Part 4: Special Populations, Surveillance & Implementation Science
CLABSI prevention in neonates, immunocompromised patients, hemodialysis catheters, and long-term catheters; NHSN surveillance methodology; SIR calculation; CUSP framework; daily goals checklist; nurse empowerment; zero CLABSI sustainability.
1. Special Populations
1.1 Neonates
Neonatal ICU (NICU) patients — particularly very low birth weight (VLBW, <1500 g) and extremely low birth weight (ELBW, <1000 g) infants — face unique challenges for CLABSI prevention due to limited vascular access options, thin and immature skin, prolonged need for central venous access (TPN, medications), and immune system immaturity.12
1.1.1 Epidemiology in Neonates
CLABSI rates in NICUs are directly correlated with birthweight, with the smallest and most premature neonates having the highest rates:
| Birthweight Category | Approximate CLABSI Rate (per 1,000 CL-Days) |
|---|---|
| ≤750 g | 1.5–2.5 |
| 751–1000 g | 1.0–1.5 |
| 1001–1500 g | 0.5–1.0 |
| 1501–2500 g | 0.3–0.8 |
| >2500 g | 0.3–0.6 |
Coagulase-negative staphylococci are the most common causative organisms in neonatal CLABSI (40–50% of isolates), followed by S. aureus, gram-negative bacilli, and Candida spp.1
1.1.2 Neonatal-Specific Prevention Considerations
| Practice | Neonatal Adaptation |
|---|---|
| Skin antisepsis | 2% CHG in 70% alcohol is recommended for term and near-term neonates; use with caution in premature infants <26 weeks gestational age or during the first 2 weeks of life due to risk of skin irritation and potential absorption through immature skin; povidone-iodine is an alternative, but should be wiped off after drying. Monitor for local skin reactions12 |
| Daily CHG bathing | Not routinely recommended for neonates <2 months of age; limited data on safety in premature infants; consider on a case-by-case basis in consultation with neonatology and infection prevention |
| Catheter site selection | Umbilical venous and arterial catheters are commonly used in the first 7–14 days of life; PICCs are the primary long-term central access device in neonates. Umbilical venous catheters should ideally be removed or replaced with a PICC by day 14 to reduce infection risk1 |
| Catheter size | Smallest available catheter; single-lumen preferred when possible |
| Maximal sterile barriers | Full application as in adults, adapted for neonatal body size |
| Central line bundle | Same five components as adult bundle, with neonatal-specific adaptations as above |
| Umbilical catheter care | Keep the umbilical stump clean and dry; do not apply topical antibiotic ointment or cream to the umbilical catheter insertion site (risk of promoting fungal infection); change dressing if soiled or non-occlusive1 |
| Catheter dwell time | Remove umbilical venous catheters as soon as possible and no later than 14 days; remove umbilical arterial catheters as soon as possible and no later than 5 days; PICCs may remain longer if clinically indicated but should be removed as soon as they are no longer necessary1 |
1.1.3 Fluconazole Prophylaxis in ELBW Neonates
In NICUs with high rates of invasive candidiasis (>5% incidence among ELBW infants), fluconazole prophylaxis (3–6 mg/kg IV or PO twice weekly for the first 6 weeks of life) has been shown in randomized trials to reduce invasive Candida infections by approximately 80% without significant adverse effects or emergence of fluconazole-resistant Candida. This strategy is recommended for consideration in high-incidence NICUs.3
1.2 Immunocompromised Patients
Immunocompromised patients — including those with hematologic malignancies, solid organ transplants, hematopoietic stem cell transplants (HSCT), HIV/AIDS, and those receiving high-dose immunosuppressive therapy — have elevated CLABSI risk due to:4
- Impaired neutrophil function and/or absolute neutropenia
- Disrupted mucosal barriers (mucositis from chemotherapy/radiation)
- Prolonged central line dwell times (often months to years for tunneled catheters/ports)
- Frequent catheter manipulations (chemotherapy, blood products, TPN, medication administration)
- Colonization with resistant organisms (MRSA, VRE, Candida spp., multidrug-resistant gram-negatives)
