National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Events (1)
- Ambulatory Care and Surgery (1)
- Catheter-Associated Urinary Tract Infection (CAUTI) (6)
- (-) Central Line-Associated Bloodstream Infections (CLABSI) (22)
- Children/Adolescents (5)
- Clostridium difficile Infections (1)
- Communication (2)
- Comprehensive Unit-based Safety Program (CUSP) (1)
- Critical Care (2)
- Decision Making (1)
- Disparities (1)
- Electronic Health Records (EHRs) (1)
- Evidence-Based Practice (3)
- Guidelines (1)
- Healthcare-Associated Infections (HAIs) (20)
- Healthcare Costs (2)
- Health Information Technology (HIT) (1)
- Home Healthcare (1)
- Hospitals (3)
- Infectious Diseases (3)
- Inpatient Care (1)
- Intensive Care Unit (ICU) (6)
- Medical Errors (1)
- Medicare (2)
- Methicillin-Resistant Staphylococcus aureus (MRSA) (2)
- Nursing (2)
- Outcomes (1)
- Patient-Centered Outcomes Research (1)
- Patient Safety (10)
- Payment (1)
- Prevention (4)
- Quality Improvement (2)
- Quality Measures (1)
- Quality of Care (5)
- Risk (1)
- Sepsis (1)
- Surgery (1)
- Urinary Tract Infection (UTI) (5)
AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 22 of 22 Research Studies DisplayedHsu HE, Mathew R, Wang R
Health care-associated infections among critically ill children in the US, 2013-2018.
The purpose of this study was to examine changes over time in CLABSI and CAUTI rates between 2013 and 2018 in neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs) using prospective surveillance data from community hospitals, children's hospitals, and pediatric units within general hospitals. The investigators concluded that recent trends in CLABSI rates noted in this study among critically ill neonates and children in a large cohort of US hospitals indicated that past gains have held, without evidence of further improvements, suggesting novel approaches for CLABSI prevention are needed.
AHRQ-funded; HS025008; HS018414.
Citation: Hsu HE, Mathew R, Wang R .
Health care-associated infections among critically ill children in the US, 2013-2018.
https://www.pubmed.ncbi.nlm.nih.gov/33017011
JAMA Pediatr 2020 Dec;174(12):1176-83. doi: 10.1001/jamapediatrics.2020.3223..
JAMA Pediatr 2020 Dec;174(12):1176-83. doi: 10.1001/jamapediatrics.2020.3223..
Keywords: Children/Adolescents, Catheter-Associated Urinary Tract Infection (CAUTI), Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Intensive Care Unit (ICU)
Rinke ML, Oyeku SO, Ford WJH
Costs of ambulatory pediatric healthcare-associated infections: Central-line-associated bloodstream infection (CLABSIs), catheter-associated urinary tract infection (CAUTIs), and surgical site infections (SSIs).
Ambulatory healthcare-associated infections (HAIs) occur frequently in children and are associated with morbidity. Less is known about ambulatory HAI costs. This retrospective case control study estimated additional costs associated with pediatric ambulatory central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSIs) following ambulatory surgery. The authors concluded that ambulatory HAI in pediatric patients were associated with significant additional costs.
AHRQ-funded; HS024432.
Citation: Rinke ML, Oyeku SO, Ford WJH .
Costs of ambulatory pediatric healthcare-associated infections: Central-line-associated bloodstream infection (CLABSIs), catheter-associated urinary tract infection (CAUTIs), and surgical site infections (SSIs).
Infect Control Hosp Epidemiol 2020 Nov;41(11):1292-97. doi: 10.1017/ice.2020.305..
Keywords: Children/Adolescents, Healthcare-Associated Infections (HAIs), Central Line-Associated Bloodstream Infections (CLABSI), Catheter-Associated Urinary Tract Infection (CAUTI), Urinary Tract Infection (UTI), Ambulatory Care and Surgery, Healthcare Costs, Surgery
Thate JA, Couture B, Schnock KO
Information needs and the use of documentation to support collaborative decision-making: implications for the reduction of central line-associated blood stream infections.
