CLABSI Insertion Bundle: The 5 Elements That Prevent Central Line Infections

The central line insertion bundle — first described by Peter Pronovost in the landmark Michigan Keystone study — is the foundational intervention for CLABSI prevention. When all five bundle elements are implemented consistently for every central line insertion, the results are dramatic: the Keystone study reduced Michigan ICU CLABSI rates by 66% within 3 months and brought median rates to zero, where they remained for years after.

The insertion bundle works because each element addresses a distinct mechanism of catheter-related infection. Eliminating even one element reduces the bundle’s protective effect — the “all-or-nothing” principle.

Parent guide: CLABSI Prevention: Complete Clinical Reference

The 5 Elements of the Insertion Bundle

Element 1: Hand Hygiene

Standard: Perform hand hygiene with soap and water or alcohol-based hand rub (ABHR) immediately before catheter insertion and before any catheter manipulation.

Evidence base: Staphylococci and other skin-resident organisms are the primary pathogens in CLABSI. Hand transmission from clinician to patient during insertion is a primary contamination route. Hand hygiene with ABHR achieves ≥3-log reduction in skin flora within 30 seconds; surgical handwash with CHG provides even greater reduction.

Practice requirement:

ABHR immediately before donning sterile gloves for insertion
Any break in sterile technique (touching unsterile surface, coughing into gown) requires re-gloving and hand hygiene
Hand hygiene is required even when sterile gloves are worn — gloves can have undetected micro-perforations

Element 2: Maximal Sterile Barrier (MSB)

Standard: Use maximal sterile barrier precautions during CVC and PICC insertion: sterile full-length body drape, sterile gown, sterile gloves, surgical mask, and cap for the inserter. Assistant and observers: surgical mask and cap.

Evidence base: Standard sterile gloves and small fenestrated drape precautions are inadequate for central venous catheter insertion. The large exposure area of CVC insertion requires a full-body drape. MSB reduces CLABSI rates compared to standard precautions by 6.3-fold (Mermel et al., Annals of Internal Medicine, 2000).

What MSB means:

Full-body drape: Covers the entire patient, leaving only the insertion site exposed. Must be maintained intact throughout the procedure.
Sterile gown: Worn by the inserter (and assistant if directly handling catheter components).
Sterile gloves: Non-latex or latex (per patient allergy), appropriate size for procedural dexterity.
Surgical mask: Covers nose and mouth; worn by inserter, assistant, and anyone within close proximity to the sterile field.
Cap/hat: Covers all hair; worn by anyone present in the procedure area.

Important: Breaking the sterile field — touching an unsterile surface, reaching past the drape, contaminating gloves — requires immediate acknowledgment, re-preparation, and if catheter components have been contaminated, use of new sterile components.

Element 3: CHG Skin Antisepsis

Standard: Prepare the skin at the insertion site with >0.5% chlorhexidine gluconate (CHG) in alcohol solution (2% CHG/70% isopropyl alcohol preferred). Allow full dry time before needle insertion.

Evidence base: CHG is superior to povidone-iodine for pre-insertion skin antisepsis in multiple randomized trials (Chaiyakunapruk et al., Ann Intern Med, 2002; RR 0.49 vs. povidone-iodine). The alcohol component provides rapid bactericidal action; CHG provides sustained residual activity (hours) that continues killing organisms after the procedure.

Dry time is critical: The antiseptic must be fully dry before insertion. Inserting a needle through wet antiseptic carries the antiseptic into the bloodstream and also reduces antiseptic efficacy (the alcohol must evaporate for the CHG to bind to skin proteins). Standard dry time: 30–60 seconds for CHG-IPA solutions.

Application technique: Apply CHG-IPA using the provided applicator (friction back-and-forth) for 30 seconds over the insertion site and a generous surrounding area. Do not wipe off; do not blot; let dry completely.

Neonates (<2 months): CHG-IPA safety in very preterm neonates is not established. Use povidone-iodine (with rinse after) or per NICU protocol.

Element 4: Optimal Site Selection

Standard: Select the insertion site that minimizes infectious and mechanical complications. Avoid the femoral vein for routine CVC insertion when alternatives are available.

