Primary bloodstream infections associated with central venous catheters (CLABSI) represent serious adverse events in oncology patients hospitalized in intensive care units (ICUs), contributing to increased morbidity, length of stay, and hospital costs. In June 2024, a marked increase in the incidence density (ID) of CLABSI was identified in a 34-bed oncological ICU. The objective of this study was to describe the extraordinary actions adopted and to evaluate their impact on reducing the infection rate.

A quasi-experimental study with retrospective analysis, conducted in a public quaternary oncology hospital. The intervention occurred between July and September 2024. Initially, a root cause analysis was conducted using the Ishikawa diagram. Subsequently, corrective measures were defined using the 5W2H tool and included: in-person training on catheter insertion and maintenance, daily bedside audits using checklists, intensified active surveillance, implementation of the central venous catheter maintenance bundle in the electronic medical record, technovigilance of vascular access devices, and feedback of indicators with a shared action plan. Intervention effectiveness was assessed by comparing the CLABSI incidence density (number of infections per 1,000 catheter-days) before and after the intervention, using a chi-square test for two Poisson rates. Statistical significance was considered at p < 0.05.

The CLABSI ID in June 2024 reached 10.8, a value well above the 2023 annual average (3.8). After the intervention, a progressive decline in incidence density was observed: July (5.8), August (5.5), and September (0.0) infections per 1,000 catheter-days (p = 0.005). Care audits demonstrated greater adherence to recommended practices, with immediate correction of nonconformities. The multidisciplinary approach fostered team engagement and contributed to the sustainability of the implemented actions.

The adoption of structured interventions based on root cause analysis and multidisciplinary strategies significantly reduced the ID of CLABSI in an oncological ICU. The sustained decline, together with improved adherence to safe practices, demonstrates the positive impact of educational actions, systematic audits, and proactive risk management. The results reinforce the importance of continuous surveillance and engagement of healthcare teams in infection prevention.