American Journal of Infection Control 48 (2020) 770−776

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American Journal of Infection Control

journal homepage: www.ajicjournal.org

Major Article

Failure of central venous catheter insertion and care bundles in a high

central line−associated bloodstream infection rate, high bed occupancy
hospital
Amalia Karapanou RN, MSc a, Anna-Maria Vieru MD b, Michail A. Sampanis RN, MSc a,
Angeliki Pantazatou MD c, Ioannis Deliolanis MD c, George L. Daikos MD b, Michael Samarkos MD b,*
a
Infection Control Committee, Laikon Hospital, Athens, Greece
b
First Department of Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
c
Microbiology Laboratory, Laikon Hospital, Athens, Greece

Key Words: Background: Our hospital has several characteristics different from the settings in which the central venous
Patient care bundles catheter (CVC) care bundle has been implemented so far, that is, care bundles or protocols are not systemati-
Central venous catheters cally used, and the prevalence of central line−associated bloodstream infections (CLABSI) is high, as is bed
Bacteremia occupancy rate. We examined the effectiveness of CVC care bundles.
Catheter-related infections
Methods: Modified CVC bundles were implemented across all settings of our hospital. During both phases of
Nursing staff
the study, we collected data on CLABSI, and we monitored CVC insertion and management practices with
Patient safety
direct observation audits.
Results: We have studied 913 CVC insertions (454 in PRE and 459 in POST) for 11,871 catheter-days. The inci-
dence of CLABSI was 8.3 per 1,000 catheter-days PRE, and 7.6 per 1,000 catheter-days POST (incidence rate
ratio, 0.92; 95% confidence interval, 0.60-1.40). Compliance with the CVC insertion bundle increased from
8.4%-74.3% (P < .0001). The CVC management bundle compliance also increased from 11.4%-57.7% (P < .0001).
Conclusions: Despite improved compliance after the intervention, implementation of a modified CVC bundle
failed to decrease CLABSI incidence. Higher bundle compliance rates may be necessary for a significant
decrease in the incidence of CLABSI, along with the appropriate organizational culture and levels of staffing.
© 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All
rights reserved.

Central line−associated bloodstream infections (CLABSI) repre-
sent a major challenge to patient safety and a significant burden to
health systems. More than 20% of bloodstream infections in acute
care hospitals in Europe are CLABSI.1 These infections carry an attrib-
utable mortality of up to 30%,2 and they are probably the most costly
health care−associated infections.3
It has been estimated that up to 65%-70% of CLABSIs are prevent-
able,4,5 and several factors, such as catheter insertion site, type of
catheter, and type of dressing are important for their prevention.6
Care bundles are small sets—usually 3 to 5—of evidence-based inter-
ventions that, when implemented collectively and reliably, improve
the delivery of health care and improve patient outcomes.7 Care bun-
dles for central venous catheter (CVC) insertion and management
*Address correspondence to Michael Samarkos, MD, First Department of Medicine,
Medical School, National and Kapodistrian University of Athens, Laikon Hospital, 17
Agiou Thoma St, Athens, Greece 11527.
E-mail address: msamarkos@med.uoa.gr (M. Samarkos).
Conflicts of interest: None to report.
have decreased the incidence rate of CLABSIs significantly.8 However,
the effectiveness of these interventions might not be the same across
all settings. As Speroff et al9 remarked, incorporating improvement
methods is complex, highly context-dependent, and may take long.
Thus there might be differences depending on the level of care (ie,
intensive care unit [ICU] vs patient wards), on the experience in
implementation and use of care bundles, as well as on differences in
safety culture.10
Our hospital has several characteristics that differ from the setting
in which the CVC care bundle has been implemented so far. First,
care bundles or protocols are not systematically used in patient care.
Second, the prevalence of CLABSI in the European Centre for Disease
Prevention and Control point prevalence survey of 2012 was high, as
bloodstream infections accounted for 45.4% of all hospital-acquired
infections, and 50% of which were catheter-related (hospital data).
Third, the bed occupancy rate of our hospital is very high, with medi-
cal wards systematically registering occupancy rates well over 100%.
Fourth, our hospital is understaffed in registered nurses.11 Finally,

