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CLABSI
Palmdale Regional Medical Center, Palmdale, CA
Aim Statement
Decrease Central Line Associated Blood
Stream Infection Rate from .4 to .24 from
2011 baseline by December 31, 2013.
Why is this project important?
An estimated 41,000 central line-associated
bloodstream infections(CLABSI) occur in
U.S. hospitals each year. These infections
are usually serious infections typically
causing a prolongation of hospital stay and
increased cost and risk of mortality
(cdc.gov/nhsn/psc manual.pdf).
Changes being Tested,
Implemented or Spread
Run Charts
Lessons Learned
• Procedure /dressing change requires two (2)
participants, a principle, and assistant.
• All supplies related to/used for central lines are
kept in a centralized place. (medication room in
RED bins).
Recommendations and Next
Steps
• Ongoing surveillance to ensure practice of having
a two person dressing change team.
• Accountability for sterile procedures.
• Encourage the same vigilance with central line
processes vs. peripheral IV lines.
Team Members
• Diane Morrow, RN, Director, ICU-Team Lead
• Use of “Swab Caps” with dressings consisting of
Biopatch with Sorbeview. (Implemented)
• Initiated the use of a CLIP kit (a bundle including
drape, mask, gown, sign for outer door) &
instructed nursing to close the room door during
procedure. (Implemented)
• Redirected staff to encourage MD use of jugular
over femoral access & to utilize anesthesia
providers over cardiology or surgeons.
(Implemented)
• Jack Schwartz, MPA, CMRP, Director Supply
Chain
• Karen Faulis, RN, Chief Operating Officer
• Michael Cohen, MD, Infectious Disease
• Joan Cordova, RN, MSN, Manager, Infection
Control
• Suzette Creighton, MA, CPHRM, CPHQ, HACP,
Director, Quality
• Nawanna Chaidez, RN, CPHQ, HACP, Director,
Risk Management
• David Choi, Director, PharmD, Pharmacy
• Tracy Denley, LVN, Infection Control Assistant