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P13 - CLABSI: From a Devastating Loss to a Successful Story

Introduction: Central line-associated bloodstream infections (CLABSIs) have been designated as a “never event” and may result in increase in hospital cost and increased risk in morbidity and mortality. There are an estimated 250,000 bloodstream infections that occur in the U.S. annually. The CLABSI rate is estimated to be at 0.8 per 1000 central line days in ICUs (CDC.gov, 2019). The data are sparse in the number of cases outside of ICU. In 2019, the Centers for Disease Control (CDC) reported through the National Healthcare Safety Network (NHSN), the acute care hospital reporting to NHSN of CLABSIs by state differentiating ICU cases versus non-ICU cases. That year, there were 12,039 cases in ICUs and 13,784 cases in the wards. In all cases, 35% of mortality was attributed to CLABSI infections.

This story began in a 35-bed medicine/telemetry unit of a large urban academic level-one hospital on July 25, 2017. A patient was admitted with an accessed central line in situ and developed severe sepsis that day. It progressed rapidly and resulted in negative patient outcome which was attributed to CLABSI. This devastating loss resonated with the staff and served as an impetus for the unit leadership to prompt initiatives towards a zero-CLABSI standard.

Purpose: The purpose of the initiative is to optimize central line maintenance care and surveillance of practices and reduce and potentially eliminate CLABSI in a non-ICU setting of an urban academic medical center. An objective is to elevate the knowledge base and skill set of direct care nurses.

Description: The theoretical framework of Lewin’s change theory was used for the unit’s CLABSI eradication program.

Unfreeze: Education of staff regarding the problem of CLABSI, contributing factors and outcomes, established CLABSI prevention practices.

Change: CLABSI champions, just-in-time coaching, leadership rounding, daily central line audit tool; two RN-site and dressing assessment in-between shifts.

Refreezing: Post number of days without CLABSI daily on the quality board, check necessity of central lines daily during multidisciplinary rounds or huddles with health care team and spot checks.

Other interventions implemented as supplemental to the core measures are:
• Patient and visitor education about central lines and prevention of infection tactics
•    Utilization of checklists when manipulating central lines like dressing changes, drawing of blood specimen, de-clotting of line by CLABSI unit champions
•    Collaboration with physicians for blood culture draws as baseline data on patients with pre-existing central lines on admission to the hospital
•    Implementation of a 10 must-haves list for CLABSI eradication for the staff to include in daily practice as standard work

Outcome: Since July 25, 2017, the unit has zero CLABSI. It has been 1,390 days without CLABSI as of May 15, 2021. The next steps are to maintain and sustain the standard work surrounding CLABSI eradication with new staff to ensure the continuation of this successful story.