It is clear that interdisciplinary communication and collaboration have the potential to mitigate healthcare-associated harm, yet there is limited research on how communication through documentation in the patient record can support collaborative decision making. Understanding what information is needed to support collaborative decision making is necessary to design electronic health information systems that facilitate effective communication and, ultimately, safe care. To explore this issue, the investigators focused on information needs related to central venous catheter management and the prevention of central line-associated blood stream infections.
AHRQ-funded; HS0235335.
Citation: Thate JA, Couture B, Schnock KO .
Information needs and the use of documentation to support collaborative decision-making: implications for the reduction of central line-associated blood stream infections.
Comput Inform Nurs 2020 Nov 2;39(4):208-14. doi: 10.1097/cin.0000000000000683..
Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Decision Making, Communication, Electronic Health Records (EHRs), Health Information Technology (HIT), Nursing
Vaughn VM, O'Malley M, Flanders SA
Association of infectious disease physician approval of peripherally inserted central catheter with appropriateness and complications.
The purpose of this study was to evaluate whether infectious disease physician approval prior to PICC placement for intravenous antimicrobials was associated with more appropriate device use and fewer complications. The authors concluded that this cohort study suggested that, when PICCs were placed for intravenous antimicrobial therapy, infectious disease physician approval of PICC insertion was associated with more appropriate device use and fewer complications.
AHRQ-funded; HS026530; HS025891.
Citation: Vaughn VM, O'Malley M, Flanders SA .
Association of infectious disease physician approval of peripherally inserted central catheter with appropriateness and complications.
JAMA Netw Open 2020 Oct;3(10):e2017659. doi: 10.1001/jamanetworkopen.2020.17659..
Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Infectious Diseases, Adverse Events
Keller S, Salinas A, Williams D
Reaching consensus on a home infusion central line-associated bloodstream infection surveillance definition via a modified Delphi approach.
A consensus on a central line-associated bloodstream infection (CLABSI) surveillance definition in home infusion is needed to standardize measurement and benchmark CLABSI to provide data to drive improvement initiatives. Experts across fields including home infusion therapy, infectious diseases, and healthcare epidemiology convened to perform a 3-step modified Delphi approach to obtain input and achieve consensus on a candidate home infusion CLABSI definition. This paper describes the process.
AHRQ-funded; HS025782.
Citation: Keller S, Salinas A, Williams D .
Reaching consensus on a home infusion central line-associated bloodstream infection surveillance definition via a modified Delphi approach.
Am J Infect Control 2020 Sep;48(9):993-1000. doi: 10.1016/j.ajic.2019.12.015..
Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Home Healthcare
Hsu HE, Wang R, Broadwell C
Association between federal value-based incentive programs and health care-associated infection rates in safety-net and non-safety-net hospitals.
The authors assessed the association of Hospital-Acquired Condition Reduction Program (HACRP) and Hospital Value-Based Purchasing (HVBP) implementation with changes in rates of targeted health care-associated infections and disparities in rates among safety-net and non-safety-net hospitals. They found that HACRP and HVBP implementation was not associated with any improvements in targeted health care-associated infections among safety-net or non-safety-net hospitals or with changes in disparities in infection rates. They concluded that, given the persistent health care-associated infection rate disparities, these programs appear to function as a disproportionate penalty system for safety-net hospitals that offer no measurable benefits for patients.
AHRQ-funded; HS018414.
Citation: Hsu HE, Wang R, Broadwell C .
Association between federal value-based incentive programs and health care-associated infection rates in safety-net and non-safety-net hospitals.
JAMA Netw Open 2020 Jul;3(7):e209700. doi: 10.1001/jamanetworkopen.2020.9700..