Prevention Strategies Specific to Immunocompromised Patients:
| Strategy | Details |
|---|---|
| Standard insertion and maintenance bundles | Full implementation required — no elements should be omitted in immunocompromised patients |
| Daily CHG bathing | Recommended for hospitalized immunocompromised patients with central lines |
| CHG-impregnated dressings | Recommended as a supplemental strategy |
| Antimicrobial-impregnated catheters | Consider for short-to-medium-term nontunneled catheters in neutropenic patients with expected catheter dwell time >5 days |
| Antimicrobial lock therapy (prophylactic) | Consider for long-term catheters in patients with recurrent CLABSI |
| MBI-LCBI classification | Ensure surveillance correctly categorizes mucosal barrier injury CLABSI to avoid misattribution of infections caused by bacterial translocation rather than catheter contamination |
Catheter Management in Neutropenic Patients with Bacteremia/Fungemia:
| Scenario | Recommendation |
|---|---|
| S. aureus bacteremia | Remove catheter (same as non-immunocompromised) |
| Candida fungemia | Remove catheter (mandatory) |
| Coagulase-negative staphylococci | Salvage may be attempted if clinically stable and catheter is long-term/difficult to replace; use systemic + lock therapy |
| Gram-negative bacteremia (non-Pseudomonas) | Salvage may be attempted in stable patients with long-term catheters; monitor closely; remove if no improvement in 48–72 hours |
| Pseudomonas aeruginosa | Strong consideration for catheter removal due to high relapse rates with salvage |
| Mycobacterial CRBSI (nontuberculous mycobacteria) | Remove catheter — NTM biofilm is extremely difficult to eradicate |
1.3 Hemodialysis Catheters
Central venous catheters used for hemodialysis carry among the highest CLABSI rates of any catheter type due to frequent manipulation (3 times per week), large-bore lumens, and the immunocompromised state of patients with end-stage renal disease.15
1.3.1 Hierarchy of Vascular Access for Hemodialysis
A well-established hierarchy of preferred vascular access exists for hemodialysis, based on infection risk and long-term vascular outcomes:5
| Access Type | Relative Infection Risk | Preferred Status |
|---|---|---|
| Native arteriovenous fistula (AVF) | Lowest | Most preferred — “Fistula First” initiative |
| Arteriovenous graft (AVG) | Intermediate | Second choice when AVF not feasible |
| Tunneled cuffed hemodialysis catheter | High | Third choice — for patients awaiting maturation of AVF/AVG or those without permanent access options |
| Nontunneled hemodialysis catheter | Highest | Temporary use only; replace with tunneled catheter if HD access needed >1–2 weeks |
1.3.2 Prevention Strategies for Hemodialysis Catheters
| Strategy | Details |
|---|---|
| Minimize catheter use | Promote timely AVF/AVG creation and maturation; every effort should be made to avoid catheter-dependent dialysis |
| Site selection | Internal jugular vein preferred (right side when possible); avoid subclavian (risk of subclavian vein stenosis precluding future AVF); avoid femoral when possible1 |
| Topical antibiotic/antiseptic ointment | Apply povidone-iodine ointment or polysporin/bacitracin-based ointment at the catheter exit site after each dialysis session and at dressing changes (check catheter material compatibility)15 |
| Antimicrobial lock solutions | Recommended for tunneled hemodialysis catheters, especially in patients with prior CLABSI history. Options include: 4% citrate lock, taurolidine-citrate lock, or antibiotic lock (gentamicin-citrate, cefazolin). Antimicrobial lock solutions reduce CLABSI by 50–80% in hemodialysis catheter populations6 |
| Aseptic dialysis catheter access protocol | Dialysis staff should use surgical masks (patient and staff), perform hand hygiene, apply clean gloves for cap removal, then sterile gloves for catheter access; scrub catheter hubs for ≥15 seconds with antiseptic; use sterile technique throughout5 |
| Staff training and competency | All dialysis staff must complete standardized training in catheter care, aseptic technique, and infection prevention; competency should be assessed annually |
