CLABSI Elimination - Keep It Simple: Use of a Simple Visual Cue to Enhance Care Compliance

Background: Central line-associated bloodstream infections (CLABSI) adversely affect patient outcomes and substantially increase hospitalization costs. Methodist Mansfield Medical Center is a 160-bed, acute care, community hospital serving the DFW metroplex.  The CLABSI reduction efforts in our ICU were initially successful, but a resurgence in CLABSIs occurred within a few months of initial implementation.

Objective: To implement a team-based approach towards elimination of CLABSI in our ICU, incorporating staff suggestions to help aid visual compliance of our preventative efforts.

Methods: Our efforts leading to the initial CLABSI reduction focused on the central line (CL) insertion process. With the resurgence in CLABSIs, a Performance Improvement (PI) team was re-established. This PI team consisted of front-line ICU Nursing staff, ICU leadership, and an Infection Prevention Practitioner. The team developed a “CLABSI Problem Statement”, which provided an opportunity for an in-depth evaluation of the potential issues with the CL insertion and maintenance process that could potentially contribute to a CLABSIs. By systematic use of this tool, issues with central line maintenance were identified as the main culprit in resurgence of our CLABSIs. In addition to the CL "Bundle measures" already in place, the following additional measures were implemented:

• Daily audits of all care issues for all CLs in the ICU;
• CHG baths every 24 hrs on all patients with CL;
• CL dressings to be changed every Thursday and as needed;
• All CL tubings to be dated, including IV piggyback tubings;
• IV tubing and add-on devices changed every Thursday;
• CL caps changed aseptically every Thursday with tubing changes.

To improve compliance with the weekly cap/ tubing changes, staff suggestion for use of color coded caps was implemented (green used during the biweekly payday week, and red used for the other week).

Results:  Since implementation of the additional CLABSI prevention interventions, including color coded caps, in FY2010 QTR 2, the CLABSI rate dropped to zero in FY2010 QTR 3, and remained at zero though FY2010 QTR 4. No CLABSI has occurred in ICU since Jan. 30, 2010. The process improvement initiatives in the ICU have since been implemented throughout the remainder of the facility, and have resulted in the entire facility being CLABSI-free for over 6 months.

Conclusions: Focus on problem identification and intervention may be effective in the short-term, but sustained improvement requires ongoing monitoring, with need for further intervention when gaps in care are identified. Staff involvement in problem identification and process improvement is critical. Finally, the use of color-coded caps served as a visual cue for ensuring compliance with scheduled changes of the caps and tubings. This simple and novel intervention aided the ICU (and eventually the entire facility) in reaching the goal of CLABSI elimination.

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