aim statement

Decrease Central Line Associated Blood Stream Infection Rate

from .4 to .24 from 2011 baseline by December 31, 2013.

Why is this project important?An estimated 41,000 central line-

associated bloodstream infections(CLABSI) occur in U.S.

hospitals each year. These infections are usually serious infections typically causing a

prolongation of hospital stay and increased cost and risk of

mortality (cdc.gov/nhsn/psc manual.pdf).

Aim Statement

Changes being Tested, Implemented or Spread

Recommendations and Next Steps

Lessons LearnedRun Charts

• Use of “Swab Caps” with dressings consisting of Biopatch with Sorbeview. (Implemented)

• Initiated the use of a CLIP kit (a bundle including drape, mask, gown, sign for outer door) & instructed nursing to close the room door during procedure. (Implemented)

• Redirected staff to encourage MD use of jugular over femoral access & to utilize anesthesia providers over cardiology or surgeons. (Implemented)

• Procedure /dressing change requires two (2) participants, a principle, and assistant.

• All supplies related to/used for central lines are kept in a centralized place. (medication room in RED bins).

Team Members

CLABSIPalmdale Regional Medical Center,

Palmdale, CA

• Ongoing surveillance to ensure practice of having a two person dressing change team.

• Accountability for sterile procedures.• Encourage the same vigilance with central

line processes vs. peripheral IV lines.

• Diane Morrow, RN, Director, ICU-Team Lead• Jack Schwartz, MPA, CMRP, Director Supply

Chain• Karen Faulis, RN, Chief Operating Officer• Michael Cohen, MD, Infectious Disease• Joan Cordova, RN, MSN, Manager, Infection

Control• Suzette Creighton, MA, CPHRM, CPHQ,

HACP, Director, Quality• Nawanna Chaidez, RN, CPHQ, HACP,

Director, Risk Management• David Choi, Director, PharmD, Pharmacy• Tracy Denley, LVN, Infection Control

Assistant