| Surveillance | Track hemodialysis catheter BSI rates separately; report to the national dialysis event surveillance system |
1.3.3 Catheter Locking Solutions for Hemodialysis
| Solution | Concentration | Advantages | Disadvantages |
|---|---|---|---|
| Heparin (standard) | 1,000–5,000 units/mL | Maintains catheter patency; widely available | No antimicrobial activity; risk of HIT |
| 4% trisodium citrate | 4% (w/v) | Anticoagulant + mild antimicrobial; low toxicity; cost-effective | Less antimicrobial activity than dedicated antimicrobial locks |
| Taurolidine-citrate | 1.35% taurolidine + 4% citrate | Broad-spectrum antimicrobial; low resistance potential; maintains patency | Higher cost than heparin; not universally available |
| Gentamicin-citrate | Gentamicin 320 mcg/mL in 4% citrate | Strong gram-negative coverage; maintains patency | Concern for aminoglycoside resistance with prolonged use; systemic absorption negligible |
| 70% ethanol | 70% ethanol | Broad-spectrum including biofilm; cost-effective | Catheter material compatibility concerns (polyurethane degradation); must check manufacturer guidance |
1.4 Long-Term Central Venous Catheters (Tunneled and Implanted Ports)
Long-term catheters (tunneled catheters and subcutaneous ports) used in oncology, long-term antibiotic therapy, TPN-dependent patients, and chronic conditions have distinct CLABSI prevention considerations:17
- Intraluminal colonization is the predominant pathogenesis mechanism (hub contamination) rather than extraluminal skin migration
- Maintenance bundle compliance is the primary prevention focus (scrub the hub, aseptic technique, dressing care)
- Port access requires specific aseptic technique: skin antisepsis over the port site with CHG-alcohol, access with a noncoring (Huber) needle using sterile technique, and secure dressing over the accessed needle
- Port de-access should follow aseptic technique with proper flushing and heparin locking per institutional protocol
- Patient and caregiver education is critical for patients who manage their catheters in outpatient or home settings (e.g., home TPN, home antibiotic infusion)
2. Surveillance and Reporting
2.1 NHSN Surveillance Methodology
The national healthcare safety reporting network provides a standardized methodology for CLABSI surveillance that enables valid inter-facility and intra-facility comparisons.89
Required Data Elements:
| Element | Description |
|---|---|
| Numerator | Number of CLABSIs identified using standardized surveillance definitions during the reporting period |
| Denominator | Total number of central line-days during the reporting period (sum of the number of patients with one or more central lines on each day of the reporting period) |
| CLABSI rate | (Number of CLABSIs / Number of central line-days) x 1,000 = CLABSIs per 1,000 central line-days |
| Central line utilization ratio | Number of central line-days / Number of patient-days |
| Location type | Each unit maps to a specific location type (e.g., medical ICU, surgical ICU, NICU by birthweight category) for appropriate benchmarking |
2.2 Standardized Infection Ratio (SIR)
The SIR is the primary summary metric used for national and state-level CLABSI benchmarking and public reporting. It is a risk-adjusted measure that compares the observed number of infections to the expected number based on national baseline data.89
SIR = Observed Number of CLABSIs / Expected Number of CLABSIs
| SIR Value | Interpretation |
|---|---|
| SIR = 1.0 | Facility CLABSI rate equals the national baseline |
| SIR < 1.0 | Facility CLABSI rate is lower than the national baseline (better performance) |
| SIR > 1.0 | Facility CLABSI rate is higher than the national baseline (worse performance) |
| Statistical significance | Determined by 95% confidence interval; if the CI excludes 1.0, the difference is statistically significant |
Expected number of CLABSIs is calculated by multiplying the number of central line-days in each location type by the national pooled mean CLABSI rate for that location type, then summing across all locations. This risk-adjustment accounts for differences in patient case mix across unit types.
