Skip to main content Accessibility help

An Economic Analysis of Adherence Engineering to Improve Use of Best Practices During Central Line Maintenance Procedures

  • Richard E. Nelson (a1) (a2), Aaron W. Angelovic (a1), Scott D. Nelson (a1) (a3), Jeremy R. Gleed (a1) and Frank A. Drews (a4)...



Adherence engineering applies human factors principles to examine non-adherence within a specific task and to guide the development of materials or equipment to increase protocol adherence and reduce human error. Central line maintenance (CLM) for intensive care unit (ICU) patients is a task through which error or non-adherence to protocols can cause central line-associated bloodstream infections (CLABSIs). We conducted an economic analysis of an adherence engineering CLM kit designed to improve the CLM task and reduce the risk of CLABSI.


We constructed a Markov model to compare the cost-effectiveness of the CLM kit, which contains each of the 27 items necessary for performing the CLM procedure, compared with the standard care procedure for CLM, in which each item for dressing maintenance is gathered separately. We estimated the model using the cost of CLABSI overall ($45,685) as well as the excess LOS (6.9 excess ICU days, 3.5 excess general ward days).


Assuming the CLM kit reduces the risk of CLABSI by 100% and 50%, this strategy was less costly (cost savings between $306 and $860) and more effective (between 0.05 and 0.13 more quality-adjusted life-years) compared with not using the pre-packaged kit. We identified threshold values for the effectiveness of the kit in reducing CLABSI for which the kit strategy was no longer less costly.


An adherence engineering–based intervention to streamline the CLM process can improve patient outcomes and lower costs. Patient safety can be improved by adopting new approaches that are based on human factors principles.

Infect Control Hosp Epidemiol 2015;00(0): 1–7


Corresponding author

Address all correspondence to Richard E. Nelson, PhD, 500 Foothill Blvd, Salt Lake City, UT 84148 (


