Elimination of Central Line Associated Blood Stream Infections on General Medical Surgical

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Advisor: Jim Pelegano MD MS


Hospital acquired central line associated blood stream infections (CLABSIs) in the intensive care unit are considered preventable and a never event for healthcare systems. Currently financial penalties are associated with these specific infections; the rates are also publically reported on Hospital Compare for healthcare consumer to review. Our current approach to hospital acquired infections is to eliminate them completely. Our current ICU acquired CLABSIs are zero and have been for several years; however we reported three CLABSI since October 2012 on our general medical surgical units. We reviewed the current practice and use of evidenced based recommendations in our processes. We completed a root cause analysis on all three CLABSIs to identify potential solution to eliminate CLABSIs throughout the entire hospital. We utilized a multidisciplinary team to develop new processes to review the data and use quality improvement tools to develop action plans to successfully eliminate CLABSI on general medical surgical floors for the subsequent six months. The team completed a failure modes effect analysis to evaluate potential failures and impacts of the failures. We leveraged the support of our Quality and Safety Committee of the Board to address any barriers encountered to achieve our strategic goal to eliminate all hospital acquired infections. There are potential associated cost savings including decrease length of stay (LOS), use of potentially costly antibiotics for treatment, and nonpayment in the future for all hospital acquired infections. Additionally avoiding hospital acquired increases patient satisfaction which is currently 30% of value based purchasing and will assist in the reduction of litigation and malpractice suits.

Presentation: 31 minutes

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