Study Design Interdisciplinary approach

We assembled an interdisciplinary team comprising a lead general surgeon, an infectious disease specialist, an anesthetist, a continuous quality improvement (CQI) expert, and all frontline staff (Fig. 1A). The team aimed to develop a systematic flowchart and checklist for measuring catheter utilization and understanding how this data could guide ongoing improvement efforts to minimize CR-BSIs. The process of catheter utilization encompassed assessment of indications, insertion, maintenance, and removal. Based on published literature on CR-BSIs, the team compiled a list of potential risk factors, categorizing them based on whether they are associated with insertion, routine maintenance, or removal (Fig. 1B). In our general surgery ward, junior staff were responsible for catheter insertion, while nurses of various levels handled maintenance. Recognizing catheter utilization as an area where effective improvements could be measured, the team focused on enhancing the process of insertion, maintenance, and removal.

Fig. 1

Strategies for CQI. A. Formation of an interdisciplinary team. The interdisciplinary team consists of a general surgery leader, an infectious disease specialist, an anesthesiologist, frontline staff, and a CQI expert B. Identification of risk factors for catheter insertion, routine maintenance, and removal. The team compiled a list of risk factors associated with catheter usage by reviewing relevant literature on CR-BSI C. System process map for catheter use. We developed a comprehensive process map to measure real-time catheter use and CQI. Routine Extraction/Removal: This is performed when treatment is no longer needed or when the catheter has expired. Non-routine Extraction/Removal: This is performed due to suspected infection, catheter-related complications, or catheter damage

Formation of the insertion team

A dedicated CVC insertion team was established, comprising senior anesthetists, junior anesthetists, and interns. Catheter insertions were performed only when hemodynamic changes were deemed necessary, such as in cases of surgery, severe trauma, shock, and acute circulatory failure, or when required for high nutritional therapy or intravenous antibiotic treatment. The expertise of senior anesthetists, their understanding of infection prevention, and their strict adherence to standardized checklists significantly bolstered the team’s capabilities. It has been documented that inexperienced healthcare providers elevate the risk of infection during catheter insertion [10]. Therefore, anesthetists conducted catheter insertions in the operating room or vascular access room, following aseptic procedures and under appropriate supervision. In addition to developing the innovative checklist, senior anesthetists also provided the scientific rationale underpinning the recommended actions.

The effectiveness of CQI in various healthcare settings inspired us to adopt a similar approach. CQI focuses on addressing iterative challenges faced by frontline staff, guided by real-time process measurements to make informed decisions. Through systematic measurement of crucial procedures impacting clinical outcomes, CQI empowers teams to optimize enhancement endeavors and maintain progress [12,13,14]. Infection control practitioners closely monitored both the quality of catheter insertions (inputs) and the occurrences of CR-BSI (outputs). Before implementing CQI, we developed a systematic flowchart and checklist to monitor the utilization of catheters in real time (Fig. 1C and Supplementary file 1).

We chose the FOCUS-PDCA model for CQI to analyze and enhance our procedures. This model, developed by Hospital Corporation of America (HCA), has proven to be an effective strategy for performance improvement [15]. It has been successfully employed in various medical specialties, including nursing, laboratory science, trauma care, and surgical procedures. The acronym “FOCUS-PDCA” represents a methodology centered on identifying a process for improvement, assembling a knowledgeable team, clarifying the existing understanding of the process, understanding the reasons for change, and selecting a strategy to initiate the PDCA cycle. The PDCA cycle, also known as the Deming cycle, signifies an iterative quality improvement process that includes four stages: plan and make improvements, evaluate the outcomes, take action, and sustain the gains [15, 16].

The fishbone diagram, originally a component of quality assurance plans in the manufacturing sector, has found extensive application as a healthcare safety tool for conducting root cause analysis of system errors in medical facilities and other healthcare settings [17, 18]. This diagram aids in categorizing complex medical errors into distinct groups, with the visual representation of interconnected categories in the fishbone structure revealing potential areas for improvement (Fig. 2).

Fig. 2

Fishbone Diagram of the Comprehensive Evaluation Framework for CR-BSI. The fishbone diagram represents the potential causes of CR-BSI, encompassing the categories of environment, materials, personnel, and/or practice protocols

We delineate the process of improving catheter utilization, which involves assembling a multidisciplinary team, gaining insights from existing literature on catheter utilization, identifying infection causes using the fishbone diagram, choosing a process management strategy, planning and making improvements based on the checklist, conducting measurement checks, and taking action to maintain and sustain the improvements.