Hide All
1. Sax, H, Uckay, I, Richet, H, Allegranzi, B, Pittet, D. Determinants of good adherence to hand hygiene among healthcare workers who have extensive exposure to hand hygiene campaigns. Infect Control Hosp Epidemiol 2007;28:12671274.
2. Drews, FA. Adherence engineering: a new approach to increasing adherence to protocols. Ergonomics in Design 2013;21:1925.
3. Berwick, DM. Disseminating innovations in health care. JAMA 2003;289:19691975.
4. McGlynn, EA, Asch, SM, Adams, J, et al. The quality of health care delivered to adults in the United States. New Engl J Med 2003;348:26352645.
5. Klevens, RM, Edwards, JR, Richards, CL Jr., et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep 2007;122:160166.
6. Richards, MJ, Edwards, JR, Culver, DH, Gaynes, RP. Nosocomial infections in combined medical-surgical intensive care units in the United States. Infect Control Hosp Epidemiol 2000;21:510515.
7. Laupland, KB, Lee, H, Gregson, DB, Manns, BJ. Cost of intensive care unit-acquired bloodstream infections. J Hosp Infect 2006;63:124132.
8. Mermel, LA. Prevention of intravascular catheter-related infections. Ann Intern Med 7 2000;132:391402.
9. O’Grady, NP, Alexander, M, Dellinger, EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Infect Control Hosp Epidemiol 2002;23:759769.
10. DeLucia, PR, Ott, T, Palmieri, P. Performance in nursing. Rev Human Factor 2009;5:140.
11. Parker, J, Coiera, E. Improving clinical communication: a view from psychology. J Am Med Inform Assoc 2000;7:453461.
12. Drews, FA, Musters, A, Samore, M. Error producing conditions in the intensive care unit. Advances in patient safety: from research to implementation. Vol 5. Rockville, MD: Agency for Healthcare Research and Quality; 2008.
13. Krueger, G. Sustained work, fatigue, sleep loss and performance: a review of the issues. Work & Stress 1989;3:129141.
14. Grundgeiger, T, Sanderson, P. Interruptions in healthcare: theoretical views. Int J Med Inform 2009;78:293307.
15. Grundgeiger, T, Sanderson, P, MacDougall, HG, Venkatesh, B. Interruption management in the intensive care unit: predicting resumption times and assessing distributed support. J Exp Psychol Appl 2010;16:317334.
16. Drews, FA, Bakdash, JZ, Mallin, BM. Adherence engineering: increasing adherence for central line maintenance procedures. 2014 (under review).
17. Galpern, D, Guerrero, A, Tu, A, Fahoum, B, Wise, L. Effectiveness of a central line bundle campaign on line-associated infections in the intensive care unit. Surgery 2008;144:492495.
18. Zimlichman, E, Henderson, D, Tamir, O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med 2013;173:20392046.
19. Angus, DC, Linde-Zwirble, WT, Sirio, CA, et al. The effect of managed care on ICU length of stay: implications for medicare. JAMA 1996;276:10751082.
20. Wu, AW, Pronovost, P, Morlock, L. ICU incident reporting systems. J Crit Care Jun 2002;17:8694.
21. Young, MP, Birkmeyer, JD. Potential reduction in mortality rates using an intensivist model to manage intensive care units. Eff Clin Pract 2000;3:284289.
22. Hall, MJ, Levant, S, DeFrances, CJ. Trends in inpatient hospital deaths: National Hospital Discharge Survey, 2000–2010. NCHS Data Brief, no 118. Hyattsville, MD: National Center for Health Statistics. 2013.
23. Stevens, V, Geiger, K, Concannon, C, Nelson, RE, Brown, J, Dumyati, G. Inpatient costs, mortality and 30-day re-admission in patients with central-line-associated bloodstream infections. Clin Microbiol Infect 2014;20:O318O324.
24. Halton, KA, Cook, DA, Whitby, M, Paterson, DL, Graves, N. Cost effectiveness of antimicrobial catheters in the intensive care unit: addressing uncertainty in the decision. Crit Care 2009;13:R35.
25. Gold, MR, Franks, P, McCoy, KI, Fryback, DG. Toward consistency in cost-utility analyses: using national measures to create condition-specific values. Med Care 1998;36:778792.
26. Brouwer, W, Rutten, FFH, Koopmanschap, M. Costing in economic evaluations. In: Drummond M, McGuire A, eds. Economic evaluation in health care: merging theory with practice. New York, NY: Oxford University Press; 2001.
27. Graves, N, Harbarth, S, Beyersmann, J, Barnett, A, Halton, K, Cooper, B. Estimating the cost of health care-associated infections: mind your p's and q's. Clin Infect Dis 2010;50:10171021.
28. Cooper, K, Frampton, G, Harris, P, et al. Are educational interventions to prevent catheter-related bloodstream infections in intensive care unit cost-effective? J Hosp Infect 2014;86:4752.
29. Ye, X, Rupnow, M, Bastide, P, Lafuma, A, Ovington, L, Jarvis, WR. Economic impact of use of chlorhexidine-impregnated sponge dressing for prevention of central line-associated infections in the United States. Am J Infect Control 2011;39:647654.
30. Stone, PW, Pogorzelska-Maziarz, M, Herzig, CT, et al. State of infection prevention in US hospitals enrolled in the National Health and Safety Network. Am J Infect Control 2014;42:9499.
31. Furuya, EY, Dick, A, Perencevich, EN, Pogorzelska, M, Goldmann, D, Stone, PW. Central line bundle implementation in US intensive care units and impact on bloodstream infections. PloS One 2011;6:e15452.
32. Pogorzelska, M, Stone, PW, Furuya, EY, et al. Impact of the ventilator bundle on ventilator-associated pneumonia in intensive care unit. Int J Qual Health Care 2011;23:538544.
33. Drews, FA. Human Error. In: Carayon P, ed. Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 2011.
34. Stevens, V, Geiger, K, Concannon, C, Nelson, RE, Brown, J, Dumyati, G. Inpatient costs, mortality and 3-day re-admission in patients with central-line-associated bloodstream infections. Clin Microbiol Infect 2014;20:318324.
35. Halton, KA, Cook, DA, Whitby, M, Paterson, DL, Graves, N. Cost effectiveness of antimicrobial catheters in the intensive care unit: addressing uncertainty in the decision. Crit Care 2009;13:R35.


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed