Eliminating CLABSI, A National Patient Safety Imperative: Neonatal CLABSI Prevention

Executive Summary


In August 2011, the Health Research & Educational Trust (HRET), partnering with the Perinatal Quality Collaborative of North Carolina (PQCNC), implemented a national, neonatal central line-associated bloodstream infection (NCLABSI) reduction project in Neonatal Intensive Care Units (NICU). This effort was a component of the AHRQ-funded national project to reduce CLABSI, which is a significant contributor to morbidity and mortality for infants as well as adults and to excess costs. 

This NCLABSI project brought together neonatal State-based networks recruited and led by a neonatologist, also referred to as a State clinical lead. These State clinical leads worked with their State hospital associations and recruited NICUs to participate, submit CLABSI data to PQCNC for real-time feedback, and engage unit teams to improve safety culture using the Comprehensive Unit-Based Safety Program (CUSP). The project had two primary aims: 1) create and support statewide CLABSI collaboratives committed to reducing CLABSI and 2) improve safety culture.


  • A total of 100 units participated representing 9 States.
  • Through the course of the study, over 17,000 central lines were placed.
  • Over 127,000 maintenance notes were logged representing over 8,400 unique patients.
  • CLABSI rates decreased from 2.043 at baseline to 0.855 in August 2012, a 58 percent relative reduction.
  • During the course of the study, an estimated 131 infections were prevented which translates to an estimated 14-41 deaths prevented and over $2.2 million in excess costs averted.

Next Steps

All nine participating States in NCLABSI have completed plans to sustain this work. Six new States have also expressed commitment to spreading the interventions of this project to NICUs in their State. 


Moving forward, the work started in NCLABSI will continue to gain momentum through the State neonatal quality collaboratives and can only grow stronger with additional partnerships through quality improvement organizations, hospital engagement networks, insurers, family and patient groups, and other national stakeholders.

Approximately $906,000 was invested in the national NCLABSI project resulting in infections prevented and deaths avoided. With over $2.2 million in excess costs averted, the return on investment is over 143 percent to date.

Page last reviewed January 2013
Page originally created January 2013
Internet Citation: Executive Summary. Content last reviewed January 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/cusp/clabsi-neonatal/nclabsisum.html