Maintaining Zero Infections: Central Line Associated Blood Stream Infections

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
mfarahani@hqinstitute.org.