Description
CLABSI Quality Initiative Proposal
NURS-FPX6016 Make a quality initiative proposal (7–10 PowerPoint slides) through a presentation, interpreting and communicating dashboard data to support the proposal. (I will add the narration to the PowerPoint slides)
Health care providers are perpetually striving to improve care quality and patient safety. To accomplish enhanced care, outcomes need to be measured. Next, data measures must be validated. Measurement and validation of information support performance improvement. Health care providers must focus attention on evidence-based best practices to improve patient outcomes.
Health informatics, along with new and improved technologies and procedures, are at the core of all quality improvement initiatives. Data analysis begins with provider documentation, researched process improvement models, and recognized quality benchmarks. All of these items work together to improve patient outcomes. Professional nurses must be able to interpret and communicate dashboard information that displays critical care metrics and outcomes along with data collected from the care delivery process.
A basic principle of quality measurement is: If you can’t measure it, you can’t improve it.
–Agency for Healthcare Research and Quality (2021)
In the previous assessment, you analyzed the effectiveness of an existing quality initiative. Now that you’ve done that, this assessment gives you experience interpreting and communicating dashboard data for the purpose of making a quality initiative proposal of your own. And you’ll make your proposal through a PowerPoint presentation, including using speaker notes in the Notes section of the slides, much like you might in your health care setting.
Health care providers are on an endless quest to improve both care quality and patient safety. This unwavering commitment requires hospitals and care givers to increase their attention and adherence to treatment protocols to improve patient outcomes. Health informatics, along with new and improved technologies and procedures, are at the core of virtually all QI initiatives. The data gathered by providers, along with process improvement models and recognized quality benchmarks, are all part of a collaborative, continuing effort. As such, it is essential that professional nurses are able to correctly interpret and effectively communicate information revealed on dashboards that display critical care metrics.
In this assessment, you will make a QI initiative proposal based on a health issue of professional interest to you. This proposal will be based on an analysis of dashboard metrics from a health care facility. You have two options:
Option 1
If you have access to dashboard metrics related to a QI initiative proposal of interest to you:
Analyze data from the health care facility to identify a health care issue or an area of concern. You will need access to reports and data related to care quality and patient safety. If you work in a hospital setting, contact the quality management department to obtain the data you need.
You will need to identify basic information about the health care setting, size, and specific type of care delivery related to the topic that you identify. You are expected to abide by standards for compliance with the Health Insurance Portability and Accountability Act (HIPAA).
Complete the following steps for your proposal:
Analyze data to identify a health care issue or an area of concern as it relates to a state, national, or accreditation benchmark requirement relevant to your professional setting.
Outline a QI initiative proposal based on the selected health issue or area of concern and supporting data analysis to improve identified dashboard metric. The interactive activity Designing a Quality Improvement Initiative can get you going on the first steps of a QI process and your assessment.
Identify the target areas of improvement and outcome measures.
Include the QI model that will be utilized.
Specify evidence-based strategies that will be utilized.
Integrate interprofessional perspectives and actions to lead quality improvements in patient safety, cost-effectiveness, and work-life quality.
Specify roles and responsibilities.
Apply effective collaboration strategies to promote QI of interprofessional care.
Include specific communication tools.
Deliver a persuasive, coherent, and effective audiovisual presentation. Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.
Be sure that your proposal, at minimum, addresses each of the bullet points. You may also want to read the Data Analysis and Quality Improvement Initiative Proposal Scoring Guide to better understand the performance levels that relate to each grading criterion. Additionally, be sure to review the Guiding Questions: Data Analysis and Quality Improvement Initiative Proposal [DOCX] Download Guiding Questions: Data Analysis and Quality Improvement Initiative Proposal [DOCX]document for additional clarification about things to consider when creating your assessment.
Guiding Questions
Data Analysis and Quality Improvement Initiative Proposal
This document is designed to give you questions to consider and additional guidance to help you successfully complete the Data Analysis and Quality Improvement Initiative Proposal assessment. You may find it useful to use this document as a prewriting exercise, an outlining tool, or a final check to ensure you have sufficiently addressed all the grading criteria for this assessment. This document is a resource to help you complete the assessment. Do not turn in
this document as your assessment submission.
Analyze data to identify a health care issue or an area of concern.
● What data does your institution gather? (Or, what data were provided in the media piece?)
● What is the quality of the data, and what can be learned from it? What does it tell you? What is missing?
● What is an organized way of looking at different data outputs?
● What metrics indicate opportunities for quality improvement?
● What are the trends? (Existence of data does not necessarily equate to a trend.)
● What are the outcome measures? What information do you need to calculate specific rates?
● Assess the stability of processes or outcomes. Are the outcomes fairly predictable? Identify any problematic variations or performance failures.
● Include the selected data set that was analyzed in the proposal. This could be a table or chart. Outline a quality improvement initiative proposal based on a selected health issue or area of concern and supporting data analysis.
● What benchmarks align to existing quality improvement initiatives set by local, state, or federal health care policies or laws?
● What quality initiatives currently exist (if any) related to the selected issue? Why are they insufficient?