2.3 Surveillance Best Practices
| Practice | Details |
|---|---|
| Trained infection preventionists (IPs) | CLABSI surveillance should be conducted by trained IPs who have completed standardized training on the national surveillance definitions and methodology |
| Prospective surveillance | Active, prospective laboratory-based surveillance (reviewing blood culture results daily and assessing central line presence) is the gold standard; retrospective chart review alone is less sensitive |
| Consistent application of definitions | The surveillance definition is applied uniformly — CLABSI is an association-based (not causation-based) definition; secondary BSI exclusion rules must be applied rigorously |
| Denominator data collection | Daily central line-day counts should be collected consistently; methods include daily census at a fixed time or electronic extraction from the EHR |
| Data validation | Internal validation assessments and periodic external validation (e.g., state health department validation surveys) ensure data accuracy |
| Feedback to clinical staff | CLABSI rates and SIR should be reported to frontline staff regularly (at least monthly) using clear, visual displays (run charts, control charts) |
| Investigate every CLABSI | Each CLABSI event should trigger a root cause analysis or structured review to identify contributing factors and opportunities for improvement |
2.4 Mandatory Reporting
Many U.S. states mandate public reporting of CLABSI rates through the national healthcare safety reporting network. Additionally, the hospital value-based purchasing program and hospital-acquired condition reduction program use CLABSI performance metrics for payment adjustments. Hospitals in the bottom quartile of HAI performance may face financial penalties.9
3. Implementation Science and Quality Improvement
3.1 The Comprehensive Unit-Based Safety Program (CUSP) Framework
The CUSP framework is a structured quality improvement approach that integrates evidence-based technical interventions (the central line insertion and maintenance bundles) with adaptive interventions that address the culture of safety, teamwork, and communication within clinical units.1011
CUSP Components:
| Component | Description |
|---|---|
| Science of safety education | Staff learn about the science of patient safety, human factors, systems thinking, and the epidemiology of healthcare-associated infections |
| Identify defects | Frontline staff (nurses, physicians, respiratory therapists, pharmacists) identify safety hazards and system failures through structured assessments (“How will the next patient be harmed on this unit?”) |
| Senior executive partnership | A senior hospital executive (CMO, CNO, VP) is paired with each unit to provide leadership support, remove barriers, and champion safety initiatives |
| Learn from defects | Root cause analyses and structured event reviews are conducted for each CLABSI and near-miss; lessons are shared with the team and used to drive system improvements |
| Implement teamwork and communication tools | Daily goals sheets, structured handoffs, multidisciplinary rounds, and team communication strategies (such as structured briefings and debriefings) are implemented |
Evidence for CUSP:
The statewide collaborative initiative in Michigan combined the CUSP framework with the central line insertion bundle and achieved a 66% sustained reduction in ICU CLABSI rates.11 The national safety program subsequently extended the CUSP-CLABSI model to over 1,000 ICUs across 44 states, demonstrating a 41% reduction in CLABSI nationally with sustained results over 18–24 months.12 The CUSP model has since been adapted for other HAIs (CAUTI, VAP, SSI) and has been endorsed as a best practice for implementing infection prevention bundles.
3.2 Daily Goals Checklist
A daily goals checklist (also called a daily goals sheet or daily rounding checklist) is a structured tool used during multidisciplinary ICU rounds to ensure that all elements of patient care — including CLABSI prevention — are systematically reviewed for every patient every day.1013
CLABSI-Related Items on the Daily Goals Checklist:
| Item | Question |
|---|---|
| Central line necessity | “Does this patient still need a central line today? Can we transition to peripheral IV or midline?” |
| Central line site assessment | “Is the central line dressing intact, clean, and dated? Is the insertion site free of signs of infection?” |
| Dressing change needed | “Is the dressing due for replacement (every 7 days for transparent, every 2 days for gauze)?” |
| CHG bathing | “Has the patient received daily CHG bathing?” |
| Tubing change intervals | “Are administration sets due for replacement based on infusate type?” |
| Central line insertion bundle compliance (for new lines) | “Was the full insertion bundle followed for any central lines placed today?” |
3.3 Nurse Empowerment and Interdisciplinary Collaboration
Nurse empowerment to halt procedures and challenge practices that violate evidence-based protocols is a critical cultural component of successful CLABSI prevention programs.101113
Key Principles:
- Authority to stop the line: Bedside nurses are explicitly authorized and expected to halt a central line insertion if any bundle element is violated (hand hygiene not performed, sterile barrier break, chlorhexidine not applied, improper site without documentation of rationale)
- Speaking up for safety: Nurses should be trained and supported in using structured communication tools (e.g., CUS — “I’m Concerned, I’m Uncomfortable, this is a Safety issue”) to escalate safety concerns without fear of retribution
