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Use of Implementation Science for a Sustained Reduction of Central-Line–Associated Bloodstream Infections in a High-Volume, Regional Burn Unit

  • Geeta Sood (a1), Julie Caffrey (a2), Kelly Krout (a3), Zeina Khouri-Stevens (a4), Kevin Gerold (a5), Stefan Riedel (a1) (a6), Janet McIntyre (a3), Lisa L. Maragakis (a1) (a7), Renee Blanding (a8), Jonathan Zenilman (a1), Richard Bennett (a9) and Peter Pronovost (a10)...

We describe the use of implementation science at the unit level and organizational level to guide an intervention to reduce central-line–associated bloodstream infections (CLABSIs) in a high-volume, regional, burn intensive care unit (BICU).


A single center observational quasi-experimental study.


A regional BICU in Maryland serving 300–400 burn patients annually.


In 2011, an organizational-level and unit-level intervention was implemented to reduce the rates of CLABSI in a high-risk patient population in the BICU. At the organization level, leaders declared a goal of zero infections, created an infrastructure to support improvement efforts by creating a coordinating team, and engaged bedside staff. Performance data were transparently shared. At the unit level, the Comprehensive Unit-based Safety Program (CUSP)/ Translating Research Into Practice (TRIP) model was used. A series of interventions were implemented: development of new blood culture procurement criteria, implementation of chlorhexidine bathing and chlorhexidine dressings, use of alcohol impregnated caps, routine performance of root-cause analysis with executive engagement, and routine central venous catheter changes.


The use of an implementation science framework to guide multiple interventions resulted in the reduction of CLABSI rates from 15.5 per 1,000 central-line days to zero with a sustained rate of zero CLABSIs over 3 years (rate difference, 15.5; 95% confidence interval, 8.54–22.48).


CLABSIs in high-risk units may be preventable with the a use a structured organizational and unit-level paradigm.

