Central Line-Associated Bloodstream Infections (CLABSI)

Publication ID: 1474499503
Published on: August 2023
Major Revision: August 20, 2023


Our actionable evidence-based practices were designed by world-renowned patient safety experts to serve as proven step-by-step guidelines on eliminating the top causes of preventable harm. This blueprint has a proven track record of ensuring the best patient care. Please note that our guidelines are continually updated and incorporate the latest safety practices recognized as the gold standard of care.
Frontline staff

This blueprint outlines the steps that frontline staff can follow to prevent Central Line-Associated Bloodstream Infections.


  1. Watch a short training video on placing central lines. This applies to all credentialed staff, including clinicians inserting the lines and nurses assisting or observing for any inadvertent break in protocol.
  2. Create a standardized central line insertion kit.
  3. Obtain patient consent.
  4. Perform a “time-out” before commencing the procedure.
  5. Use ultrasound guidance for all central line placements to identify the optimal vein and place the line safely.
  6. Scrub up and wear gown, gloves, cap, and mask (clinicians).
    1. Use a full sterile barrier for providers and patients for the insertion of CVCs, PICCs, or guidewire exchange.Scrub up and wear gown, gloves, cap, and mask (clinicians).
    2. Use a sterile sleeve to protect pulmonary artery catheters during insertion.
  7. Cover patient with a full-body sterile drape.
  8. Place patient slightly head down if tolerated and needed to enlarge the target vein.
  9. Identify target vein with ultrasound if the patient is awake, then inject local anesthetic to prevent pain.
  10. Use extreme care to avoid an accidental pneumothorax when inserting a central line in the subclavian vein, the optimal site for insertion (the internal jugular vein and, secondly, the femoral vein can be used as alternatives if necessary).
  11. Maintain strict sterile techniques when placing the central line, and use a sterile sheath for the ultrasound.
  12. Enter the ultrasound-identified vein with a needle and syringe, then aspirate the venous blood.
  13. Following insertion of the needle and aspirating venous blood, insert the guidewire through the needle and use the ultrasound guidance to ensure that the guidewire is going in the correct direction. Ensure that air is not entrained through the needle.
  14. Use ultrasound guidance to introduce a dilator down the guidewire without damaging the wire or the vein.
  15. Remove the dilator, with the guidewire remaining in good position, and pass down the venous catheter into the vein along the guidewire again, using ultrasound vision to ensure proper catheter placement.
  16. Pass the catheter over the wire, and use ultrasound to position it correctly in the superior vena cava with no tension on the vein wall. (The proximal end of the wire is observed to be extruded from the catheter so that it can be extracted easily.)
  17. Remove the wire and have it noted down by the observation nurse. Aspirate the catheter and flush with saline though all ports, then suture it in place.
  18. Place a sterile dressing over the catheter and insertion site. Take a chest radiograph to ensure correct positioning and no pneumothorax.


  1. Perform daily assessments of the need for line and remove when no longer needed. Only healthcare personnel who are properly trained should be doing the maintenance on the central line.
  2. Minimize blood draws from the line.
  3. Maintain a sterile dressing and replace it in a sterile manner if it becomes soiled.
  4. Document daily discussion of line necessity in the patient’s medical record.

Standardized Access Procedures

  1. Watch a short training video on placing central lines. This applies to all credentialed staff, including clinicians inserting the lines and nurses assisting or observing for any inadvertent break in protocol.
  2. Use clean (for temporary CVLs) or sterile (for permanent CVLs) gloves when accessing the line.
  3. Scrub up and wear gown, gloves, cap, and mask (clinicians).
    1. Use a scrubbing device with an alcohol product, such as chlorhexidine with alcohol or 70% alcohol, to disinfect catheter hub and stopcocks.
    2. If you are using a pad, make sure you don’t contaminate it before use and use only on one hub.
      1. NEVER reuse prep pads.
    3. Rub for 15 seconds if alcohol is used plus 15 seconds to dry, or rub for 30 seconds if CHG is used plus 30 seconds to dry (unless directed otherwise by the manufacturer’s instructions), generating friction by scrubbing in a twisting motion as if you were juicing an orange.
    4. Make sure you scrub the top of the hub well, not just the sides.
    5. Prevent hub from touching anything while drying.
  4. Access the stopcock or injection port only with sterile devices.
  5. Infuse medication or draw blood.
  6. Follow standardized dressing, cap, and tubing change procedures/timing.
    1. Scrub skin around site with CHG for 30 seconds (2 minutes for femoral site), followed by complete drying. For patients with contraindication to CGH (allergy), scrub skin with alcohol or povidone-iodine.
      1. Note: there may be institutional preference for CHG use for infants < 2 months of age.
  7. Change crystalloid tubing once every 72 hours.
  8. Change tubing used to administer blood products once every 24 hours or more frequently per institutional standard.
  9. Change tubing used for lipid and TPN infusions once every 24 hours.
  10. Document date dressing/cap/tubing was changed or is due for change.
  11. Consider when hub of catheter or insertion site is exposed while wearing a mask (all providers and assistants) and shielding patient’s face, endotracheal tube (ETT), or trach with mask or drape.
  12. Discard gloves and perform hand hygiene when the procedure is completed.