https://doi.org/10.1016/j.ajic.2019.11.018
0196-6553/© 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
 A. Karapanou et al. / American Journal of Infection Control 48 (2020) 770−776
chlorhexidine gluconate 2% is not available in Greece, and transpar-
ent semipermeable dressings are in short supply in our hospital.
Consequently, the aim of our study was to evaluate the effective-
ness of a modified CVC bundle on the incidence of CLABSI in a setting
lacking in safety culture, with high CLABSI incidence, high bed occu-
pancy rate, and relatively limited resources.
METHODS
Setting
We have conducted a quasiexperimental pre−post study at Laikon
Hospital, a tertiary care, university-affiliated hospital in Athens, with 574
beds that includes hematology−oncology wards and both solid organ
and bone marrow transplantation units. All wards (medical, surgical, and
ICU), except the emergency department, were included in the study.
Procedures
The study consisted of 3 phases: preintervention (PRE, January 1
to June 30, 2016), intervention (INT, July 1 to September 30, 2016),
and postintervention (POST, October 1, 2016 to March 31, 2017). Dur-
ing the preintervention phase, we collected baseline data on CLABSI.
For the CLABSI surveillance, we used the Centers for Disease Control
and Prevention/National Healthcare Safety Network definition.12 In
brief, CLABSI is defined as a laboratory-confirmed bloodstream infec-
tion not related to an infection at another site that develops within
48 hours of a central line placement. If >1 CLABSI occurred on the
same catheter, we recorded only the initial one. Data collected
included dates of catheter insertion and removal, site of catheteriza-
tion, number of lumens, urgency of insertion, and setting were the
insertion occurred. We have also collected data on whether the index
catheterization was the initial one, or it was performed to replace
another CVC. Finally, we also collected data on patient demographics,
ward, admission diagnosis, presence of comorbidities, interventions
such as mechanical ventilation and parenteral nutrition, pathogens
isolated from blood cultures, and patient outcomes.
The intervention phase consisted of the implementation of the
CVC insertion and maintenance care bundles. The bundles were
based on the ones issued by the Greek Centre for Control and Preven-
tion of Diseases (KEELPNO) with some modifications.13 The elements
of the insertion bundle included hand hygiene, maximal barrier
precautions (total body drape and personal protective equipment),
aseptic technique throughout the insertion, and use of transparent
dressing. The management bundle consisted of hand hygiene, hub
antisepsis with alcohol-based handrub, and aseptic technique during
the procedure. In both cases, bundle undertaking required compli-
ance with all bundle elements.
All wards prepared and stocked CVC insertion kits, which
included all materials required by the bundle, as well as the CVC
insertion checklist. We did not use antimicrobial-coated catheters.
The insertion bundle, however, lacked 2 elements. The assisting
nurse did not have the option to interrupt the CVC insertion if the bun-
dle protocol was violated. Thus violations were not recorded. In addi-
tion, a checklist included in the CVC insertion kit served as a reminder
and it was not to be filled for each insertion. The management bundle
did not include daily evaluation of ongoing need of the CVC.
The intervention included training of all health care workers
involved in the insertion and maintenance of CVCs, with small group
teaching sessions with 2 of the researchers acting as facilitators (A.K.
and M.S.). During the intervention phase, we did not collect any data.
During the postintervention phase, we collected the same data as
with the preintervention phase. We also audited CVC insertion and
management practices, with direct observation in all phases of the
study. Bundle violations were noted in the audit. The audit forms
771
were based on the respective checklists that we were planning to
implement. Throughout the study we were monitoring hand hygiene
compliance monthly.
Outcomes
The main outcome was CLABSI incidence expressed as CLABSI
events per 1,000 catheter-days. Secondary outcomes included days
from CVC insertion to CLABSI, duration of catheterization, catheter
use rate, and in-hospital mortality.
Statistical analysis
We compared the PRE with the POST phase. During the INT phase,
we did not collect any data, therefore results of the POST phase do
not include the INT phase.
Continuous variables were expressed as mean and standard devi-
ation or median interquartile range, whereas qualitative variables
were expressed as absolute and relative frequencies. We used the x2
test (or the Fisher exact test when appropriate) to compare dichoto-
mous variables, and the Mann−Whitney U test to compare continu-
ous variables. A Poisson distribution was used to compare the
incidence rate of CLABSI among different groups, with the calculation
of incidence rate ratios (IRR). For the comparison of proportions, the
x2 and the Fisher exact tests were used. A stepwise multiple logistic
regression analysis (P for removal was set at .1, and P for entry was
set at .05) was performed to identify factors independently associated
with CLABSI. For time to event variables we performed survival anal-
ysis with Kaplan−Meier curves, and Cox regression.
All P values reported are 2-tailed. Statistical significance was set at
.05 and analyses were conducted using IBM SPSS Statistics version
24.0 (IBM Corporation, Armonk, NY).
The study protocol was approved by the institutional review
board (approval number 3486/10-3-2015), and permission to create
the study database was granted by the Greek Personal Data Protec-
tion Authority (decision number 1605-2/18-11-2015).
RESULTS
Patient characteristics
We recorded in total 913 CVC insertions (454, 49.7% in PRE and
459, 50.3% in POST) in 713 patients. The catheters remained in place
for 11,871 catheter-days. Mean age in the total patient population
was 66.7 § 15.4 years, however, patients in the POST phase were sig-
nificantly older than those in the PRE phase (68.2 § 14.6 years vs
65.2 § 16.1 years; Mann−Whitney U test, P = .033). The prevalence of
major comorbidities in our patients’ population was 22.3% for diabe-
tes mellitus, 8.0% for chronic obstructive pulmonary disease, 5.3% for
congestive heart failure, 33.9% for coronary heart disease, and 25.8%
for hematologic neoplasms. The prevalence of congestive heart fail-
ure and coronary heart disease were significantly higher in the POST
phase (3.6% vs 7.1%, P = .039 and 30.3% vs 37.1%, P = .037, respec-
tively). There was a difference in the PRE and POST intervention prev-
alence of prior admission to hospital (68.1% vs 76.5%; P = .012) and
dialysis (15.8% vs 10.8%; P = .046).
The most frequently isolated pathogen in the PRE phase was Aci-
netobacter baumannii (10 of 50, 20.0%), followed by coagulase-nega-
tive staphylococci (8 of 50, 16.0%), and Klebsiella pneumoniae (6 of 50,
12.0%). In the POST phase, A baumannii was again the most frequently
isolated pathogen (11 of 45, 24.4%), followed by Enterococcus faecium
(10 of 45, 22.2%), and coagulase-negative staphylococci (9 of 45,
20.0%). There was no difference in the proportion of gram-positive
pathogens isolated in the PRE and POST phase (21 of 50, 42.0% vs 24
of 45, 53.3%; P = 0.3).
772 A. Karapanou et al. / American Journal of Infection Control 48 (2020) 770−776