Keywords: Healthcare-Associated Infections (HAIs), Hospitals, Central Line-Associated Bloodstream Infections (CLABSI), Catheter-Associated Urinary Tract Infection (CAUTI), Urinary Tract Infection (UTI), Medicare, Patient Safety
Luzum M, Sebolt J, Chopra V
Catheter-associated urinary tract infection, Clostridioides difficile colitis, central line-associated bloodstream infection, and methicillin-resistant Staphylococcus aureus.
This article provides summaries of the background, epidemiology, diagnosis, and treatment of central line-associated bloodstream infection, catheter-associated urinary tract infection, Clostridioides difficile, and methicillin-resistant Staphylococcus aureus colonization and infections. Additional prevention strategies, including those related to recent national interventions, are also reviewed.
AHRQ-funded; HS022835.
Citation: Luzum M, Sebolt J, Chopra V .
Catheter-associated urinary tract infection, Clostridioides difficile colitis, central line-associated bloodstream infection, and methicillin-resistant Staphylococcus aureus.
Med Clin North Am 2020 Jul;104(4):663-79. doi: 10.1016/j.mcna.2020.02.004..
Keywords: Catheter-Associated Urinary Tract Infection (CAUTI), Urinary Tract Infection (UTI), Clostridium difficile Infections, Methicillin-Resistant Staphylococcus aureus (MRSA), Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Infectious Diseases
Meddings J, Greene MT, Ratz D
Multistate programme to reduce catheter-associated infections in intensive care units with elevated infection rates.
AHRQ’s Safety Program for ICUs aimed to reduce central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) in intensive care units with elevated rates. Included hospitals had at least one adult intensive care unit with elevated CLABSI or CAUTI rates. The investigators targeted intensive care units with elevated catheter infection rates but yielded no statistically significant reduction in CLABSI, CAUTI or catheter utilization in the first two of six planned cohorts. Improvements in the interventions based on lessons learned from these initial cohorts are being applied to subsequent cohorts.
AHRQ-funded; 233201500016I.
Citation: Meddings J, Greene MT, Ratz D .
Multistate programme to reduce catheter-associated infections in intensive care units with elevated infection rates.
BMJ Qual Saf 2020 May;29(5):418-29. doi: 10.1136/bmjqs-2019-009330..
Keywords: Catheter-Associated Urinary Tract Infection (CAUTI), Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Infectious Diseases, Patient Safety, Urinary Tract Infection (UTI), Intensive Care Unit (ICU), Hospitals, Evidence-Based Practice, Patient-Centered Outcomes Research, Inpatient Care, Critical Care
Gohil SK, Yim J, Quan K
Impact of a Central-Line Insertion Site Assessment (CLISA) score on localized insertion site infection to prevent central-line-associated bloodstream infection (CLABSI).
This study assessed the impact of a newly developed Central-Line Insertion Site Assessment (CLISA) score on the incidence of site inflammation or infection for CLABSI prevention. A cohort of adult inpatients with central venous catheters (CVCs) hospitalized in an intensive care unit or oncology ward at a large academic medical center participated. CLISA score impacts were evaluated with a CLISA score of 2 or 3 indicating insertion site inflammation and infection. The baseline study period was June 2014 through January 2015 and the intervention period April 2015 through October 2017. During that time CLISA scores of 2 or 3 in the baseline and intervention periods decreased by 78.2%. Days to removal of lines on patients with a CLISA score of 2 or 3 was 3.19 days faster after the intervention. Line dwell time also decreased by 37.1% from a mean of 14 days to 8.8 days.
AHRQ-funded; HS024424.
Citation: Gohil SK, Yim J, Quan K .
Impact of a Central-Line Insertion Site Assessment (CLISA) score on localized insertion site infection to prevent central-line-associated bloodstream infection (CLABSI).
Infect Control Hosp Epidemiol 2020 Jan;41(1):59-66. doi: 10.1017/ice.2019.291..
Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Prevention, Patient Safety
Woods-Hill CZ, Srinivasan L, Schriver E
Novel risk factors for central-line associated bloodstream infections in critically ill children.
Central-line-associated bloodstream infections (CLABSI) cause morbidity and mortality in critically ill children. In this study the investigators examined novel and/or modifiable risk factors for CLABSI to identify new potential targets for infection prevention strategies. They found that novel risk factors for CLABSI in PICU patients included acute behavioral health needs and >80 CVC accessed in the 3 days before CLABSI. They suggest that interventions focused on these factors may reduce CLABSIs in this high-risk population.
AHRQ-funded; HS025642.
Citation: Woods-Hill CZ, Srinivasan L, Schriver E .
Novel risk factors for central-line associated bloodstream infections in critically ill children.
Infect Control Hosp Epidemiol 2020 Jan;41(1):67-72. doi: 10.1017/ice.2019.302..
Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Children/Adolescents, Intensive Care Unit (ICU), Risk, Patient Safety
Nuckols TK, Keeler E, Morton SC
Economic evaluation of quality improvement interventions for bloodstream infections related to central catheters: a systematic review.
The authors systematically reviewed economic evaluations of QI interventions designed to prevent central-line-associated bloodstream infections (CLABSI) and catheter-related bloodstream infections (CRBSI) in acute care hospitals. They concluded that interventions related to central venous catheters were, on average, associated with 57% fewer bloodstream infections and substantial savings to hospitals. Larger initial investments may be associated with greater savings.
AHRQ-funded.
Citation: Nuckols TK, Keeler E, Morton SC .
Economic evaluation of quality improvement interventions for bloodstream infections related to central catheters: a systematic review.
JAMA Intern Med 2016 Dec;176(12):1843-54. doi: 10.1001/jamainternmed.2016.6610.
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Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Healthcare Costs, Quality Improvement
Mimoz O, Chopra V, Widmer A
What's new in skin antisepsis for short-term intravascular catheters: new data to address old problems?
Catheter-related infections remain a leading cause of healthcare-associated infections (HAI) in ICUs and the most preventable HAI. The authors discussed skin antiseptic solutions and included a table of practical recommendations for skin antisepsis before insertion of a short-term vascular catheter.
AHRQ-funded; HS022835.
Citation: Mimoz O, Chopra V, Widmer A .
What's new in skin antisepsis for short-term intravascular catheters: new data to address old problems?
Intensive Care Med 2016 Dec;42(12):2043-45. doi: 10.1007/s00134-016-4490-5.
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Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Patient Safety, Prevention
McAlearney AS, Hefner JL
Getting to zero: goal commitment to reduce blood stream infections.
The researchers examined goal-setting as a factor contributing to program outcomes in eight hospitals focused on preventing central line-associated bloodstream infections (CLABSIs). They conducted qualitative case studies to compare higher- and lower-performing hospitals, and explored differences in contextual factors that might contribute to performance variation. Finally, they present a goal commitment framework that characterizes factors associated with successful CLABSI program outcomes.
AHRQ-funded; 290200600022.
Citation: McAlearney AS, Hefner JL .
Getting to zero: goal commitment to reduce blood stream infections.
Med Care Res Rev 2016 Aug;73(4):458-77. doi: 10.1177/1077558715616028.
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Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Hospitals, Outcomes, Patient Safety, Prevention
Dicks KV, Lofgren E, Lewis SS
A multicenter pragmatic interrupted time series analysis of chlorhexidine gluconate bathing in community hospital intensive care units.
This study sought to determine whether daily chlorhexidine gluconate (CHG) bathing of intensive care unit (ICU) patients leads to a decrease in hospital-acquired infections (HAIs), particularly infections caused by methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). It concluded that hospitals that implemented CHG bathing attained a decrease in ICU central-line-associated bloodstream infections (CLABSIs), ICU primary BSIs, and VRE central-line-associated bloodstream infections.
AHRQ-funded; HS023866.