Line Removal

A fibrous tract forms rapidly around the central line catheter that will allow air to be entrained on catheter removal.

  1. When removing a central catheter, lay the patient as flat as clinically possible.
  2. Have a sterile swab with sterile gel immediately ready to cover the insertion site on catheter removal.
  3. Ask the patient to hold their breath.
  4. Remove catheter and immediately occlude insertion site with the sterile sponge and gel and allow patient to breathe.
  5. Cover site with an occlusive airtight Elastoplast.
  6. Allow patient to sit up to a position of comfort.

In the Pediatric ICU and Neonatal ICU

  1. Use pediatric-specific insertion and maintenance bundle checklists.
  2. Assess daily the need for and functionality of the line, insertion site, securement, and dressing, with documentation in the medical record.
  3. Change catheter tubing once every 24 hours for lines used to provide PN or blood products.
  4. Educate caretakers (parents, guardians) on best practices and empower them to reinforce compliance with maintenance care standards.
    1. Consider creating printed safety sheets or “key cards” using easy-to-understand language that summarizes maintenance care elements.
Unit Managers

This guide outlines the steps that managers can follow to prevent Central Line-Associated Bloodstream Infections.

To support your staff in maintaining a safe practice associated with central line:

  1. Create a checklist with all required maintenance bundle elements.
  2. Credential all staff involved in management of central lines by having them watch a training video.
  3. Standardize procedures for line access as well as for dressing, cap, and tubing changes.
  4. Perform daily safety rounds.
  5. Send monthly data to team and leadership.
    1. Celebrate successes:
      1. Post a running tally of CLABSI-free days in your unit where it can be easily seen.
    2. Use a systematic approach to review all hospital-acquired CLABSIs.
    3. Perform in-depth case reviews when infections do occur:
      1. Include members of the Infection Prevention and Control and Infectious Disease teams.
    4. Identify the risks that could have been avoided and modifications needed moving forward, during timely safety huddles.
  6. Ensure an insertion checklist is part of your electronic medical record.
  7. Ensure that personnel involved in insertion and maintenance of catheters are credentialed.
  8. Provide insertion credentialing for all providers.
  9. Standardize a central-line kit based on the needs of your facility.

For directly inserted central lines, the subclavian veins are less frequently associated with infections than the internal jugular vein or the femoral vein. 

To support your pediatric ICU and neonatal ICU staff in maintaining a safe practice associated with central line:

  1. Create a monthly report for the CLABSI rates and prevention bundle compliance data to present at the team/quality committee and leadership meetings.
  2. Implement standardized central venous catheter (CVC) practices.
    1. 24-hour catheter tubing change for lines used to provide PN or blood products, with access only by experienced staff and compliance with standard access procedure nurses only.
    2. Enhanced nursing education and competency for standardized CVC care.

Line stability and securement are challenges in all pediatric patients, but especially in preterm neonates in whom skin integrity is not yet fully developed. Therefore, extra attention to the insertion site and dressings is required.