Table 1
Catheter insertion−related variables before and after the intervention

PRE, n = 454 POST, n = 459 Total, n = 913

n, (%) n, (%) n, (%)

Ward Medical 248 (54.6) 226 (49.2) 474 (51.9)

Surgical 125 (27.5) 145 (31.6) 270 (29.6)
ICU 81 (17.8) 88 (19.2) 169 (18.5)
Site of catheterization Femoral* 194 (42.7) 76 (16.6) 270 (29.6)
Jugular* 150 (33.0) 255 (55.6) 405 (44.4)
Subclavian 110 (24.2) 128 (27.9) 238 (26.1)
Side of catheterization Right* 316 (69.6) 394 (85.8) 710 (77.8)
Left 138 (30.4) 65 (14.2) 203 (22.2)
Number of lumens 2 323 (71.1) 336 (73.2) 659 (72.2)
3 131 (28.9) 123 (26.8) 254 (27.80)
Urgency of insertion Elective* 367 (80.8) 410 (89.3) 777 (85.1)
Emergent 87 (19.2) 49 (10.7) 136 (14.9)
Timing of CVC insertion Initial 392 (86.3) 409 (89.1) 801 (87.7)
Catheter malfunction 39 (8.6) 27 (5.9) 66 (7.2)
Catheter infection 23 (5.1) 23 (5.0) 46 (5.0)
Insertion setting Ward 341 (75.1) 320 (69.7) 661 (72.4)
Operating room 101 (22.2) 109 (23.7) 200 (23.0)
Dialysis unit 9 (2.0) 26 (5.7) 35 (3.8)
Emergency room 3 (0.7) 4 (0.9) 7 (0.8)
Statistical significance testing for the difference in proportions between PRE and POST.
CVC, central venous catheter; ICU, intensive care unit; PRE, preintervention; POST, postintervention.
*P <.001.

