1. Saint Francis Hospital CLBSI Tennessee Patient Safety Initiative August 28, 2008 Terri Stewart MSN, RN Saundra Jirik MSN, RN

2. Do We Have a Problem? Too many central line infections Identified infections were a maintenance issue Femoral lines inserted in emergent situations

3. Do We Have a Problem? Large number of PICC lines inserted Multiple types of line kits in hospital Handwashing practices High risk populations: Sickle Cell

4. Do We Have a Problem? Lack of Bundle Compliance by physicians Education issues: Current staff and Agency staff

5. Do We Have a Problem? High risk populations: Sickle Cell Lack of Bundle Compliance with physicians Education issues: Current staff and Agency staff

6. Do We Have a Problem? Central Lines

7. Do We Have a Problem? Quit Blaming someone else I’m the problem

8. Plan of Action Developed Central Line Task Force- multidisciplinary --  Root Cause Analysis Housewide education of Nursing Staff  Save the Line Campaign  Line Audits

9. Plan of Action Nurses empowered to stop Physicians if not following Bundles Developed Checklist Femoral Lines changed in 24 hours  Line Alert Developed PICC Criteria

10. Plan of Action Patient Education Sheet Customized dressing kits Shared Line Audit results /BC results with staff Eliminated blood draws from central lines

11. Getting to Zero Involved staff in solution Unit analysis of (+) blood cultures TEGO for Dialysis lines

12. Getting to Zero Scrub the Hub Campaign with Chlorhexadine Handwashing Focus PICC insertions in Radiology

13. Where are we Now? 83% reduction in CLI in ICU 65.6% reduction in CLI housewide