To support staff training:

  1. Provide nursing education, including a care and maintenance bundle.
    1. “Just in Time” training incorporates immediate feedback to staff at the time of line care.
  2. Provide enhanced pediatric and neonatal ICU nursing education with regular assessment of enhanced and competency standard for CVC care practices for all staff who handle central lines.
  3. Offer a Central Line Simulation Program.
    1. Develop education for attendings, residents, and nurses.
    2. Reinforce key curriculum concepts.
  4. Underscore importance of hand hygiene.
  5. Make sure appropriate gowning and gloving procedures are followed.
    1. Make it part of the key curriculum concepts.
  6. Make sure standardized central line insertion best practices are followed.
    1. Practice ultrasound-guided cannulation for all line placements.
  7. Provide an insertion checklist.
    1. Emphasize maintaining a sterile technique—giving immediate feedback.
  8. Provide Central Line Navigator documentation.
  9. Provide General Medical Education (GME) that includes:
    1. MD rounding navigators (removal prompt)
    2. Resident infection prevention training
  10. Ensure evidence-based practices are adhered to.
  11. Remain current with new literature findings.
  12. Make a patient/family education document available.
  13. Use an insertion checklist with staff empowerment to stop non-emergent procedure:
    1. Include a checklist to ensure adherence to proper practices. 

To support staff training in line removal:

A fibrous tract forms rapidly around the central line catheter that will allow air to be entrained on catheter removal. Educate your staff on the following steps when removing a line:

  1. When removing a central catheter, lay the patient as flat as clinically possible.
  2. Have a sterile swab with sterile gel immediately ready to cover the insertion site on catheter removal.
  3. Ask the patient to hold their breath.
  4. Remove catheter and immediately occlude insertion site with the sterile sponge and gel and allow patient to breathe.
  5. Cover site with an occlusive airtight Elastoplast.
  6. Allow patient to sit up to a position of comfort. 

To measure the outcomes:

CLABSI is defined by the CDC National Healthcare Safety Network (NHSN) as a primary bloodstream infection (BSI) in a patient that had a central line within the 2 calendar days before the development of the BSI and is not related to an infection at another site. To meet this definition, infections must be validated using the hospital-acquired infection (HAI) standards. Infection rates can be stratified by unit types further defined by the CDC. Infections that were present on admission (POA) are not considered HAIs and not counted. 

CLABSI rates are expressed per 1,000 central line days:
Numerator: Number of laboratory-confirmed bloodstream infections
Denominator: Total number of central line days
CLABSI rate per 1,000 central line days = (Number of laboratory-confirmed bloodstream infections / Total number of central line days) x 1,000 

CLABSI can be displayed as a Standardized Infection Ratio (SIR) using the following formula:
SIR = Observed CLABSI / Predicted CLABSI
Predicated infections are calculated by NHSN and available by location (unit type) from the baseline period. 

Indirect impact:

Any patient with a peripheral or central line will benefit from several of the interventions being instituted.

Direct impact:

All patients requiring a central line. 

To support accurate data collection and analysis:

  1. Capture complete documentation elements:
    1. Number of operator attempts per line placement.
    2. % of patients compliant with daily CHG treatments and site disinfection.
    3. % of insertion with completed checklist.
  2. Capture complete bundle compliance data:
    1. Measure insertion and maintenance separately.
    2. % of line insertions following all bundle components.
    3. % compliance with standard maintenance bundle during access and/or dressing, cap, or tubing change.
    4. Monitor performance and compliance with the insertion bundle on a routine basis.
  3. Capture data on quality and effectiveness of patient education:
    1. % of patients/families educated about infection prevention.
  4. Collect data on repetitive patterns, trends, variation to standard practices and complication rates.
  5. Audit all (100%) central lines inserted.

Incidents of CLABSI can be collected through surveillance (at least once per month) or gathered through electronic medical records documentation. Denominators documented electronically must match manual counts (+/- 5%) for a 3-month validation period.
Direct observation by dedicated, trained “champions” is the best practice for generating reliable procedural compliance data.
Hospitals can choose to include additional bundle components.

Hospital Executives

This protocol outlines the steps that executives can follow to prevent Central Line-Associated Bloodstream Infections.

More than 700,000 healthcare-associated infections (HAIs) are estimated to occur each year in the US, resulting in 99,000 deaths and $28–$45 billion in extra healthcare costs.

Central line-associated bloodstream infection (CLABSI) is a serious infection that occurs when bacteria or viruses enter the bloodstream through the central line. Researchers estimate that up to 41,000 patients in US hospitals acquire CLABSI each year. CLABSI is a source of serious harm and death in hospitalized patients. Researchers think CLABSIs occur due to:

  1. Heavy bacterial colonization at the insertion site.
  2. A “non-tunneled” catheter being placed in the arm or leg rather than placement in the chest.
  3. Catheterization lasting longer than 3 days.
  4. Less stringent barrier precautions for catheter insertions, which significantly increases the risk of a catheter-related infection.
  5. The presence of multiple lumens, which may increase the opportunity for infection.
  6. Host factors, including complex, chronic illness, immunocompromised state, prolonged hospitalization.