Catheterization-related variables
Table 1 shows variables related with the CVC insertion in the 2
phases of the study and in the total study population. The femoral site
insertion decreased significantly from 42.7% (194 of 454) in the PRE to
16.6% (76 of 459) in the POST period (x2, P < .001), whereas jugular
site insertion increased significantly (33.0%, 150 of 454 to 55.6%, 255 of
459; P < .001). The urgency of insertion (emergent vs elective) also dif-
fered, with significant decrease in emergent CVC insertions from 19.2%
(87 of 454) to 10.7% (49 of 459) in the POST phase (x2, P < .001).
Outcomes
The CLABSI incidence decreased from 8.3 (50 CLABSIs in 5,998
catheter-days) PRE to 7.6 (45 CLABSIs in 5,873 catheter-days) CLABSIs
per 1,000 catheter-days POST intervention. The decrease, however,
was not significant (IRR, 0.92; 95% confidence interval [CI], 0.60-
1.40). Similarly, the rate of CLABSI was not significantly decreased in
subgroups such as medical patients (IRR, 0.64; 95% CI, 0.34-1.17;
P = .12), patients with CVC at the subclavian site (IRR, 0.54; 95%
CI, 0.19-1.37; P = .15), and patients in which the CVC was inserted in
the ward (IRR, 0.87; 95% CI, 0.54-1.38; P = .53).
The median time from CVC insertion to CLABSI in the 2 study
phases was 12.0 days (95% Cl, 10.0-15.0) for the PRE and 10.0 days
(95% CI, 8.0-12.0) for the POST. We have performed survival analyses
(Kaplan−Meier curves) to compare the time from CVC insertion to
CLABSI between the 2 study phases, however, the difference was not
significant (Fig 1, log-rank test x2 = 0.1461, P = .7).
Catheter use rate did not differ between the PRE and the POST
phase of the study (7.5 per 100 patient-days vs 7.8 per 100 patient-
days; IRR, 1.032; exact 95% CI, 0.90-1.17; x2, P = .62).
The overall in-hospital mortality was 27.1% (193 of 713) and did
not differ between the 2 phases of the study (PRE 24.4%, 86 of 353 vs
POST 29.7%, 107 of 360; x2, P = .11). Patients with CLABSI, as expected,
had significantly higher mortality (41.2% [35 of 85] vs 25.6% [161 of
628]; Fisher exact test, P = .004).
Risk factors for CLABSI
We examined several variables as risk factor for CLABSI (Table 2).
When CLABSI was examined as a dichotomous variable, we found
that it was associated with hospitalization in the ICU (x2, P = .002),
with insertion after previous CVC infection (x2, P < .001), and with
insertion of CVCs with 3 versus 2 lumens (Fisher exact test, P = .002),
whereas insertion in the operating room was associated with signifi-
cantly lower probability of CLABSIs (x2, P = .031). When we investi-
gated CLABSI rate in relation to possible risk factors (Table 2), we
found that CLABSI rate was significantly higher in the ICU (IRR, 2.04;
P = .02), and with insertion after previous CVC infection (IRR, 2.65;
P = .0027). In addition, duration of catheterization was significantly
longer in patients with CLABSI vs patients with no CLABSI (median
16.0 [95% CI, 13.0-19.0] vs 10.0 [95% CI, 10.0-11.0] days; Mann−Whit-
ney U test, P < .001), and so was length of hospital stay (median 21
[95% CI, 203.0-23.0] vs 34 days [95% CI, 30.0-39.0]; Mann−Whitney
U test, P < .001).
Monthly bed occupancy rates during the study ranged from
49.5%-118.5% (median 83.2%), thus we examined the association of
monthly bed occupancy rate of the department in which the patient
was hospitalized when the CVC was inserted, with CLABSI. However,
there was no difference in bed occupancy rate between patients with
and without CLABSI (Mann−Whitney U test, P = .105).
To investigate for risk factors, we performed logistic regression in
which the outcome was CLABSI and the independent variables were
ward, indication for insertion, insertion setting, number of CVC
lumens, study phase, and duration of catheterization (Table 3). Only
CVC insertion because of previous CLABSI was independently associ-
ated with CLABSI (odds ratio, 2.6; P = .017). Duration of catheteriza-
tion was also statistically significantly associated with CLABSI
(P = .001). An odds ratio of 1.03 per extra day with a CVC could be rel-
evant when the catheter remains in place for a long time.
We have also performed Cox regression to examine the effect of
different variables (eg, ward, number of lumens, and others) to the