Citation: Dicks KV, Lofgren E, Lewis SS .
A multicenter pragmatic interrupted time series analysis of chlorhexidine gluconate bathing in community hospital intensive care units.
Infect Control Hosp Epidemiol 2016 Jul;37(7):791-7. doi: 10.1017/ice.2016.23.
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Keywords: Catheter-Associated Urinary Tract Infection (CAUTI), Central Line-Associated Bloodstream Infections (CLABSI), Intensive Care Unit (ICU), Methicillin-Resistant Staphylococcus aureus (MRSA), Prevention, Patient Safety, Healthcare-Associated Infections (HAIs)
Pronovost PJ, Cleeman JI, Wright D
AHRQ Author: Cleeman JI
Fifteen years after to Err is Human: a success story to learn from.
This paper provides a historical profile of the central line-associated bloodstream infection (CLABSI) success story, comparing infection rates before and 15 years after the IOM report. It discusses the five elements essential to the national success in reducing CLABSI rates: a reliable and valid measurement system, evidence-based care practices, investment in implementation sciences, local ownership and peer learning communities, and coordination and alignment of CLABSI reduction efforts.
AHRQ-authored.
Citation: Pronovost PJ, Cleeman JI, Wright D .
Fifteen years after to Err is Human: a success story to learn from.
BMJ Qual Saf 2016 Jun;25(6):396-9. doi: 10.1136/bmjqs-2015-004720.
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Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Patient Safety, Medical Errors, Evidence-Based Practice, Quality of Care
Rock C, Thom KA, Harris AD
A multicenter longitudinal study of hospital-onset bacteremia: time for a new quality outcome measure?
This study evaluates hospital-onset bacteremia (HOB) as a healthcare-associated infection-related outcome measure by assessing the association between HOB and central-line-associated bloodstream infection (CLABSI) rates and comparing the power of each to discriminate quality among intensive care units (ICUs). The researchers found that change in HOB rate is strongly associated with change in CLABSI rate and has greater power to discriminate between ICU performances.
AHRQ-funded; HS022291.
Citation: Rock C, Thom KA, Harris AD .
A multicenter longitudinal study of hospital-onset bacteremia: time for a new quality outcome measure?
Infect Control Hosp Epidemiol 2016 Feb;37(2):143-8. doi: 10.1017/ice.2015.261.
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Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Patient Safety, Quality Measures, Quality Measures
Ricciardi R, Moy E, Wilson NJ
AHRQ Author: Ricciardi R and Moy E
Finding the true north: lessons from the National Healthcare Quality and Disparities Report.
The authors delineate important features and findings of the 2014 report. For example, it shows that one measure of patient safety improved quickly. The rate of central line–associated bloodstream infection per 1000 medical and surgical discharges (age 18+ years or obstetric admissions) improved at an annual rate of change of more than 10 percent. This success reflects the direct impact that nurses can have in making care safer for their patients.
AHRQ authors Ricciardi and Moy
Citation: Ricciardi R, Moy E, Wilson NJ .
Finding the true north: lessons from the National Healthcare Quality and Disparities Report.
J Nurs Care Qual 2016 Jan-Mar;31(1):9-12. doi: 10.1097/ncq.0000000000000164..
Keywords: Quality of Care, Disparities, Patient Safety, Nursing, Central Line-Associated Bloodstream Infections (CLABSI)
Calderwood MS, Vaz LE, Tse Kawai A
Impact of hospital operating margin on central line-associated bloodstream infections following Medicare's hospital-acquired conditions payment policy.
In October 2008, Medicare ceased additional payment for hospital-acquired conditions not present on admission. The researchers evaluated the policy's differential impact in hospitals with high vs low operating margins. They concluded that Medicare's payment policy may have had an impact on reducing central line-associated bloodstream infections in hospitals with low operating margins.
AHRQ-funded; HS018414.
Citation: Calderwood MS, Vaz LE, Tse Kawai A .
