Central Line Associated Blood Stream Infections Centinela Hospital Medical Center Inglewood, CA November, 2014 AIM Statement Run Chart Reduce CLABSI rate by 40% from 2011 baseline of .64% to .32% by December 2014. • Implement real-time debrief team huddles when a CLABSI is identified. • Incorporate high reliability tools/training. Team Members Interventions • Infection Control Chair: Dr. Patrice Marcarelli, MD Test (T), Interventions (I), Spread (S) • Implemented scrub-the-hub campaign and training. (I,S) • Chief Nursing Officer: Mohammed Naser, RN, MSN • Implemented Dual Caps (disinfectant caps) on all central lines. (I,S) • Daily CHG baths in critical care areas and high risk patients. (T,I,S) • Hardwired the process for assessing continued need for the central line daily. (T,I,S) • Requirement of completing the CLIP adherence bundle form. (T,I,S) • Director of Nursing: Lakesha Dixon, RN • Director Medical/Surgical: Kennetha Gaines, RN, MSN Data Source: Comprehensive Data System-HRET as of 09-09-2014 Lessons Learned • Need to standardize practices for dressing change. • Annual competency of all staff. (I,S) • System wide practice changes require more time. • Monitoring the utilization of all central lines (daily needs assessment). (T,I,S) • Analysis of each CLABSI to identify root cause. (I,S) • Implement electronic triggers for maintenance & dressing changes. (T,I,S) • Director Telemetry: Denise Flaws, RN, BSN • Director Critical Care: Cecilia Pacleb, RN • Review policies to ensure that all CLIP components are addressed. (I,S) • ICP rounding on all central line patients. (I,S) Next Steps • Director Cardiology: Tony Gasset, RN, BSN • Director Infection Prevention: Tavonia Ekwegh, RN, DNP, RN-C • Infection Preventionists: • Jean Browne, RN • Katrina Ang, IP • Darick Hays, IP Resources • HQI CLABSI Harm Elimination Toolkit is available on the HQI website at hqinstitute.org < Tools and Resources. • Questions: Contact Mahsa Farahani, Project Manager, HQI at 916-552-7521, email [email protected]. • Praveena Mallam, PA • Coordinator: Dawn Jones, IP