time from CVC insertion to CLABSI. Only CVC change because of pre-
vious CLABSI was independently associated with time to CLABSI (haz-
ard ratio, 2.4 [95% CI, 1.2-4.7]; P = .014).
Bundle compliance
During the intervention phase, small group teaching sessions
regarding the insertion and management of CVC were attended by
139 of 201 nurses (69.1%) and 82 of 93 physicians (88.2%).
 A. Karapanou et al. / American Journal of Infection Control 48 (2020) 770−776
Fig 1. Kaplan−Meier curve showing the probability of CLABSI according to the duration of catheterization in the 2 study phases. CLABSI, central line−associated bloodstream infec-
tion; PRE, preintervention; POST, postintervention.
Compliance with the CVC insertion bundle (n = 153 observations)
increased significantly from 8.4% (7 of 83) in the PRE phase to 74.3%
(52 of 70) in the POST phase (x2, P < .0001). In the PRE phase, the com-
pliance was lowest for use of maximal barrier precautions (9.6%, 8 of
83) and hand hygiene (27.7%, 23 of 83), whereas in the POST phase,
compliance was lowest for maximal barrier precautions (87.1%, 61 of
70) and for the use of transparent dressing (74.3%, 52 of 70).
The CVC management bundle compliance (n = 295 observations)
also increased from 11.4% (15 of 132) in the PRE phase to 57.7% (94 of
163) in the POST phase (x2, P < .0001). The bundle element with the
lowest compliance in the PRE phase was hand hygiene before manag-
ing the CVC (31.3%, 42 of 132) and in the POST phase was use of ster-
ile gloves (63.2%, 103 of 163). Details regarding compliance with the
individual components of the bundles in the 2 phases of the study
are presented in Fig 2.
DISCUSSION
Implementation of the CVC care bundle in ICU and non-ICU
patients reduced CLABSI rates from 8.3 to 7.6 CLABSI per 1,000 cathe-
ter-days, however, the reduction was not significant. However, we
reduced significantly catheterizations of the femoral vein from
42.7%-16.6%, the insertion bundle compliance increased from 8.4%-
74.3%, and the management bundle from 11.4%-57.5%. In our analysis
of risk factors for CLABSI we could only find that ICU hospitalization,
use of 3 versus 2 lumen catheters, previous CLABSI, and duration of
catheterization were associated with CLABSI in univariate analyses,
however, only previous CLABSI and duration of catheterization were
773
independently associated with CLABSI in multivariate analysis. We
could not associate compliance with the care bundles or with any of
their elements with patient outcomes because our study was
designed as an ecological one. Compliance was estimated by audit,
thus we lacked data on the bundle compliance for each patient as it
has been done in other studies.14 Although we have hypothesized
that bed occupancy rate would influence the CLABSI rate, we could
not establish such an association.
In contrast to our study, CVC care bundles have generally suc-
ceeded in significantly reducing CLABSI rates.8 There are several possi-
ble contributing factors to the failure of our care bundles. Our setting
had some unique characteristics. The baseline incidence was a rela-
tively high CLABSI incidence for a mixed setting, however, there have
been reported even higher baseline CLABSI rates in the literature.15
The bundle was a modification of the ones widely used.13,16 An
important difference was that the assisting nurse was not given the
option to interrupt the insertion of the CVC when the bundle was vio-
lated because of the reluctance of our nurses to challenge physicians.
There is a rather strong hierarchical structure in Greek hospitals,
with physicians occupying the higher levels. It is apparent that imple-
mentation of care bundles has certain requirements in terms of orga-
nizational culture, which unfortunately, we lacked. Furthermore, a
checklist served as a reminder only, and it did not have to be filled in
each CVC insertion, as the nursing staff suggested that it would add
to their already increased workload. In our hospital, there are on
average 3 registered nurse to 40 patients in the wards during the
morning shift and 2 during the afternoon and night shift (personal
observation). In general, the nurse−patient ratio in Greece is the
774 A. Karapanou et al. / American Journal of Infection Control 48 (2020) 770−776