● Identify target areas for improvement.
● Define what processes can be modified to improve outcomes. You may find it helpful to review models for quality improvement initiatives in Week 4.
● Identify evidence-based strategies to improve quality. Evaluate quality improvement initiatives on the selected health issue with existing quality
indicators from other facilities, government agencies, and non-governmental bodies on quality improvement.
● Analyze challenges that meeting prescribed benchmarks can pose for a heath care organization and the interprofessional team. Integrate interprofessional perspectives to lead quality improvements in patient safety, cost effectiveness, and work-life quality.
● Define interprofessional roles and responsibilities as they relate to the data and the quality improvement initiative.
● How would you make sure that all relevant roles are fully engaged in this effort?
● What non-nursing concepts would you incorporate into the initiative?
● How would outcomes to measure the effect of the intervention affect the interprofessional team?
● Briefly reflect on the impact of the proposed initiative on work-life quality of the nursing staff and interprofessional team. How is work-life quality improved or enriched by the initiative? Apply effective communication strategies to promote quality improvement of interprofessional care.
● What kind of interprofessional communication strategies will be effective to promote and ensure the success of this performance improvement plan or quality improvement initiative?
● What types of communications would you recommend in addition to writing?
● Are there any communication models (CUS, SBAR) you would include in your initiative proposal? Deliver a persuasive, coherent, and effective audiovisual presentation. Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.
● Is your analysis logically structured?
● Is your analysis 7–10 PowerPoint slides, with speaker notes (not including title slide and attached reference list)?
● Is your writing clear and free from errors?
● Did you use a minimum of five sources? Were they published within the last five years?
● Are they cited in current APA format throughout the plan?
● Have you included an attached reference list?
Your assessment should also meet the following requirements:
Length of submission: 7–10 PowerPoint slides, with speaker’s notes, not including title slide and attached reference list. Balance text with visuals. Avoid text-heavy slides. Use speaker’s notes for additional content.
Length of presentation: No more than 10 minutes.
Number of references: Cite a minimum of five sources (no older than seven years, unless a seminal work) of scholarly or professional evidence to support your evaluation, recommendations, and plans. Review the Nursing Master’s Program (MSN) Library Guide for guidance.
APA formatting: Resources and citations are formatted according to current APA style. Review the Evidence and APA section of the Writing Center for guidance.
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
Competency 2: Plan quality improvement initiatives in response to routine data surveillance.
Analyze data to identify a health care issue or area of concern as it relates to a state, national, or accreditation benchmark requirement.
Outline a quality improvement initiative proposal based on a selected health care issue or area of concern and supporting data analysis to improve identified dashboard metrics.
Competency 4: Integrate interprofessional perspectives to lead quality improvements in patient safety, cost-effectiveness, and work-life quality.
Integrate interprofessional perspectives and specify actions to lead quality improvements in patient safety, cost-effectiveness, and work-life quality.
Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.
Apply effective collaboration strategies to promote quality improvement of interprofessional care.
Create a persuasive, coherent, and effective audiovisual presentation. Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.
REFERENCE
Agency for Healthcare Research and Quality. (2021). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospi…
Unformatted Attachment Preview
NewYork-Presbyterian Hospital
Sites: All Centers
Infection Prevention Policy and Procedure Manual
Number: IC-301
Page 1 of 10
TITLE:
INSERTION, MAINTENANCE, USE, AND REMOVAL OF CENTRAL
VENOUS CATHETERS IN ADULT AND PEDIATRIC PATIENTS
(OTHER THAN NEONATAL ICU PATIENTS)
POLICY:
All staff inserting and maintaining central venous catheters (CVC) must adhere to
established guidelines to prevent central line-associated bloodstream infections
(CLABSI).
Refer to IC-302 Insertion and Maintenance of Central Venous Catheters in Neonatal
ICU Patients for patients who are less than forty-eight (48) hours old. For the
insertion, care and maintenance of peripherally inserted central catheters (PICC),
refer to PROC 720 Central Venous Catheter (CVC) – Maintenance and Removal
PURPOSE:
To reduce the risk of CVC-related infections by establishing appropriate clinical
standards for the aseptic insertion and maintenance of catheters (e.g., PICC lines,
venous, and right atrial lines) inserted into the central circulation.
APPLICABILITY:
1. All practitioners (i.e., MD, NP, and PA) who are credentialed to insert central
venous catheters in adults and pediatric patients older than 48 hours within the
NYPH jurisdiction
2. Registered nurses (RN) who assist with the procedure, monitor the patient, and
maintain the CVC
3. This policy does not refer to PICCs placed by the Vascular Access Team, as this
team has specific policies that address their practice
4. Licensed independent practitioners who are currently credentialed in CVC
insertion are privileged to supervise catheter insertions. Re-credentialing will be
in accordance with the Medical Staff By-Laws and Rules and Regulations.
PROCEDURE:
1. MD/NP/PA performing the procedure will perform an assessment o f vasculature,
patient comorbidities, contraindications, infusate characteristics and anticipated
duration of IV therapy to determine the most appropriate access device (i.e.,
PIV, Midline, PICC, triple lumen catheter, etc.)
