Table 2 Overview of CLABSI program timeline and outcome results

2015

Hospital joined safety network, formed steering committee, attended network education sessions, and conducted extensive corporate communications regarding initiative.

CLABSI outcome data submission to network initiated (ICUs only)

2016

CLABSI education and unit-based auditing initiated (three ICUs only), began collection of outcomes data by unit.

Performance relative to external comparators and change in outcomes over time was variable across ICUs

2017

CLABSI education and unit-based auditing spread hospital-wide. Outcome data available for all units.

Performance relative to comparators and change over time was variable among units (Pediatric ICU, Neonatal ICU, and Cardiac ICU, general medical, surgical, and specialty units)

2018

Hospital-wide 1 year 10% non-MBI CLABSI reduction goal, and three-year 30% HAC reduction goal (including CLABSI) established.

New central HAC audit team created to increase audit reliability hospital-wide. Audits performed by both central team and unit-based leaders.

CLABSI oversight committee created and leadership rounding initiated.

Hospital level goals not achieved (variable changes in outcomes across units)

2019

Expanded hospital CLABSI committees to include additional CLABSI physician group, passive disinfecting caps implemented, mandatory unit-leadership Aseptic Non-Touch Technique (ANTT) sessions completed and ANTT e-learning module delivered to all unit-based nurses.

Hospital-wide 10% non-MBI CLABSI reduction goal exceeded

2020

Continued 2019 interventions and spread of in-person, unit-based ANTT education sessions.

Sustained rate of improvement, resulting in a 30% reduction in total CLABSI hospital-wide (using statistical process control, centreline shifted from 1.9 to 1.3 CLABSI per 1000 line days)