Table 2
Univariate risk factors analysis for CLABSI

Variable CLABSI (n, %) CLABSI/1,000 catheter-days IRR (95% CI), P value

Ward Medical 51 (10.8) 7.73 1.38 (0.77-2.57), .28

Surgical* 16 (5.9) 5.63 N/A
ICU 28 (16.6)y 11.51 2.04 (1.06-4.04), .02
Site of catheterization Femoral 27 (10.0) 7.64 1.13 (0.62-2.08), .77
Jugular 46 (11.4) 9.05 1.34 (0.78-2.33), .32
Subclavian* 22 (9.2) 6.76 N/A
Number of lumens 2 55 (8.3) 7.30
3 40 (15.7)z 9.22 1.26 (0.90-1.72), .15
Urgency of insertion Elective 85 (10.9) 8.02
Emergent 10 (7.4) 7.87 0.98 (0.45-1.89), .99
Indication for CVC insertion Initial* 74 (9.2) 7.22 N/A
Catheter malfunction 8 (12.1) 8.46 1.17 (0.49-2.43), .69
Catheter infection 13 (28.3)x 19.17 2.65 (1.35-4.82), .0027
Insertion setting Operating room*,k 10 (4.8) 4.73 N/A
Ward 80 (12.1) 8.76 1.85 (0.96-4.0), .07
Dialysis unit 5 (14.3) 9.16 1.93 (0.51-6.21), .20
ER 0.0 0.00 N/A
Prior admission No 22 (9.7) 8.78
Yes 73 (10.6) 7.79 0.89 (0.54-1.50), .6
Infection on admission No 7 (8.3) 5.56
Yes 88 (10.6) 8.29 1.49 (0.69-3.81), .4
Surgery No 61 (11.2) 8.06
Yes 34 (9.3) 7.90 0.98 (0.62-1.51), .9
Antimicrobial administration No 14 (12.8) 10.57
Yes 81 (10.1) 7.68 0.73 (0.41-1.39), .2
Chemotherapy No 79 (10.9) 8.37
Yes 16 (8.4) 6.57 0.78 (0.43-1.35), .4
Immunosuppression No 70 (11.0) 8.42
Yes 25 (9.0) 7.02 0.83 (0.50-1.33), .5
Mechanical ventilation No 68 (10.4) 8.06
Yes 27 (10.3) 7.86 0.97 (0.60-1.54), .9
Parenteral nutrition No 78 (10.2) 7.92
Yes 17 (11.4) 8.42 1.06 (0.59-1.81), .7
Nasogastric tube No 52 (10.3) 7.93
Yes 43 (10.6) 8.10 1.02 (0.66-1.56), .9
Urinary catheter No 22 (9.1) 7.17
Yes 73 (10.9) 8.29 1.16 (0.71-1.96), .6
Dialysis No 81 (10.3) 7.88
Yes 14 (10.9) 8.82 1.12 (0.58-1.99), .6
Statistical significance testing for the difference in proportions between number of CLABSI and CLABSI.
CI, confidence interval; CLABSI, central line−associated bloodstream infection; CVC, central venous catheter; ER, emergency room; ICU, intensive care unit; IRR, incidence rate ratios;
N/A, not applicable.
*Baseline category for rate comparison.
y
P = .002.
z
P = .002.
x
P <.001.
k
P = .031.

