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Process Redesign Leads to Lower CLABSI Incidence

Truman Medical Centers (TMC), a Kansas City, Mo., essential hospital system, recorded 17 central line-associated blood stream infections (CLABSIs) in its intensive care units (ICUs) in 2012.

To reduce the incidence of this infection, the system participated in the CLABSI collaborative of America’s Essential Hospitals former, federally supported Essential Hospitals Engagement Network. TMC also formed a CLABSI committee, which was tasked with identifying the most common causes of CLABSI within the system. These efforts helped TMC reduce the number of CLABSIs to five in 2013.

The TMC CLABSI committee examined internal data to determine which improvement strategies would have the highest return on investment. Based on the data, the committee focused on one strategy for each of the three stages of central line care: insertion, maintenance, and removal.

With respect to insertion, the committee eliminated the paper-based central line checklist and launched a streamlined, easy-to-follow program in the electronic health record (EHR). Although TMC traditionally had high compliance with the central line bundle for central line maintenance, root cause analyses showed that most CLABSIs stemmed from poor line maintenance.

To make the maintenance process more reliable, the team implemented Curos port protectors. These caps — which contain 70 percent isopropyl alcohol-saturated foam to kill bacteria and prevent infection — eliminate the need for nurses to “scrub the hub” for 15 seconds prior to accessing the central line, a time-consuming practice that often is done improperly.

Finally, to standardize the daily needs assessment and accomplish timely line removal, the team built a daily 4 am prompt into the EHR to require nurses to chart a medical necessity for the central line. If there is no medical necessity, the system automatically reprompts the nurse at 9 am to call the clinician to either have the line removed or to assign a medical necessity.

While these strategies helped reduce CLABSI incidence by 71 percent from 2012 to 2013, TMC continues to work to eradicate the infection. To achieve this goal, the team developed a CLABSI investigation tool that is used to find the source of each CLABSI in the hospital.

The checklist tool has two versions: one for clinicians involved in central line insertion and one for caregivers who helped maintain the central line. The checklists cover all the possible causes of the infection, from breaches in hand hygiene to maintenance bundle elements to patient factors and nursing ratios.

TMC said this investigation strategy holds all caregivers accountable and empowers them to become more involved in the harm reduction process, as well as allows the team to identify trends to better target CLABSI improvement strategies.

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