National Patient Safety Awareness Week

We achieved a 51% reduction in our facility wide, mean CLABSI rate in 2009 compared with calendar year 2008. Our CLABSI rate in 2007 was 4.6. Unfortunately, our rate increased in 2008 to 5.5, partly due to a transition to a valve system for accessing IV lines. In 2009, we had 53, 323 line days and 144 CLABSI events, 101 less than the year before, and a mean rate of 2.7.Our journey began in 2006/2007 with implementation of a central line insertion bundle, development of a policy to support the implementation and empowerment of nurses to monitor and stop line insertion procedures. We also began auditing compliance with the bundle and providing feedback to physicians, management, and staff.In February 2008, we transitioned to the Smart Site valve and began seeing an increase in CLABSI rates within a month. With repeated educational efforts, the CLABSI rates did not decrease. In September 2008, we formed a Zero BSI team to address the increasing rates. Four pilot inpatient units and Ambulatory Care participated. Our goal was to achieve rates of zero in all four units by April 2009. Our team focused on development of an IV line care and maintenance bundle and very specific BSI prevention educational modules for all staff that touch IV lines. The educational modules were completed by pilot unit staff and have become part of clinical orientation as well as being required of current staff. We surveyed staff prior to and after education, audited IV line care and access practices and developed a Clinical Scene Investigation tool for the investigation of BSI events. By April 2009, there was only one CLABSI in the four pilot units. We then rolled out the new bundle and the educational modules housewide. Also, reduction of CLABSI rates is a leadership evaluation goal for appropriate management staff. We improved feedback and transparency of individual unit rates. In late 2009, we joined the Stop BSI initiative and have 16 units enrolled in teams. Departments, such as Anesthesia, Pharmacy, the Emergency Departments, Interventional Radiology, are represented on our teams. Teams are developing daily goals checklists, monitoring compliance with the line insertion bundle, sharing The Science of Safety and Josie King Story videos with staff. Not only are individual teams meeting, we also meet once a month as a group with representatives from each team. We have calculated CLABSI events prevented and calculated excess days and costs prevented and lives saved and have shared this information throughout the facility. We continue to stress our goal of zero CLABSI. Dr. Pronovost, if you are reading this, we wish to have you and Dr. Miller visit the Medical University of South Carolina. Dr. Michelle Hudspeth with our Children’s Hospital has communicated with Marlene and I have been in touch with Christine. Please come help us drive our rates to zero.

Linda Formby

Manager, Infection Prevention and Control

Medical University of South Carolina

SC