Table 3 compliance threshold above which bundles are effective, however,

Multivariable analysis (logistic regression) of risk factors for central line−associated there are such data for other infection control interventions such as
bloodstream infection hand hygiene.17 Importantly, compliance with the maintenance bun-
Variable Odds ratio (95% CI) P dle in the POST phase was <60%. This might be critical, given that
maintenance bundles should be performed several times daily,
Study phase 0.90 (0.58-1.40) .636
whereas the insertion bundle must be performed only once. Thus
Insertion because of catheter malfunction 0.99 (0.43-2.27) .976
Insertion because of catheter infection 2.60 (1.19-5.72) .017 noncompliance with the maintenance bundle may have a cumulative
Three-lumen catheter 1.28 (0.79-2.08) .322 effect larger than that of noncompliance with the insertion bundle.
Duration of catheterization 1.04 (1.02-1.06) .001 We assessed compliance rates by a direct observation, noncovert
Insertion in the ward 1.71 (0.77-3.81) .190 audit. It is possible that our audit results do not reflect actual practice.
Insertion in the dialysis unit 2.14 (0.63-7.21) .221
ICU 1.31 (0.73-2.34) .370
First, we have observed only 153 of the 913 CVC insertions (16.8%),
and second because of the so-called Hawthorne effect. There are
CI, confidence interval; ICU, intensive care unit.
studies on hand hygiene compliance suggesting that the Hawthorne
effect might lead to significantly inflated compliance rates and this
lowest in the European Union (344 per 100,000 population in 2014 might be the case in our study too.18 In addition, the violations of the
compared with an European Union average of 864).11 Although bun- insertion bundle were not recorded, except in the context of the com-
dle compliance in our hospital increased after the intervention, it was pliance audit (discussed earlier). This is an important limitation in our
still relatively low. In the systematic review of CVC care bundles in study, as we cannot fully explain our findings.
critically ill patients by Ista et al,8 the majority of the included studies Our study had relatively short duration, so that there was not ade-
reported a preintervention bundle compliance that was at least com- quate time for the intervention to be incorporated into everyday
parable to our POST phase levels. There is not an established critical practice, as this might take long.15,19
 A. Karapanou et al. / American Journal of Infection Control 48 (2020) 770−776 775

Fig 2. Compliance with individual elements and overall bundle compliance for the CVC insertion (upper panel) and the CVC maintenance bundle (lower panel) before (PRE) and
after (POST) the intervention. CVC, central venous catheter; PPE, personal protective equipment.

Understaffing may have played a role in our results. We do not
have accurate data regarding the nurse staffing per department during
our study, however, we have already discussed the influence of under-
staffing on the study procedures, and in addition there is evidence that
the level of nurse staffing may affect CLABSI rates in surgical ICUs.20
significantly reduce CLABSI rates. We suggest that care bundles are
more than checklists of actions, and their success is, at least in part,
context-dependent. Requirements in terms of organizational cul-
ture and staffing are probably critical to successful care bundle
implementation.

