Central Line Associated Blood Stream Infections Centinela Hospital Medical Center AIM Statement
Central Line Associated Blood Stream Infections
Centinela Hospital Medical Center
Reduce CLABSI rate by 40% from 2011
baseline of .64% to .32% by
• Implement real-time debrief team huddles
when a CLABSI is identified.
• Incorporate high reliability tools/training.
• Infection Control Chair: Dr. Patrice Marcarelli,
Test (T), Interventions (I), Spread (S)
• Implemented scrub-the-hub campaign and
• Chief Nursing Officer: Mohammed Naser,
• Implemented Dual Caps (disinfectant caps)
on all central lines. (I,S)
• Daily CHG baths in critical care areas and
high risk patients. (T,I,S)
• Hardwired the process for assessing
continued need for the central line daily.
• Requirement of completing the CLIP
adherence bundle form. (T,I,S)
• Director of Nursing: Lakesha Dixon, RN
• Director Medical/Surgical: Kennetha Gaines,
Data Source: Comprehensive Data System-HRET as of 09-09-2014
• Need to standardize practices for dressing change.
• Annual competency of all staff. (I,S)
• System wide practice changes require more time.
• Monitoring the utilization of all central lines
(daily needs assessment). (T,I,S)
• Analysis of each CLABSI to identify root
• Implement electronic triggers for
maintenance & dressing changes. (T,I,S)
• Director Telemetry: Denise Flaws, RN, BSN
• Director Critical Care: Cecilia Pacleb, RN
• Review policies to ensure that all CLIP
components are addressed. (I,S)
• ICP rounding on all central line patients. (I,S)
• Director Cardiology: Tony Gasset, RN, BSN
• Director Infection Prevention: Tavonia
Ekwegh, RN, DNP, RN-C
• Infection Preventionists:
• Jean Browne, RN
• Katrina Ang, IP
• Darick Hays, IP
• HQI CLABSI Harm Elimination Toolkit is available on the
HQI website at hqinstitute.org < Tools and Resources.
• Questions: Contact Mahsa Farahani, Project Manager, HQI
at 916-552-7521, email [email protected]
• Praveena Mallam, PA
• Coordinator: Dawn Jones, IP