Transcript Saint Francis Hospital CLBSI

Saint Francis Hospital
CLBSI
Tennessee Patient Safety Initiative
August 28, 2008
Terri Stewart MSN, RN
Saundra Jirik MSN, RN
Do We Have a Problem?
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Too many central line infections
Identified infections were a
maintenance issue
Femoral lines inserted in emergent
situations
Do We Have a Problem?
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Large number of PICC lines inserted
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Multiple types of line kits in hospital
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Handwashing practices
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High risk populations: Sickle Cell
Do We Have a Problem?
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Lack of Bundle Compliance by
physicians
Education issues: Current staff and
Agency staff
Do We Have a Problem?
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High risk populations: Sickle Cell
Lack of Bundle Compliance with
physicians
Education issues: Current staff and
Agency staff
Do We Have a Problem?
Central
Lines
Do We Have a Problem?
Quit Blaming someone else
I’m the problem
Plan of Action
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
Developed Central Line Task Forcemultidisciplinary -- Root Cause
Analysis
Housewide education of Nursing
Staff
Save the Line Campaign
 Line Audits

Plan of Action
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Nurses empowered to stop
Physicians if not following Bundles
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Developed Checklist
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Femoral Lines changed in 24 hours
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Line Alert
Developed PICC Criteria
Plan of Action
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Patient Education Sheet
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Customized dressing kits
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Shared Line Audit results /BC
results with staff
Eliminated blood draws from central
lines
Getting to Zero
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Involved staff in solution
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Unit analysis of (+) blood cultures
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TEGO for Dialysis lines
Getting to Zero
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Scrub the Hub Campaign with
Chlorhexadine
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Handwashing Focus
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PICC insertions in Radiology
Where are we Now?
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83% reduction in CLI in ICU
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65.6% reduction in CLI housewide