Infect Control Hosp Epidemiol 2017;38:1306–1311

Corresponding author
Address correspondence to Geeta Sood, MD, Division of Infectious Diseases, Mason F. Lord Building, Center Tower, 3rd Floor, Johns Hopkins Bayview Medical Center, 5200 Eastern Avenue, Baltimore, MD, 21224 (
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1. 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.
2. Januel, JM, Harbarth, S, Allard, R, et al. Estimating attributable mortality due to nosocomial infections acquired in intensive care units. Infect Control Hosp Epidemiol 2010;31:388394.
3. Pronovost, PJ, Cleeman, JI, Wright, D, Srinivasan, A. Fifteen years after To Err is Human: a success story to learn from. BMJ Qual Saf 2016;25:396399.
4. Dudeck, MA, Edwards, JR, Allen-Bridson, K, et al. National Healthcare Safety Network report, data summary for 2013, Device-associated module. Am J Infect Control 2015;43:206221.
5. O’Sullivan, ST, O’Connor, TP. Immunosuppression following thermal injury: the pathogenesis of immunodysfunction. Br J Plast Surg 1997;50:615623.
6. Brusselaers, N, Monstrey, S, Snoeij, T, et al. Morbidity and mortality of bloodstream infections in patients with severe burn injury. Am J Crit Care 2010;19:e81e87.
7. Shupp, JW, Pavlovich, AR, Jeng, JC, et al. Epidemiology of bloodstream infections in burn-injured patients: a review of the national burn repository. J Burn Care Res 2010;31:521528.
8. Bang, RL, Gang, RK, Sanyal, SC, Mokaddas, E, Ebrahim, MK. Burn septicaemia: an analysis of 79 patients. Burns 1998;24:354361.
9. Lee, HG, Jang, J, Choi, JE, et al. Blood stream infections in patients in the burn intensive care unit. Infect Chemother 2013;45:194201.
10. Lesseva, M. Central venous catheter-related bacteraemia in burn patients. Scand J Infect Dis 1998;30:585589.
11. Raz-Pasteur, A, Hussein, K, Finkelstein, R, Ullmann, Y, Egozi, D. Blood stream infections (BSI) in severe burn patients—early and late BSI: a 9-year study. Burns 2013;39:636642.
12. Santucci, SG, Gobara, S, Santos, CR, Fontana, C, Levin, AS. Infections in a burn intensive care unit: experience of seven years. J Hosp Infect 2003;53:613.
13. Mason, AD, McManus, AT, Pruitt, BA. Association of burn mortality and bacteremia. A 25-year review. Arch Surg 1986;121:10271031.
14. Appelgren, P, Björnhagen, V, Bragderyd, K, Jonsson, CE, Ransjö, U. A prospective study of infections in burn patients. Burns 2002;28:3946.
15. Patel, BM, Paratz, JD, Mallet, A, et al. Characteristics of bloodstream infections in burn patients: an 11-year retrospective study. Burns 2012;38:685690.
16. Wurtz, R, Karajovic, M, Dacumos, E, Jovanovic, B, Hanumadass, M. Nosocomial infections in a burn intensive care unit. Burns 1995;21:181184.
17. Sood, G, Heath, D, Adams, K, et al. Survey of central line-associated bloodstream infection prevention practices across american burn association-certified adult burn units. Infect Control Hosp Epidemiol 2013;34:439440.
18. Pronovost, PJ, Weaver, SJ, Berenholtz, SM, et al. Reducing preventable harm: observations on minimizing bloodstream infections. J Health Organ Manag 2017;31:29.
19. Pronovost, P, Needham, D, Berenholtz, S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:27252732.
20. Pronovost, PJ, Berenholtz, SM, Needham, DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ 2008;337:a1714.
21. Greenhalgh, DG, Saffle, JR, Holmes, JHt, et al. American Burn Association consensus conference to define sepsis and infection in burns. J Burn Care Res 2007;28:776790.
22. Hogan, BK, Wolf, SE, Hospenthal, DR, et al. Correlation of American Burn Association sepsis criteria with the presence of bacteremia in burned patients admitted to the intensive care unit. J Burn Care Res 2012;33:371378.
23. Murray, CK, Hoffmaster, RM, Schmit, DR, et al. Evaluation of white blood cell count, neutrophil percentage, and elevated temperature as predictors of bloodstream infection in burn patients. Arch Surg 2007;142:639642.
24. Vindenes, H, Bjerknes, R. The frequency of bacteremia and fungemia following wound cleaning and excision in patients with large burns. J Trauma 1993;35:742749.
25. Beard, CH, Ribeiro, CD, Jones, DM. The bacteraemia associated with burns surgery. Br J Surg 1975;62:638641.
26. Petersen, SR, Umphred, E, Warden, GD. The incidence of bacteremia following burn wound excision. J Trauma 1982;22:274279.
27. Mamattah, HJ, Beard, CH, Jones, DM. Bacteremia in the burned patient. J Clin Pathol 1973;26:388389.
28. Keen, A, Knoblock, L, Edelman, L, Saffle, J. Effective limitation of blood culture use in the burn unit. J Burn Care Rehabil 2002;23:183189.
29. Wright, MO, Tropp, J, Schora, DM, et al. Continuous passive disinfection of catheter hubs prevents contamination and bloodstream infection. Am J Infect Control 2013;41:3338.
30. Oto, J, Imanaka, H, Konno, M, Nakataki, E, Nishimura, M. A prospective clinical trial on prevention of catheter contamination using the hub protection cap for needleless injection device. Am J Infect Control 2011;39:309313.
31. Timsit, JF, Mimoz, O, Mourvillier, B, et al. Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults. Am J Respir Crit Care Med 2012;186:12721278.
32. Eyer, S, Brummitt, C, Crossley, K, Siegel, R, Cerra, F. Catheter-related sepsis: prospective, randomized study of three methods of long-term catheter maintenance. Crit Care Med 1990;18:10731079.
33. Cobb, DK, High, KP, Sawyer, RG, et al. A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters. N Engl J Med 1992;327:10621068.
34. Cook, D, Randolph, A, Kernerman, P, et al. Central venous catheter replacement strategies: a systematic review of the literature. Crit Care Med 1997;25:14171424.
35. Sheridan, RL, Neely, AN, Castillo, MA, et al. A survey of invasive catheter practices in US burn centers. J Burn Care Res 2012;33:741746.
36. Maki, DG, Kluger, DM, Crnich, CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc 2006;81:11591171.
37. Popp, JA, Layon, AJ, Nappo, R, Richards, WT, Mozingo, DW. Hospital-acquired infections and thermally injured patients: chlorhexidine gluconate baths work. Am J Infect Control 2014;42:129132.
38. van Duin, D, Jones, SW, Dibiase, L, et al. Reduction in central line-associated bloodstream infections in patients with burns. Infect Control Hosp Epidemiol 2014;35:10661068.
39. Marshall, M, Pronovost, P, Dixon-Woods, M. Promotion of improvement as a science. Lancet 2013;381:419421.
40. Pronovost, PJ, Sutcliffe, KM, Basu, L, Dixon-Woods, M. Change the story, change the results. Bull WHO 2017;95:478480.
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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
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