Maintaining Zero Infections: Central Line Associated Blood Stream Infections Community Hospital of the Monterey Peninsula Monterey, CA November, 2014 AIM Statement Run Chart To maintain the 40% reduction and achieved rate of zero central line associated bloodstream infections (CLABSI) in ICU 2013 and zero throughout the organization in 1Q-2Q 2014 through the use of evidencebased best practices 2012. Present (from 0.47 baseline to zero target) Continue reinforcement of spread through performance reports targeted for audience. Team Members • Infection Prevention Work Group (infection control committee; includes physician leaders), all act as leads for project message • Physician champions: • Medical Director ICU: Dr. John Koostra, MD Interventions Data Source: Comprehensive Data System-HRET as of 09-09-2014 • Insertion checklist developed and utilized. • Mask. • Hair cover. • Sterile gowns. • Sterile gloves. • Maximum sterile barrier drape. • Spread: CHG skin cleansing, CHG split dressing (BioPatch) throughout the hospital. CHG daily bath for ICU patients and surgical patients on morning of surgery through postoperative day 2. • ScrubSite alcohol-impregnated sponge devices to enable aseptic port access including disinfection of internal as well as external lumen of some devices. • Medical Director Infection Prevention: Dr. Rita Koshinski, DO • Infection Prevention Coordinator, Quality Management Department: Patti Emmett, MS,RN,CIC • Maintain 100% compliance with bundle: • Clean hands. Next Steps Lessons Learned • ICU champion (director and an intensivist) on board up front essential to quickly move practice patterns. • Prompt feedback on changes in infection rates reinforces practice improvements (infection prevention). • Addition of earlier CHG bathing of surgical patients is possible now with our new Pre-Operative Clinic, consistent with IHI recommendations. • Real time case drilldown to understand trigger for spikes and analyze root cause. • ScrubSite device remains well-accepted among caregivers and patients. • Nurse Director ICU: Deborah Sober, BSN, CCRN • Data Analyst (EMR, Reports): Ro Davies 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].