Central Line Associated Blood Stream Infections Centinela Hospital Medical Center AIM Statement

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