- Shared accountability: CLABSI prevention is a team responsibility — physicians, nurses, pharmacists, respiratory therapists, and support staff all play defined roles
- Non-punitive culture: Safety events and near-misses are treated as opportunities for system improvement, not as bases for individual blame
- Feedback loops: Bundle compliance data and CLABSI rates are shared with all team members regularly, reinforcing ownership and accountability
3.4 Central Line Insertion Cart and Standardization
Standardization of the insertion process through a dedicated central line cart, pre-assembled insertion kits, and a mandatory pause (time-out) before insertion reduces variability, prevents omission of bundle elements, and supports a culture of safety.1011
Standardization checklist:
| Element | Standard |
|---|---|
| All supplies in one location | Central line cart or pre-assembled kit readily available in the ICU |
| Insertion checklist present | Printed checklist attached to cart or included in kit |
| Observer role assigned | Bedside nurse or designated observer reviews checklist in real time |
| Time-out performed | Standardized pause before skin puncture to verify indication, site, and bundle compliance |
| Post-insertion documentation | Real-time documentation of bundle compliance, insertion site, catheter type, number of attempts, and any complications |
3.5 Team Communication Strategies
| Strategy | Application to CLABSI Prevention |
|---|---|
| Multidisciplinary rounding | Daily ICU rounds include discussion of central line necessity, dressing status, and maintenance bundle compliance for every patient |
| Structured handoffs | Shift-change and transfer-of-care handoffs include central line status, insertion date, dressing condition, and outstanding maintenance tasks |
| Safety huddles | Brief (5–10 minute) team huddles at shift start to identify patients with central lines, discuss any concerns, and assign catheter care tasks |
| Unit-level CLABSI data sharing | Monthly posting of CLABSI rates, SIR trends, and bundle compliance data on the unit (visual management boards); celebration of milestones (e.g., days since last CLABSI) |
| Peer-to-peer accountability | Culture in which any team member can respectfully remind colleagues about hand hygiene, hub disinfection, or dressing integrity |
4. Achieving and Sustaining Zero CLABSI
4.1 The Zero-Harm Aspiration
While zero CLABSI is not universally achievable in every patient population and clinical context, many ICUs have demonstrated that sustained periods of zero CLABSI are attainable through comprehensive, rigorous, and sustained implementation of evidence-based practices. The goal of zero — rather than “acceptably low” — is a powerful cultural driver that frames every CLABSI as a preventable harm warranting investigation and corrective action.1114
4.2 Key Elements of Sustained Zero CLABSI
| Element | Details |
|---|---|
| Leadership engagement | Administrative and clinical leaders visibly prioritize CLABSI prevention; resources (staffing, supplies, education) are committed; CLABSI performance is a standing agenda item at leadership meetings |
| Bundle compliance >95% | Both insertion and maintenance bundle compliance are measured regularly and maintained above 95%; any decline triggers immediate corrective action |
| Active surveillance with rapid feedback | Every potential CLABSI is identified promptly; root cause analyses are conducted within days; findings are shared with the team; corrective actions are implemented and tracked |
| Ongoing education and competency assessment | Annual education for all staff involved in central line insertion and maintenance; competency verification for critical skills (insertion technique, dressing changes, hub disinfection); onboarding training for new staff |
| Sustained culture of safety | Non-punitive reporting, empowered frontline staff, interdisciplinary collaboration, and continuous improvement mindset are embedded in unit culture |
| Avoiding complacency | Units with sustained low or zero CLABSI rates are at risk of “prevention fatigue” — diminished vigilance and declining compliance over time; strategies to combat complacency include regular bundle compliance audits, refresher education, simulation exercises, and celebration of sustained performance |
| Escalation protocol | Any CLABSI event triggers a standardized escalation process: immediate notification of unit leadership and infection prevention; structured event review within 48–72 hours; identification of contributing factors; implementation of corrective actions; follow-up to verify effectiveness |
| Patient and family engagement | Educate patients and families about central line care, the importance of hand hygiene, and how to speak up if they observe potential lapses in catheter care (e.g., healthcare workers not performing hand hygiene before accessing the line) |
4.3 Addressing the Post-Pandemic Challenge
The COVID-19 pandemic disrupted CLABSI prevention gains in many facilities, with increased rates attributed to staffing shortages, use of unfamiliar temporary staff, increased central line utilization in critically ill COVID-19 patients, reduced infection prevention oversight capacity, and supply chain disruptions (CHG products, dressing supplies). Recovery strategies include:15
| Strategy | Details |
|---|---|