Intervention measure 1: Formation of the maintenance team

We established a CVC maintenance team, which included nursing management, nursing personnel, and infection control staff. Nursing leadership played a pivotal role in strengthening the team by adhering to a comprehensive checklist, leveraging their expertise in preventing bloodstream infections, and facilitating initial team discussions. Regular meetings were held by the maintenance team to strategize and implement effective measures. All members of the nursing team acknowledged the challenge of reducing infection rates among general surgery patients. A group of experienced nurses collaborated closely with the team to incorporate catheter maintenance into health education programs, with the goal of minimizing variations in nursing practices and strategies. To ensure consistency and adherence to best practices, a dedicated surgical nurse documented all action items and took responsibility for the daily catheter maintenance tasks. Strict guidelines were followed for catheter removal in cases of occlusion, phlebitis, local/bloodstream infection, uncontrollable bleeding, or discontinuation of specific medications.

Intervention measure 2: Catheter insertion practices

Inserters are required to strictly adhere to standard insertion site protocols and rigorously follow all infection-reduction procedures, even in life-threatening situations, within the emergency care unit, intensive care unit (ICU), or operating room.

Intervention measure 3: Hand Hygiene and sterile gloves

Ensuring proper hand hygiene and employing sterile gloves before catheter insertion contribute to the reduction of CR-BSIs. Acknowledging the efficacy of hand sanitizers for hand disinfection compared to soap and water, we endorse the practice of proper hand hygiene and the use of sterile gloves.

Intervention measure 4: Chlorhexidine skin preparation

Effective skin disinfection at the puncture site plays a pivotal role in infection reduction. Notably, chlorhexidine skin preparation has demonstrated superior efficacy in reducing CR-BSIs compared to povidone-iodine and/or alcohol. Even in cases where alternative disinfectants are employed, we recognize the significance of considering chlorhexidine.

Intervention measure 5: Maximum sterile barriers

Numerous studies emphasize the critical role of maximum sterile barriers (gloves, gowns, masks, and patient drapes) in preventing infections during catheter insertion, maintenance, and removal [19, 20]. Our checklist records individual barriers used or neglected throughout the intervention. In our context, “maximum” denotes the comprehensive utilization of all four protective barriers.

Intervention measure 6: Dressings

Transparent dressings are scheduled for replacement every 7 days, whereas gauze dressings are changed every 3 days. Dressings should be promptly replaced if they become soiled, wet, loose, or bloodstained, if the date of last change is unknown, or if any other signs indicating susceptibility to infection are observed. Additionally, it is recommended to perform chlorhexidine skin preparation when changing dressings.

Intervention measure 7: Standardized practices

Our approach to CR-BSI prevention involves meticulous standardization at every stage of catheter management. (1) Catheter insertion preparation: Rigorous hand hygiene, maximum sterile barriers, chlorhexidine skin preparation, and maintaining a sterile procedural environment are ensured. During catheter insertion, surgical site disinfection measures, involving the use of 2% chlorhexidine for cleansing and placement of sterile drapes, are consistently applied. A thin sterile adhesive dressing is then applied to protect the insertion site. (2) Catheter maintenance: This phase includes hand hygiene, regular dressing changes, authorized injection caps usage, access site cleaning, and overall line care. Competency standards for catheter dressing changes are collaboratively established by nursing administration and general surgery nursing practitioners. Regular meetings led by infectious disease physicians identify areas for improvement or negligence in CR-BSI cases with severe consequences. (3) Nursing staff training: Group and subsequent team-led small-group demonstrations of daily catheter maintenance procedures and dressing changes ensure uniform practices. Continuous education minimizes practice variations among staff. (4) Pre-intervention chart reviews: Chart reviews identify compliance gaps in daily bathing or showering provision and recording, rectified through targeted education for nursing personnel and patients. Hospital wards prominently display posters emphasizing the importance of CR-BSI prevention. (5) Catheter removal preparation and procedure: Stringent protocols, including hand hygiene, chlorhexidine skin preparation, and a sterile procedural environment, are followed. The same surgical disinfection measures are implemented during catheter removal, and the insertion site is secured with a sterile dressing. Principles from patient safety to reinforce nurses’ adherence to CDC guidelines [21].

Data collection and analysis

CR-BSI diagnosis was conducted according to well-recognized standards, which included culturing a 5-cm segment of the catheter tip and peripheral venous blood [2]. Data collection commenced in the first quarter (Q1) of 2015 and concluded in Q1 of 2017. Electronic medical records (EMR) were utilized to assess the CR-BSI incidence rate and document catheter insertion and daily maintenance. Pre-intervention data were gathered in Q1 of 2015, involving a retrospective review of CR-BSI rates for each quarter from Q1 2015 to Q1 2016. Post-intervention data were gathered quarterly, spanning CR-BSI rates from Q2 2016 to Q1 2017 for each respective quarter. Statistical significance was determined using unpaired Student’s t-tests or proportion tests, with differences considered significant for P-value < 0.05. The analysis was conducted using the SPSS software (version 11.0). No instances of data duplication were detected.