infection control and hospital epidemiology september 2010, vol. 31, no.

concise communication

A Simple Educational Intervention
to Decrease Incidence of Central Line–
Associated Bloodstream Infection
(CLABSI) in Intensive Care Units
with Low Baseline Incidence of CLABSI
Alfonso Pérez Parra, MD; Marı́a Cruz Menárguez, PhD;
Marı́a Jesús Pérez Granda, RN; Marı́a Jesús Tomey, RN;
Belén Padilla, MD; Emilio Bouza, MD, PhD
After an educational intervention in 3 intensive care units, 34 central
line–associated bloodstream infections occurred in 11,582 central
venous catheter [CVC]-days, compared with 45 episodes in 10,661
CVC-days before intervention (4.22 vs 2.94 episodes per 1,000 CVC-
days [30.9% reduction]; P p .03, Wilcoxon rank sum test; P p
.11, Poisson regression analysis).
Infect Control Hosp Epidemiol 2010; 31(9):964-967
Central line–associated bloodstream infection (CLABSI) is an
important cause of increased morbidity, mortality, and excess
healthcare costs in intensive care units (ICUs).1 The Infectious
Diseases Society of America (IDSA)–Centers for Disease Con-
trol and Prevention (CDC) guidelines for prevention of in-
travascular catheter–related infections consider the education
and training of healthcare providers a priority.2
Most studies assessing the effect of educational interven-
tions on the incidence of CLABSI have been performed in
institutions or units with excessive baseline incidences3 and
combine educational and other interventions,4 thus making
it difficult to evaluate the effect of a single intervention. The
aims of our study were to analyze the effect of a single, evi-
dence-based educational intervention on the incidence of
CLABSI in ICUs with acceptable baseline incidences and to
assess the knowledge of standards for CLABSI prevention
among healthcare workers in a large teaching hospital.
methods
We performed an observational, pre- and postintervention
study during the period from February 2006 through August
2007 in 3 adult ICUs (medical, general postsurgery, and car-
diac postsurgery) with a joint total of 60 beds in a tertiary
university hospital in Madrid, Spain. In November 2006, a
short lecture (15 minutes) on 10 main points of the IDSA-
CDC guidelines for the prevention of intravascular catheter–
related infections was given to all ICU workers (physicians,
residents, nurses, and students) on all shifts. The lecture was
preceded (a few minutes before) and followed (6 months
after) by identical multiple-choice questionnaires to assess
healthcare worker knowledge of the 10 selected points (Table
1). Each test took an average of 15–20 minutes to complete.
No other interventions potentially affecting the incidence
of CLABSI were performed: there were no changes in hospital
policy on prevention of CLABSI or in the availability of sup-
plies used (type of central venous catheter [CVC], connectors,
antiseptics, or other supplies used in CVC insertion and care).
No changes in CLABSI diagnosis procedures were introduced
in the microbiology laboratory. The staff members respon-
sible for data collection did not change during the study
period. In our center, CVCs are routinely inserted by phy-
sicians and managed by nurses.
The hospital protocol for the prevention of intravascular
device–related infections, which was approved by the hospi-
tal Committee for Infection Control and Antibiotics Policy
(CICAP), follows the definitions and recommendations of
the IDSA-CDC guidelines.2 The numbers of confirmed epi-
sodes of CLABSI and CVC-days are recorded by a designated

table 1. Main Points in Infectious Diseases Society of America–Centers for Disease Control
and Prevention Guidelines on Prevention of Central Line–Associated Bloodstream Infection
(CLABSI) Covered in Lectures and in the Preintervention and Postintervention Tests Completed
by Intensive Care Unit Workers in Madrid, Spain
1. Use of a full sterile sheet when preparing the CVC insertion site
2. Choice of the subclavian vein as the preferred site of insertion
3. Use of closed needleless catheter connection systems
4. Disinfection of clean skin with 2% chlorhexidine gluconate solution before CVC insertion
5. CVC site dressing regimens
6. Aseptic technique during CVC care and maintenance (hand washing and use of gloves)
7. Optimal frequency of CVC dressing replacement
8. Use of parenteral nutrition through a multilumen CVC
9. Management of suspected CLABSI (change avoiding guide wire technique)
10. Replacement of administration sets, needleless systems, and parenteral fluids
note. CVC, central venous catheter.
 educational intervention to decrease clabsi 965

figure 1. Monthly incidence of central line–associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP)
from 2006 through 2008 in all 3 intensive care units participating in an educational intervention. The intervention was performed in
November 2006 (rectangle). The preintervention period began in February 2006 and ended in October 2006 (9 months; dashed line), and
the postintervention period was from December 2006 through August 2007 (9 months; dashed line). Mean preintervention and postin-
tervention annual incidences are also shown (thick dashed line). CVC, central venous catheter.

