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Case Study


Eliminating Central Line Infections and Spreading Success at High-Performing Hospitals

One of the most common types of health care–associated infections is the central line–associated bloodstream infection (CLABSI), which can result when a central venous catheter is not inserted or maintained properly. About 43,000 CLABSIs occurred in hospitals in 2009; nearly one of five infected patients died as a result. This report synthesizes lessons from four hospitals that reported they did not experience any CLABSIs in their intensive care units in 2009. Lessons include: the importance of following evidence-based protocols to prevent infection; the need for dedicated teams to oversee all central line insertions; the value of participation in statewide, national, or regional CLABSI collaboratives or initiatives; and the necessity for close monitoring of infection rates, giving feedback to staff, and applying internal and external goals. The report also presents ways these hospitals are spreading prevention techniques to non-ICU units, and strategies for preventing other health care–associated infections.

Read the case studies from the four hospitals—Bronson Methodist Hospital of Kalamazoo, Mich.; Englewood Hospital and Medical Center of Englewood, New Jersey; Presbyterian Intercommunity Hospital of Whittier, Calif.; and Southern Ohio Medical Center of Portsmouth, Ohio. You can also view comparative performance data for these and other hospitals on

This case studies series was created for . The goal of is to foster health care quality improvement by promoting transparency and public reporting, and by providing tools and case studies of top performers to aid organizations in their own improvement efforts.



Publication Details



S. Silow-Carroll, and J. N. Edwards, Eliminating Central Line Infections and Spreading Success at High-Performing Hospitals, The Commonwealth Fund, December 2011.