While intensive care unit (ICU) patients have the highest chance of acquiring CLABSIs, central venous catheters are becoming increasingly used outside the ICU, exposing more patients to the risk. In fact, recent data suggest that the greatest numbers of patients with central lines are in hospital units outside the ICU, most notably dialysis units. While central line use is increasing outside the ICU, since 2008, the Centers for Medicare and Medicaid Services (CMS) has implemented a policy of reduced reimbursement for reasonably preventable hospital-acquired conditions, including CLABSIs. This policy change can represent a significant financial burden to a hospital because increased hospital costs due to CLABSIs can be more than $48,000 per case.

CLABSIs and other HAIs, however, are mostly preventable. Interventions that focus on reducing CLABSIs have resulted in reductions ranging from 38% to 80%. In one study, researchers observed a 66% decrease in CLABSIs after implementing a multi-component intervention in the ICUs of 67 Michigan hospitals. In another study conducted across 32 hospitals in Pennsylvania, CLABSIs decreased by 68%, following targeted interventions between April 2001 and March 2005. Other studies have shown similar reductions in CLABSIs, saving lives and dramatically reducing costs.

A variety of guidelines and recommendations have been identified to prevent CLABSI, including those published by:

  1. The Healthcare Infection Control Practices Advisory Committee
  2. The Institute for Healthcare Improvement
  3. The Agency for Healthcare Research and Quality

These recommendations share the following components to reduce and prevent CLABSI:

  1. Implementing a method to detect the true incidence of CLABSI, such as information technology to collect and calculate catheter days.
  2. Providing adequate infrastructure for the intervention, including an adequately staffed infection prevention and control program, and adequate laboratory support for timely processing of samples.
  3. Implementing a catheter insertion and maintenance checklist.
  4. Monitoring the continued need for intravascular access on a daily basis and prompt removal when the catheter is no longer needed.
  5. Measuring unit-specific occurrence of CLABSI as part of performance evaluations.

Researchers estimate that the use of process change and the use of technology to reduce CLABSI can save up to $2.7 billion per year while significantly improving quality and safety. Closing the performance gap will require hospitals and healthcare systems to commit to action in the form of specific leadership, action, and technology plans, examples of which are delineated below for utilization or reference. This is provided to assist hospitals in prioritizing their efforts when designing and implementing evidence-based bundles for CLABSI reduction.

Hospital governance, senior administrative leadership, clinical leadership, and safety/risk management leadership need to work collaboratively to reduce CLABSI. To achieve a goal of zero preventable deaths, leaders need to commit to taking these key actions.

Show leadership’s commitment to reducing CLABSI:

  1. Hospital governance and senior administrative leadership must commit to becoming aware of major performance gaps in their own organization.
  2. Hospital governance, senior administrative leadership, and clinical/safety leadership must close their own performance gap by implementing a comprehensive approach.
  3. Healthcare leadership must demonstrate their commitment and support by:
    1. Taking an active role in championing process improvement
    2. Giving their time, attention, and focus
    3. Removing barriers
    4. Providing necessary resources
  4. Healthcare leadership must reinforce their commitment by:
    1. Shaping a vision of the future
    2. Clearly defining goals
    3. Embracing and reinforcing a Culture of Safety so that staff feel empowered to actively participate in CLABSI prevention activities
    4. Supporting staff as they work through improvement initiatives
    5. Measuring results
    6. Communicating progress toward goals

Actions speak louder than words. As role models, leadership must “walk the walk” as well as “talk the talk” when it comes to supporting process improvement across the organization. There are many types of leaders within a healthcare organization, and for process improvement to truly be successful, leadership commitment and action are required at all levels. The board, the C-suite, senior leadership, physicians, directors, managers, and unit leaders all have important roles and need to be engaged.

