When central line-associated bloodstream infections (CLABSIs) spiked in an oncology unit of an acute care hospital in Philadelphia from October 2009 to March 2010, noncompliance with intravenous needleless connector disinfection was suspected as a factor. The hospital implemented a disinfection cap, a device designed to address compliance/variance issues with connector disinfection protocols. However, the incidence of CLABSIs increased again in 1 unit, apparently as the result of poor compliance with cap use. The hospital addressed the problem with multiple measures, after which the incidence of CLABSIs again continued to decline. Overall, 50% fewer CLABSIs occurred in the first 21 months after cap implementation. Potential net financial savings from cap use were calculated to be $464,440 a year.
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