voluntary surveillance is the heterogenous set of hospitals participating over the years, with different patient populations, initial CRBSI incidences, and reporting rates. This complicates straightforward interpretation of the results and multilevel analysis can only partially account for this. Second, there was no standardized way of collecting the data from the patient file (checklist or text), and it was at each hospital’s discretion to decide how to organize the, sometimes challenging, recording of the compliance with the bundle elements. Checklist items are not necessarily reported correctly[17]. While word had it that a few hospitals default reported ‘yes’ for all bundle elements, because it was considered daily practice in their hospital, most hospitals only reported information that was available in the patient file. A hospital that by default answered ‘yes’ for all elements probably overestimated compliance, but hospitals only reporting information available from the patient file, may have underestimated compliance. Removing the hospital years reporting 100% compliance from the data gave highly similar results (not shown). Third, in this real‐life setting hospitals may differ in culturing practices. While some hospitals culture all CVCs, others only culture the CVCs that are suspected of CRBSI. This might have changed over time in hospitals and between hospitals during the study period. In conclusion, following a national program to introduce an intervention bundle, CRBSI incidence decreased significantly. In the ICU, with relatively low CRBSI incidence, the compliance with the CRBSI intervention bundle was not associated with CRBSI risk. Outside the ICU, the introduction of a CRBSI bundle appeared to be an effective method to reduce CRBSI rates. Hospitals and departments with relatively high CRBSI incidences will benefit from implementing the CRBSI intervention bundle to improve patient care. ACKNOWLEDGEMENTS The authors wish to thank all participating hospitals and hospital staff for their contribution. 230 Chapter 9
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