Create the infrastructure needed to make changes:

Change management is a critical element that must be included to sustain any improvements. Recognizing the needs and ideas of the people who are part of the process—and who are charged with implementing and sustaining a new solution—is critical in building the acceptance and accountability for change. A technical solution without acceptance of the proposed changes will not succeed. Building a strategy for acceptance and accountability of a change initiative greatly increases the opportunity for success and sustainability of improvements. “Facilitating Change,” the change management model The Joint Commission developed, contains four key elements to consider when working through a change initiative to address HAIs:

  1. Plan the Project:
    1. At the start of project, build a strong foundation for change by:
      1. Assessing the culture for change
      2. Defining the change
      3. Building a strategy
      4. Engaging the right people
      5. Painting a vision of the future
      6. Inspiring people
    2. Ask for support and active involvement in the plan to reduce:
      1. HAIs
      2. Get agreements.
      3. Build accountability for the outcomes.
      4. Identify a leader for the HAI initiative (this is critical to the success of the project).
      5. Understand where resistance may come from.
  2. Launch the Initiative:
    1. Align operations and guarantee the organization has the capacity to change, not just the ability to change.
    2. Launch the HAI initiative with a clear champion and a clearly communicated vision by leadership.
  3. Support the Change:
    1. Have all leaders within the organization be a visible part of the HAI initiative.
    2. Communicate frequently regarding all aspects of the HAI initiative to enhance the initiative’s chance for success.
    3. Celebrate success as it relates to a reduction in HAIs or a positive change in HAI organizational culture.
    4. Identify resistance to the HAI initiative as soon as it occurs.
  4. In addition to the change management model, leaders must:
    1. Include fundamentals of change outlined in the National Quality Forum safe practices, including:
      1. Awareness
      2. Accountability
      3. Ability
      4. Action
    2. Meet with the ICU team, infection control staff, quality and safety leaders, nurse educators, and physician champions to:
      1. Understand barriers (walk the process).
      2. Use 4E grid to develop a strategy to:
        • Engage—use stories and show baseline data.
        • Educate—teach staff about the evidence.
        • Execute—practice change.
        • Evaluate—assess feedback performance and view infections as defects.
      3. Use surveillance data to drive improvement.
      4. Monitor and provide feedback of compliance with best practices over time.
    3. Utilize patient stories—written and recorded on video—to identify gaps and inspire change in your staff.
      1. The story of Nora Bostrom, daughter of Claire McCormick and Thomas Bostrom, is an inspiring story about a CLABSI which can be freely viewed: https://www.youtube.com/watch?v=-DNuFp6KDVM.

Engage staff and use data to find areas for improvement:

  1. Develop a standardized educational plan for doctors and nurses to cover key curriculum about the insertion and maintenance of central lines.
  2. Encourage continuous process improvement through the implementation of quality process measures and metrics.
  3. Complete a root cause analysis (RCA) or multidisciplinary review when CLABSIs are identified in the unit where the infection occurred using a multidisciplinary approach, including nurses, doctors, and infection prevention professionals.
  4. Implement—and share—all learnings from the RCA.
  5. Use patient stories—written and recorded on video—to help teach and inspire change in your staff.
Patient & Families

This handbook outlines the steps that patients can follow to prevent Central Line-Associated Bloodstream Infections.

  1. Your central line catheter is a potential source of infection to your body, so always ensure that whoever accesses the line does so in a sterile manner.
  2. Do not be afraid to ask if physicians or nurses have washed their hands, have sterile gloves, and that they “scrub the hub” before accessing an injection port.
  3. If the port is a stopcock, ensure that it is capped off after access with a sterile cap.
  4. Your central line gives direct access to your heart, so always check with the nurse or physician to find out what medication is being administered.
  5. If the dressing on the line access becomes loose or soiled, call the nurse to come and replace it.

Agency for Healthcare Research and Quality. AHRQ national scorecard on hospital-acquired conditions. (2017)

Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and Non-central Line Associated Bloodstream Infection) (2023)

Buetti N, et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: (2022)

Chopra V, et al. Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals. (2021)

Drews FA, et al. Human Factors Engineering Contributions to Infection Prevention and Control. (2019)

Haddadin Y, et al. Central Line Associated Blood Stream Infections. (2019)

Latif A, et al. Eliminating Infections in the ICU: CLABSI. (2015)

Pham JC, et al. CLABSI Conversations: Lessons From Peer-to-Peer Assessments to Reduce Central Line-Associated Bloodstream Infections. (2016)

Sood G, et al. Use of Implementation Science for a Sustained Reduction of Central-Line-Associated Bloodstream Infections in a High-Volume, Regional Burn Unit. (2017)

Talbot III T.R., et al. Updated Recommendations on the Use of Chlorhexidine-Impregnated Dressings for Prevention of Intravascular Catheter-Related Infections. (2017)