nurse in each ICU and reported monthly to a CICAP member.
CLABSI incidences are calculated using these data and re-
ported as the number of episodes per 1,000 CVC-days. A
CVC-related bloodstream infection was considered to be ICU
related if it occurred at least 48 hours after admission to or
up to 48 hours after discharge from the ICU.5
We used the roll-plate technique of Maki et al6 and inter-
pretative criteria for culturing CVC tip samples and the Bactec
9240 system (Bactec Plus Aerobic/F; Becton Dickinson Mi-
crobiology Systems) for processing blood samples. Micro-
organisms were identified with use of standard procedures.7
Values for test accuracy are expressed as percentages, with
a 95% confidence interval (CI) when applicable. The com-
parison of the preintervention accuracy with the postinter-
vention accuracy was evaluated with the x2 test, 2-tailed Fisher
exact test, or t test for normally distributed variables. We
compared 9 months of pre- and postintervention incidences
of CLABSI. We also compared incidences of ventilator-as-
sociated pneumonia during the same period as a control for
our intervention. Initially, we used the Wilcoxon rank sum
test to compare montly incidence of CLABSI before and after
the intervention. To control for the confounding effects of
secular trends and external events that occurred during the
study period, we also compared the incidence of CLABSI
using the Poisson regression technique, because our depen-
dent variable (number of CLABSI episodes) was a relatively
unusual event.
A P value of less than .05 (2-tailed) was considered to
reveal a significant difference. The statistical analysis was per-
formed using SPSS, version 15.0 (SPSS), and Stata, version
9.0 (StataCorp). This study was approved by the investigation
committee of our institution.
results
We gave 30 lectures, covering all shifts in all 3 ICUs. These
were attended by 155 healthcare workers: 125 nurses (in-
cluding 22 students) and 30 physicians (including 10 resi-
dents), who completed the preintervention tests. Six months
after the educational intervention, 74 healthcare workers
completed the postintervention tests (64 nurses and 10 phy-
sicians). The mean duration of work experience among ICU
staff was 8.9 years (95% CI, 7.8–10.1 years) for nurses and
8.1 years (95% CI, 5.3–10.8 years) for physicians.
The overall incidence of CLABSI in all 3 ICUs was signifi-
cantly lower during the postintervention period: 34 CLABSI
episodes were diagnosed during 11,582 CVC-days (2.94 epi-
sodes per 1,000 CVC-days) after intervention, compared with
45 CLABSI episodes during 10,661 CVC-days (4.22 episodes
966 infection control and hospital epidemiology september 2010, vol. 31, no. 9
per 1,000 CVC-days) during the period before the interven-
tion (P p .03). Poisson regression results showed a trend to-
ward statistical significance in the effect of the intervention on
the overall CLABSI incidence: the relative risk was 0.69 (95%
CI, 0.44–1.08; P p .11) in the postintervention period, com-
pared with the preintervention period, when rates of ventila-
tor-associated pneumonia increased from 13.34 to 15.82 epi-
sodes per 1,000 ventilator-days (from 91 episodes in 6,822
ventilator-days to 118 episodes in 7,461 ventilator-days). After
the postintervention period, the incidence of CLABSI tended
to increase, approaching the baseline rate before intervention
(Figure 1).
After the educational intervention, incidence of CLABSI de-
creased in each of the ICUs: in the general postsurgery ICU,
there were 18 CLABSI episodes in 3,403 CVC-days (5.3 epi-
sodes per 1,000 CVC-days), compared with 14 episodes in
4,064 CVC-days (3.4 episodes per 1,000 CVC-days) before the
intervention (reduction of 35.8%; P p .05); in the cardiac
postsurgery ICU, there were 12 episodes in 2,842 CVC-days
(4.2 episodes per 1,000 CVC-days), compared with 8 episodes
in 2,981 CVC-days (2.7 episodes per 1,000 CVC-days; reduc-
tion of 35.7%; P p .12); and in the medical ICU, there were
15 episodes in 4,416 CVC-days (3.4 episodes per 1,000 CVC-
days), compared with 12 episodes in 4,537 CVC-days (2.6 ep-
isodes per 1,000 CVC-days; reduction of 23.5%; P p .31). The
mean percentage of correctly answered questions was initially
59.7% (95% CI, 39.9%–78.4%) among all healthcare workers,
and test results were significantly better (73.4%; 95% CI,
58.1%–88.6%; P p .01) after the intervention.
discussion
Our study shows that a simple, relatively inexpensive, evi-
dence-based and updated educational measure resulted in a
30.3% reduction in the CLABSI incidence density in adult
ICUs with already acceptable rates of CLABSI. These results
have interesting implications especially for ICUs where it is
difficult to implement care bundles for the prevention of
CLABSI because of the lack of human or economic resources.8
Evidence-based educational interventions have proven ef-
