratios (ORs) and 95% confidence intervals (CIs). Meta-regression assessed the impact of bundle/checklist interventions and high baseline rates on intervention effect. Forty-one before-after studies identified an infection rate decrease (OR, 0.39 [95% CI, .33-.46]; P < .001). This effect was more pronounced for trials implementing a bundle or checklist approach (P = .03). Furthermore, meta-analysis of 6 interrupted time series studies revealed an infection rate reduction 3 months postintervention (OR, 0.30 [95% CI, .10-.88]; P = .03). There was no difference in infection rates between studies with low or high baseline rates (P = .18). These results suggest that quality improvement interventions contribute to the prevention of central line-associated bloodstream infections. Implementation of care bundles and checklists appears to yield stronger risk reductions.

Keywords: catheter-related bloodstream infection; central line–associated bloodstream infection; meta-analysis; quality improvement intervention.

Figure 1.

Study selection flow diagram. Abbreviations: CLABSI, central line–associated bloodstream infection; QI, quality improvement.

Figure 2.

Frequency of included care items in bundles and checklists. Eighteen trials implementing bundle or checklist interventions reported which care items were implemented during the intervention period. One study used povidone-iodine in their bundle instead of chlorhexidine [57]. Hand hygiene: personnel practiced antiseptic hand hygiene before/after procedure; chlorhexidine skin antisepsis: skin disinfection before catheter insertion; maximal sterile barrier precautions: personnel wore sterile coat and gloves, mask, and hat during insertion, optimal catheter site selection: personnel strived to insert catheters in the subclavian vein, daily review of line necessity: catheter need was assessed daily with prompt removal of unnecessary central lines.

Figure 3.

Meta-analysis and subgroup analysis of before-after studies. Bundle/checklist interventions: studies implementing a bundle and/or checklist. Non–bundle/checklist interventions: studies implementing neither a bundle nor checklist. Baseline period: before intervention implementation. Post period: after start of intervention implementation. Events: total number of central line–associated bloodstream infections. Total: total number of central line days. W, weight assigned per study. Abbreviations: CI, confidence interval; OR, odds ration.

Figure 4.

Meta-analysis of interrupted time series studies: change in central line-associated bloodstream infection rate level at 3 months postintervention. Abbreviations: CI, confidence interval; OR, odds ratio.