| Recommitment to bundles | Re-establish insertion and maintenance bundle compliance monitoring; retrain staff who may have lapsed during pandemic surges |
| Staffing stabilization | Address nurse-to-patient ratios; ensure adequate staffing for catheter care responsibilities |
| Focused auditing | Increase the frequency of bundle compliance audits in the post-pandemic recovery period |
| Re-engagement with CLABSI data | Restart monthly data feedback to frontline staff; recalibrate SIR targets based on current baseline |
| Re-establishing team communication | Resume daily goals checklists, safety huddles, and multidisciplinary round discussions about central line care |
5. Technology and Innovation
5.1 Electronic Health Record (EHR) Integration
| Application | Details |
|---|---|
| Central line insertion documentation | Structured EHR templates that prompt documentation of all bundle elements (hand hygiene, sterile barriers, antisepsis, site, indication) |
| Daily central line necessity alerts | Automated clinical decision support that prompts providers to reassess central line necessity daily; best practice alerts fire for lines in place >X days without an active indication |
| Surveillance automation | Automated CLABSI surveillance algorithms that identify potential events from blood culture results and central line documentation, flagging cases for infection preventionist review |
| Bundle compliance dashboards | Real-time dashboards displaying insertion and maintenance bundle compliance rates, CLABSI rates, and SIR trends |
| Dressing change reminders | EHR-generated reminders for scheduled dressing changes based on dressing type and last change date |
5.2 Emerging Technologies
| Technology | Status | Potential Impact |
|---|---|---|
| Antimicrobial catheter coatings (next-generation) | Under investigation | Novel surface modifications (silver nanoparticle coatings, zwitterionic polymer coatings, biofilm-disrupting enzyme coatings) aim to further reduce catheter colonization |
| Real-time catheter tip monitoring | Early research | Sensor-based detection of biofilm formation on catheter surfaces; could enable preemptive catheter removal before BSI develops |
| UV-C disinfection of connectors | Commercially available | Automated UV-C devices that disinfect needleless connectors in seconds; may standardize disinfection and reduce variability |
| Closed infusion systems | Commercially available | Pre-connected, closed infusion systems that minimize hub manipulation; may reduce intraluminal contamination risk |
| Machine learning for CLABSI prediction | Under development | Predictive models using EHR data (lab values, vital signs, catheter days, medications) to identify patients at highest risk of impending CLABSI, enabling targeted preventive interventions |
6. Summary of Recommendations by Evidence Tier
Tier 1: Essential Practices (Implement Universally)
| Practice | Evidence Level |
|---|---|
| Education and training of all personnel involved in central line insertion and maintenance | IA |
| Hand hygiene before and after insertion, access, and care of central lines | IA |
| Maximal sterile barrier precautions during insertion | IB |
| >0.5% chlorhexidine-alcohol skin antisepsis for insertion and dressing changes | IA |
| Optimal site selection (subclavian preferred in adults, avoid femoral when possible) | IA |
| Daily assessment of central line necessity with prompt removal of unneeded lines | IA |
| Aseptic technique for all catheter access (scrub the hub ≥15 seconds) | IA |
| Appropriate dressing management (transparent every 5–7 days, gauze every 2 days) | IB |
| Administration set change intervals per infusate type | IA |
| Active CLABSI surveillance with feedback of rates to clinical staff | IA |
Tier 2: Supplemental Practices (Implement When CLABSI Rates Remain Elevated Despite Tier 1)
| Practice | Evidence Level |
|---|---|
| Daily CHG bathing for ICU patients | IB–II |
| CHG-impregnated dressings | IB |
| Antimicrobial-impregnated catheters (M-R or second-generation CHG-SS) | IA–IB |
| Passive disinfection caps for needleless connectors | II |
| Antimicrobial lock solutions for hemodialysis catheters | IB |
| Topical antibiotic ointment at hemodialysis catheter exit sites | IB |
Tier 3: Implementation and Culture (Essential Infrastructure)
| Practice | Evidence Level |
|---|---|
| Comprehensive unit-based safety program (CUSP) or equivalent quality improvement framework | II (strong observational evidence) |
| Central line insertion checklist with real-time observer | II |
| Nurse empowerment to stop procedures for safety violations | II |
| Daily goals checklist including central line assessment | II |
| Multidisciplinary rounding with central line discussion | II |
| Root cause analysis for every CLABSI event | II |
| Monthly feedback of CLABSI rates and bundle compliance to frontline staff | IA |
7. Evidence Grading System
The evidence categories referenced throughout this guideline follow the system used by the national healthcare infection control advisory committee:1
| Category | Definition |
|---|---|
| IA | Strongly recommended for implementation and supported by well-designed experimental, clinical, or epidemiologic studies |
| IB | Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale |
| IC | Required for implementation as mandated by federal and/or state regulation or standard |
| II | Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale |
| Unresolved | Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists |
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