fective in reducing CLABSI incidence densities,4 although few
studies evaluate the individual effectiveness of an evidence-
based educational intervention in settings with acceptable
rates in the era of zero tolerance for CLABSI.9 Furthermore,
these before-after studies mostly combine educational inter-
ventions with other preventive measures by applying care
bundles,10 which makes it difficult to evaluate the effectiveness
of individual measures.4
Some studies on the difficulties in implementing clinical
practice guidelines show that the first barrier generally iden-
tified by healthcare workers is a lack of awareness of or fa-
miliarity with the guidelines.11 Updated educational pro-
grams are therefore the first step toward achieving adher-
ence to guidelines.
We found that the initial knowledge of ICU workers about
the IDSA-CDC guidelines was good (overall proportion of
correct answers, 59.7% [95% CI, 39.9%–78.4%]). These re-
sults were similar to those of a recent European survey of
3,405 ICU nurses.12 Moreover, the results of the postinter-
vention test were significantly better (overall proportion of
correct answers, 73.4% [95% CI, 58.1%–88.6%]; P p .01).
The questions that received the greatest number of incorrect
responses (fewer than 50% correct responses) were those on
the use of full sterile barriers during CVC insertion (no. 1;
the most frequent error was the assumption that small drapes
are sufficient for CLABSI prevention) and the antiseptic of
choice for skin disinfection (no. 4). Although it is well known
that 2% chlorhexidine is currently recommended for disin-
fection of the CVC insertion site, the 2002 IDSA-CDC guide-
lines still indicate that tincture of iodine could be used.
Our study has some limitations. First, the simplicity of the
intervention makes it difficult to state with any degree of
certainty that it was responsible for the observed reduction
in incidence of CLABSI. Nevertheless, the incidence of ven-
tilator-associated pneumonia did increase after our educa-
tional intervention, and the incidence of CLABSI tended to
increase after the postintervention observation period. Sec-
ond, we did not specifically evaluate how ICU workers have
varied their CVC insertion and management practices; nev-
ertheless, no other interventions or policy changes potential-
ly affecting CLABSI rates (eg, hand-washing programs or
changes in availability of antiseptics or CVC types) were per-
formed during the study period. Third, this was a single-
center study based on a single intervention, and we believe
that educational and training programs should be repeated
and updated to remain effective over time.13 Finally, the anal-
ysis performed with the use of regression techniques did not
show statistical significance, although a decreasing trend in in-
cidence of CLABSI was detected. Therefore, our results must
be interpreted with caution. In conclusion, a single evidence-
based educational intervention could significantly reduce in-
cidence of CLABSI in ICUs where the incidence is already close
to or below the minimum acceptable rates described in inter-
national recommendations.
acknowledgments
We thank Thomas O’Boyle for his help with preparation of the manuscript
and José Marı́a Bellón (Unit of Statistics and Epidemiology, Hospital General
Universitario Gregorio Marañón, Madrid, Spain) and Cristina Fernández
(Unit of Clinic Epidemiology, Hospital Clı́nico San Carlos, Madrid, Spain)
for assistance with the statistical analysis. We thank all the ICU workers and
students for their help and participation in the study.
Financial support. Fundación para la Investigación Biomédica del Hos-
pital General Universitario Gregorio Marañón and Fondo de Investigación
Sanitaria (CM06/00037 to A.P.P.).
Potential conflicts of interest. All authors report no conflicts of interest
relevant to this article.
From the Department of Clinical Microbiology and Infectious Diseases
(A.P.P., M.C.M., B.P., E.B.), the Cardiac Postsurgical Intensive Care Unit
(M.J.P.G.), and the Medical Intensive Care Unit (M.J.T.), Hospital General

Universitario Gregorio Marañón, Madrid, and Red Española de Investigación
en Patologı́a Infecciosa (REIPI), Sevilla (E.B.), Spain.
Address reprint requests to Alfonso Pérez Parra, MD, Clinical Microbiology
and Infectious Diseases Service, Hospital General Universitario Gregorio Ma-
rañón, C/ Dr Esquerdo 46, 28007 Madrid, Spain (alfonsperezp@gmail.com).
Received December 15, 2009; accepted March 29, 2010; electronically pub-
lished July 26, 2010.
Presented in part: 48th International Conference on Antimicrobial Agents
and Chemotherapy, Washington, DC, October 25–28, 2008 (Poster K-3404).
䉷 2010 by The Society for Healthcare Epidemiology of America. All rights
reserved. 0899-823X/2010/3109-0014$15.00. DOI: 10.1086/655841
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