Evidence base:

Subclavian vein: Lowest CLABSI rate among CVC sites; highest mechanical complication risk with landmark technique; lower mechanical risk with US guidance
Internal jugular vein: Intermediate CLABSI rate; low mechanical risk with US guidance
Femoral vein: Highest CLABSI rate (skin flora density in the groin); highest DVT rate; avoid except in emergencies or when upper body access is impossible

Per Parienti et al. (2015, NEJM RCT): Subclavian had the lowest composite complication rate among IJ, subclavian, and femoral approaches.

Additional site selection considerations:

ESRD patients: Avoid subclavian approach (subclavian stenosis eliminates ipsilateral fistula options); prefer IJ
Coagulopathic patients: IJ or femoral (compressible if arterial puncture occurs); subclavian artery injury is non-compressible
Prior ipsilateral radiation or central venous stenosis: Avoid that side

Element 5: Daily Necessity Review

Standard: Review the necessity of each central venous catheter daily. Remove the catheter promptly when it is no longer required.

Evidence base: Catheter dwell time is independently associated with CLABSI risk — the longer a catheter is in place, the higher the cumulative infection risk. Removing catheters as soon as they are no longer needed is the most direct way to reduce catheter-days. Systems-level interventions including daily nursing prompts to physicians, electronic decision support, and VAT daily rounds have each been shown to reduce unnecessary catheter-days.

Implementation: Daily necessity documentation should include:

Explicit statement that the central line is still required
The specific clinical indication that continues to require central access
A plan for when central access can be discontinued (goal-directed assessment: “Will wean vasopressors today → plan to remove CVC when vasopressors off for 24 hours”)

Who is responsible: Every member of the care team shares responsibility. Nursing documents necessity; physicians order removal; the VAT or bedside nurse initiates the conversation if an unnecessary central line is identified.

Bundle Compliance: The “All-or-Nothing” Principle

The insertion bundle achieves its maximum effect only when all five elements are implemented together. Studies of individual bundle elements show modest effects; the combination of all five produces exponentially greater risk reduction.

Bundle compliance rate = (Insertions with all 5 elements documented / Total insertions) × 100%

Target: ≥95% bundle compliance on every insertion.

Enablers of compliance:

Insertion checklist completed at the bedside by the inserter or assistant
Nursing authority to stop a procedure if a bundle element is being bypassed
Real-time observer using a standardized checklist
Pre-assembled insertion kits containing all MSB components
Institutional culture supporting stopping a procedure without consequence when sterile technique is broken

Checklist Implementation

An insertion bundle checklist (completed at the time of insertion) is the documentation evidence that each bundle element was performed. TJC surveyors review insertion bundle documentation during hospital inspections.

Required checklist elements:

Hand hygiene performed before gloving
Maximal sterile barrier used (gown, gloves, drape, mask, cap)
CHG antisepsis performed; dry time met
Optimal site selected; rationale if alternative site used
Daily necessity: indication documented

Who completes the checklist: Inserter, a designated observer, or a designated assistant — institutional policy defines the role. The checklist should be part of the procedure note or a linked document in the EHR.

What the Bundle Doesn’t Cover

The insertion bundle addresses the pre-use infection window — contamination occurring during catheter placement. It does not address:

Post-insertion contamination: Hub contamination during medication administration, dressing maintenance failures
Tip malposition: An improperly positioned catheter is not addressed by infection bundle elements
Device selection: Placing a PICC when a PIV would suffice is not an insertion bundle failure

These gaps are addressed by the maintenance bundle (scrub-the-hub, CHG dressings, CHG bathing, appropriate dressing changes, line removal), which works in parallel with the insertion bundle.

Related guides:

Related policies:

References

Pronovost P, et al. (2006). An intervention to decrease CLABSI in the ICU. N Engl J Med, 355(26):2725–2732.
O’Grady NP, et al. (2011). CDC Guidelines for Prevention of Intravascular Catheter-Related Infections. MMWR, 60(RR-1).
Mermel LA, et al. (2000). Prevention of central venous catheter-related infections. Ann Intern Med, 132(5):391–402.
Chaiyakunapruk N, et al. (2002). CHG versus povidone-iodine antisepsis for CVC insertion. Ann Intern Med, 136(11):792–801.
Parienti JJ, et al. (2015). Intravascular complications of CVC by insertion site. N Engl J Med, 373(13):1220–1229.