CONCLUSIONS
References
In our setting, which is characterized by high CLABSI rates, high
1. European Centre for Disease Prevention and Control. Point prevalence survey of
bed occupancy rates, understaffing, and a hierarchical organiza- healthcare-associated infections and antimicrobial use in European acute care hos-
tional culture, implementation of CVC care bundles failed to pitals 2011-12. Stockholm: ECDC; 2013.
776 A. Karapanou et al. / American Journal of Infection Control 48 (2020) 770−776
2. Ziegler MJ, Pellegrini DC, Safdar N. Attributable mortality of central line associated
bloodstream infection: systematic review and meta-analysis. Infection 2015;43:29-36.
3. Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, et al. Health care-
associated infections: a meta-analysis of costs and financial impact on the US
health care system. JAMA Intern Med 2013;173:2039-46.
4. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating
the proportion of healthcare-associated infections that are reasonably preventable
and the related mortality and costs. Infect Control Hosp Epidemiol 2011;32:101-14.
5. Making health care safer: reducing bloodstream infections. CDC Vital Signs 2011,
Available from: https://www.cdc.gov/vitalsigns/pdf/2011-03-vitalsigns.pdf.
Accessed April 20, 2019.
6. Bell T, O’Grady NP. Prevention of central line-associated bloodstream infections.
Infect Dis Clin North Am 2017;31:551-9.
Tag edP 7. Institute for Healthcare Improvement. What is a bundle? Available from: http://
www.ihi.org/knowledge/Pages/ImprovementStories/WhatIsaBundle.aspx.
Accessed April 20, 2019.
8. Ista E, van der Hoven B, Kornelisse RF, van der Starre C, Vos MC, Boersma E, et al.
Effectiveness of insertion and maintenance bundles to prevent central-line-associ-
ated bloodstream infections in critically ill patients of all ages: a systematic review
and meta-analysis. Lancet Infect Dis 2016;16:724-34.
9. Speroff T, Ely EW, Greevy R, Weinger MB, Talbot TR, Wall RJ, et al. Quality
improvement projects targeting health care-associated infections: comparing vir-
tual collaborative and toolkit approaches. J Hosp Med 2011;6:271-8.
10. Rhee Y, Heung M, Chen B, Chenoweth CE. Central line-associated bloodstream
infections in non-ICU inpatient wards: a 2-year analysis. Infect Control Hosp Epi-
demiol 2015;36:424-30.
11. Economou C, Kaitelidou D, Karanikolos M, Maresso A. Greece: health system
review. Health Syst Transit 2017;19:1-166.
12. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-
associated infection and criteria for specific types of infections in the acute care
setting. Am J Infect Control 2008;36:309-32.
13. Greek Center for Disease Prevention and Control. Care bundles for the prevention
of central line associated bloodstream infections. Athens: KEELPNO; 2014.
14. Lee KH, Cho NH, Jeong SJ, Kim MN, Han SH, Song YG. Effect of central line bundle
compliance on central line-associated bloodstream infections. Yonsei Med J
2018;59:376-82.
15. Apisarnthanarak A, Thongphubeth K, Yuekyen C, Warren DK, Fraser VJ. Effective-
ness of a catheter-associated bloodstream infection bundle in a Thai tertiary care
center: a 3-year study. Am J Infect Control 2010;38:449-55.
16. Joint Commission. Preventing central line−associated bloodstream infections: a
global challenge, a global perspective. Oak Brook (IL): Joint Commission; 2012.
17. Sypsa V, Psichogiou M, Bouzala GA, Hadjihannas L, Hatzakis A, Daikos GL. Transmis-
sion dynamics of carbapenemase-producing Klebsiella pneumoniae and anticipated
impact of infection control strategies in a surgical unit. PLoS One 2012;7:e41068.
18. McLaws ML, Kwok YLA. Hand hygiene compliance rates: fact or fiction? Am J Infect
Control 2018;46:876-80.
19. Duane TM, Brown H, Borchers CT, Wolfe LG, Malhotra AK, Aboutanos MB, et al. A
central venous line protocol decreases bloodstream infections and length of stay
in a trauma intensive care unit population. Am Surg 2009;75:1166-70.
20. Fridkin SK, Pear SM, Williamson TH, Galgiani JN, Jarvis WR. The role of understaff-
ing in central venous catheter-associated bloodstream infections. Infect Control
Hosp Epidemiol 1996;17:150-8.