Patient safety

Bacteriemia Zero

Preventing bloodstream infections from central line venous catheters in Spanish ICUs

Purpose of this demonstration project

Building on the early success of the Keystone ICU project in Michigan State, USA to reduce catheter-related bloodstream infections (CRBSI), a collaborative agreement was established in 2008 between the Spanish Ministry of Health, Social Policy and Equality (SMoH) and WHO Patient Safety, in collaboration with the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Johns Hopkins Quality and Safety Research Group (QSRG), to assess the applicability and effectiveness of the intervention in large scale implementation throughout Spanish ICUs.

As a result, the nationwide multifactorial intervention programme, called “Bacteriemia Zero”, was designed and implemented over an 18-month period.


The Bacteriemia-zero project has translated the work from the Keystone ICU project to fit the Spanish context. All 17 health regions of the Spanish National Health System participated in the study, supported by a coordination team at national and regional levels. The implementation was conducted between April 2008 and June 2010. The original materials were adapted according to organizational and cultural characteristics. Engagement, education, execution and evaluation were key programme features, which included clinical and safety related activities at the ICU level. Data was regularly collected to facilitate the evaluation.

A total of 192 ICUs (68% of all ICUs in the country) participated in the project, involving more than 14 800 health-care professionals including physicians, registered nurses, clinical assistants and other professionals)

The intervention was effective in reducing the incidence of CRBSI by approximately 50%, in all types of hospitals.

With almost 70% of the Spanish ICUs from all regions, and over 100 000 ICU admissions over the study period, this experience is a solid example of the effectiveness of the intervention in settings with different structural, economic, social, and cultural characteristics.

This study demonstrates that large scale reductions in preventable harm are possible if guided by science, include rigorous measurement, are collaborative and sensitive to contextual differences among countries and hospitals.

What next

Bacteriemia Zero offers valuable lessons in patient safety which can help understand the role of the different enablers, barriers and success factors to implementing interventions to reduce catheter-related bloodstream infections. Learning from implementation and disseminating the lessons for wider policy change worldwide were both recognized as priority goals for WHO Patient Safety.

A package of documents is now being defined by WHO for adaptation and use globally with the aim of reducing catheter-related bloodstream infections internationally.