Discussion

In this nationally representative survey of infection preventionists performed following the delta wave of COVID-19, several insights emerged. First, we observed that many of the technical practices known to reduce rates of CLABSI remained in high use at most hospitals. ^{Reference Saint, Greene and Krein15} In view of the pandemic and disruption to healthcare delivery, infection prevention and patient safety—this is good news. However, gaps in some evidence-based practices which are known to reduce the risk of CLABSI—such as chlorhexidine bathing—were observed. Second, when querying behavioral aspects aimed to prevent CLABSI, we found several additional gaps including lack of routine feedback of infection rates to inserters of devices. Even fewer respondents indicated that appropriateness criteria or decision aids were in use before placing central access. Finally, although the perceived importance of CLABSI to leadership was rated as high by respondents, gaps in the form of staff shortages and lack of basic equipment emerged as opportunities for improvement. Collectively, these findings suggest that use of several behavioral practices for preventing this important infection remained suboptimal during the COVID-19 pandemic.

In 2022, the recommendations for strategies used to prevent CLABSI in the acute care hospital setting were updated. ^{Reference Buetti, Marschall and Drees3} The literature search supporting the recommendation update spanned from January 2012 through August 2021. As such, the evidence supporting the specific CLABSI prevention practices was temporally aligned with when our infection prevention surveys were distributed in 2021. A key change to the update was reclassifying various practices from “basic” to “essential” (practices which should be adopted by all hospitals) and “special” to “additional” (practices to be considered when CLABSI is not controlled after implementing essential practices). Our findings suggest that nearly all hospitals are implementing practices classified as essential with high strength of evidence supporting their use. For example, we found high reported use of antiseptic dressings with chlorhexidine—a practice previously listed as a special approach that became an essential practice in the 2022 update. Cross-sectional data from Saint et al. suggest that use of BIOPATCH® has steadily increased from approximately 78% in 2013 to nearly 92% in 2021. ^{Reference Saint, Greene and Krein15}

Technical innovations to prevent CLABSI such as use of alcohol-containing CHG offer relatively easy solutions to prevent these types of infections. Indeed, some have argued that they may be the most important component in reducing infection rates. ^{Reference Chopra and Shojania16} Results of this survey suggest that these practices remained in use across most of the sites surveyed. Despite the high utilization of dressings containing CHG, the practice of daily CHG bathing in critically ill patients is less prevalent, even though it is an essential practice supported by strong evidence showing its effectiveness and efficacy in reducing CLABSI. ^{Reference Frost, Alogso and Metcalfe17} In addition, use of some technical practices with mixed evidence (eg, advanced securement devices and cyanoacrylate glue) were reported. ^{Reference Timsit, Baleine and Bernard18,Reference Machin, Liu, Coupland, Davies and Thapar19} One way to consolidate these findings in the context of COVID-19 is to consider the diffusion of these practices through the lens of provider burden. Chlorhexidine bathing, while effective, requires substantial nursing time and patient cooperation. ^{Reference Destine, Capes and Reynolds20,Reference Reynolds, Woltz and Keating21} Even in times where staffing shortages were not a concern, compliance has remained suboptimal. ^{Reference Reynolds, Granger and Hatch22} In contrast, technical interventions such as use of antibiotic impregnated or antiseptic coated catheters or using more advanced securement may be associated with a higher cost but are less time-intensive than behavioral strategies. Another essential practice that requires a behavioral intervention is the use of standard processes to determine the appropriateness of central line placement prior to insertion. However, only half of the respondents reported implementing this practice. It is therefore conceivable that there is a trend toward a pragmatic, albeit misguided over-reliance on technical aspects to prevent CLABSI.

Signals supporting the assertion that technical aspects may have overshadowed what is needed from harder to achieve behavioral changes are also present when examining use of appropriateness criteria or feedback of infection rates to providers. Although these elements are known to be effective at reducing rates of infectious and non-infectious complications from catheters, they require active engagement and human interaction to be successful. The best example of this paradigm is demonstrated by the fact that only a quarter of all respondents indicated that they had implemented practices to limit collection of routine blood cultures. The practice of “pan-culturing” that is heavily ingrained in many providers is known to contribute to high rates of CLABSI, ^{Reference Fakih and Khatib23,Reference Vaughn and Chopra24} yet is among the hardest to eliminate when it comes to behavioral change. In an era where staff and supply shortages were experienced, one can understand why these behavioral changes were even more challenging to adhere to or implement.

Although this survey-based study sheds light on contemporary CLABSI prevention practices, our findings do have limitations. First, although we surveyed about one-third of all non-federal, medical/surgical US hospitals with ICU beds, employed a sampling strategy to obtain a nationally representative sample, and achieved a reasonable response rate (particularly during a pandemic), the hospitals choosing to participate may differ from those choosing not to participate, as highlighted by the high proportion of respondents who work at a facility associated with a medical school (34%). Additionally, the exclusion of acute care medical/surgical hospitals without an ICU, federally funded hospitals, and other hospital types (eg, psychiatric, OB/GYN, rehabilitation, orthopedics, various types of pediatric facilities, and acute long-term care facilities) from our sample impacts generalizability. Second, as with any survey-based study, bias in responses (eg, recall, social-desirability) may have occurred as we relied on a single respondent to report practices for their sites. We have no reason to believe that lead infection preventionists would be systematically unaware of practices to prevent CLABSI at their sites, but we cannot ascertain intra-facility differences. Third, while we asked about leadership practices, the extent these may have influenced CLABSI practices directly or indirectly is unclear. Our findings therefore should be viewed as hypothesis-generating in this respect.

Despite these limitations, our study has several strengths. First, we surveyed a large group of US infection preventionists during the COVID-19 pandemic to understand how CLABSI prevention practices were impacted. Insights from this study can help inform infection prevention policy and practice for US hospitals. For example, our findings related to promulgation of technical innovations perhaps at the expense of behavioral changes is important for sites struggling to reduce CLABSI. Second, we found that use of appropriateness criteria remains low and could represent an area for quality improvement, as has been shown by large scale studies. ^{Reference Chopra, Flanders and Saint6}

In conclusion, the results of our recent survey demonstrated high use of evidence-based technical interventions to prevent CLABSI, even during the COVID-19 pandemic when supply chains and staffing were strained. Moving forward, emphasis on behavioral interventions represents an area of opportunity for both practice and policy as human capital and leadership efforts can focus on quality initiatives.