QAPI 124 - Effect of Education and Performance Feedback to Eliminate Central Line Associated Blood Stream Infections on an Internal Medicine Unit

Background: We evaluated the outcome of targeted education and timely performance feedback to eliminate central line associated blood stream infections (CLABSI). In 2022, an internal medicine unit reported 5 CLABSIs after previously reporting no cases in 2021. The root cause analysis of all five cases identified an opportunity for improvement in compliance with central line preventative maintenance measures.

Methods: This study was conducted on a single internal medicine unit from August to September 2022 and separated into two phases. During Phase 1, a central line maintenance knowledge assessment was given to the unit nursing staff. During Phase 2, the Infection Control Specialist and Nursing Leaders educated the unit nursing staff on facility policy outlining central line preventative maintenance measures. Next, the assigned nurse would join the Infection Control Specialist and a Nursing Leader during patient rounds to assess each central line. If gaps were identified, they were addressed immediately. To assess effectiveness of this study, CLABSI rates were tracked over the next 12 calendar months (October 2022-October 2023).

Results: Evaluation of the central line knowledge assessment found inconsistencies in practice in caring for peripherally inserted central catheter and hemodialysis catheters. No CLABSI cases were reported from October 2022 – October 2023.

Conclusions: This study focused on targeted education and timely performance feedback on a single internal medicine unit which resulted in elimination of CLABSI for 12 calendar months.