Impact of hospital operating margin on central line-associated bloodstream infections following Medicare's hospital-acquired conditions payment policy.
Infect Control Hosp Epidemiol 2016 Jan;37(1):100-3. doi: 10.1017/ice.2015.250.
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Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Medicare, Quality of Care, Payment, Sepsis
Bundy DG, Gaur AH, Billett AL
Preventing CLABSIs among pediatric hematology/oncology inpatients: national collaborative results.
This study assessed the feasibility of a multicenter effort to standardize central line (CL) care and central line-associated bloodstream infection (CLABSI) tracking and to quantify the impact of standardizing these processes on CLABSI rates. It found a reduction of 28 percent in the mean CLABSI rate from 2.85 to 2.04 per 1,000 CL days over almost 3 years.
AHRQ-funded; HS019590
Citation: Bundy DG, Gaur AH, Billett AL .
Preventing CLABSIs among pediatric hematology/oncology inpatients: national collaborative results.
Pediatrics. 2014 Dec;134(6):e1678-85. doi: 10.1542/peds.2014-0582..
Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Quality of Care, Children/Adolescents
Patrick SW, Kawai AT, Kleinman K
Health care-associated infections among critically ill children in the US, 2007-2012.
The researchers examined trends in central line-associated blood stream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and ventilator-associated pneumonia (VAP) incidence rates between 2007 and 2012 based on standardized surveillance data from pediatric intensive care units (PICUs) and neonatal intensive care units (NICUs) in the United States. They found that incidence rates of CLABSIs and VAPs decreased among critically ill neonates and children during this period.
AHRQ-funded; HS018414.
Citation: Patrick SW, Kawai AT, Kleinman K .
Health care-associated infections among critically ill children in the US, 2007-2012.
Pediatrics 2014 Oct;134(4):705-12. doi: 10.1542/peds.2014-0613..
Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Urinary Tract Infection (UTI), Critical Care, Children/Adolescents, Healthcare-Associated Infections (HAIs)
Berenholtz SM, Lubomski LH, Weeks K
Eliminating central line-associated bloodstream infections: a national patient safety imperative.
The researchers conducted a collaborative cohort study to evaluate the impact of the national "On the CUSP: Stop BSI" program on CLABSI rates among participating adult intensive care units (ICUs). It found that one thousand and seventy-one adult ICUs from 44 states, the District of Columbia, and Puerto Rico implemented the national program and achieved a 43% reduction in the overall rate of CLABSI.
AHRQ-funded; 2902006000222.
Citation: Berenholtz SM, Lubomski LH, Weeks K .
Eliminating central line-associated bloodstream infections: a national patient safety imperative.
Infect Control Hosp Epidemiol 2014 Jan;35(1):56-62. doi: 10.1086/674384..
Keywords: Comprehensive Unit-based Safety Program (CUSP), Central Line-Associated Bloodstream Infections (CLABSI), Intensive Care Unit (ICU), Healthcare-Associated Infections (HAIs)
Rangachari P, Madaio M, Rethemeyer RK
Role of communication content and frequency in enabling evidence-based practices.
The study sought to promote central line bundle (CLB) implementation in a medical ICU and a pediatric ICU through periodic quality improvement (QI) interventions over a 52-week period. It found that proactive communications increased by 68 percent in the MICU and 61 percent in the PICU. During the same timeframe, both units increased CLB adherence to 100 percent. Both units also demonstrated statistically significant declines in catheter days.
AHRQ-funded; HS019785.
Citation: Rangachari P, Madaio M, Rethemeyer RK .
Role of communication content and frequency in enabling evidence-based practices.
Qual Manag Health Care 2014 Jan-Mar;23(1):43-58. doi: 10.1097/qmh.0000000000000017..
Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Communication, Evidence-Based Practice, Guidelines, Healthcare-Associated Infections (HAIs), Intensive Care Unit (ICU), Quality of Care, Quality Improvement