NewYork-Presbyterian Hospital
Sites: All Centers
Infection Prevention Policy and Procedure Manual
Number: IC-301
Page 2 of 10
2. The indication for the procedure as well as risks, benefits, and potential
alternatives shall be explained to the patient or his/her surrogate and written
consent for the procedure shall be obtained
3. The MD/NP/PA performing the procedure will notify the nurse assigned to the
patient and/or the charge nurse of the plan to insert a CVC
4. The RN will complete a note in the electronic medical record documenting the
time out and the procedure
5. When feasible, the MD/NP/PA will be accompanied by a non-sterile assistant to
assist (gather supplies, etc.) during the procedure. The assistant will ensure
compliance with the CVC insertion policy and have authority to stop the
procedure at any time a deviation from aseptic technique is observed.
6. Units that place central venous catheters must maintain a central line cart which
contains all supplies for central line insertion or use the Central Line Insertion
Bundle Kit which includes all supplies needed for central line insertion except the
central venous catheter.
7. Assemble equipment, including:
A. CVC insertion kit (or appropriate pediatric catheter insertion kit)
B. Sterile normal saline flush solution
C. Sterile gowns and gloves, masks and caps; large sterile drape, if not already
included in CVC kit
8. Insertion of a CVC:
A. Site choice: Use the femoral site as a last resort in adults. Preferred sites
may vary with age and clinical condition.
1) If a femoral line is placed in an adult patient, efforts should be made to
establish vascular access at another site in order to remove the femoral
catheter within 48 hours.
a) If changing the femoral catheter to a different site is not medically
appropriate, the rationale to continue using a femoral CVC should be
documented and the ability to remove/replace the femoral catheter
should be reevaluated on a regular basis (i.e., daily).
2) When long-term (greater than 14-30 days) intravascular therapy is
anticipated, consideration should be given to the use of long-term
devices (i.e. implanted port, tunneled catheter).
a) For anticipated duration of access of up to 14-30 days in the setting
of difficult vascular access or infusion of peripherally compatible
infusates, consider the use of a midline catheter or extended-dwell
peripheral IV rather than a central venous catheter.
NewYork-Presbyterian Hospital
Sites: All Centers
Infection Prevention Policy and Procedure Manual
Number: IC-301
Page 3 of 10
B. Position the patient in Trendelenburg or head-down tilt position (internal
jugular and subclavian sites), as tolerated.
1) Position the patient’s head away from the side of central venous
catheter insertion to prevent contamination of the insertion site
(internal jugular and subclavian sites)
2) Remove hair at insertion site, if necessary, using clippers. Do not use a
razor
C. Perform hand hygiene and don gloves
D. Prepare site with 2% chlorhexidine gluconate (CHG) and 70% isopropyl
alcohol prep. If the insertion site changes, re-prep the new insertion area.
1) Release antiseptic by pinching wings on applicator to break ampule
2) Wet sponge by repeatedly pressing and releasing the sponge against the
treatment area until liquid is visible on skin. Do not touch sponge
3) Clean the site with repeated back and forth strokes of the sponge for a
minimum of 30 seconds. At femoral or excessively moist sites, cleanse for
two minutes. Do not blot or wipe away.
4) Allow antiseptic to air dry for 30 seconds or longer. At femoral or
excessively moist sites, allow to air dry for one minute or longer. Do not
blot or wipe away.
E. Use Povidone-iodine to prep the site if the patient is allergic to 2% CHG and
70% isopropyl alcohol prep. Allow Povidone-iodine to air dry for 2 minutes
or longer. Do not blot or wipe away. Skin should be completely dry before
catheter insertion.
F. Remove gloves and perform hand hygiene. Don cap, mask with eye
protection, sterile gown and sterile gloves. Healthcare personnel performing
direct visual supervision must perform hand hygiene and don cap, mask,
sterile gown and gloves.
G. Place sterile, fenestrated drape over insertion site
H. Cover patient (from top of head to bottom of feet) with a large sterile drape
and place a disposable sterile sheath over the ultrasound probe
I. Use ultrasound guidance to identify the location of the central vein, when
appropriate
J. Flush catheter with sterile saline
K. Insert introducer needle using ultrasound guidance (if in use), detach
syringe, and observe for non-pulsatile blood flow
L. Initial insertion technique to place guidewire can occur in one of two
methods: small-bore catheter-over-needle (i.e., modified Seldinger) or
guidewire-through-needle (i.e., traditional Seldinger)
NewYork-Presbyterian Hospital
Sites: All Centers
Infection Prevention Policy and Procedure Manual
Number: IC-301
Page 4 of 10
Modified Seldinger Technique
Small-bore catheter-over-needle: Advance the small-bore cannula
over the introducer needle and insert guidewire through the small-bore
catheter. Confirmation of venous placement (see section M. below)
should occur prior to dilation of central vein when possible.
Traditional Seldinger Technique
Guidewire-through-needle: Insert guidewire through the introducer
needle and withdraw introducer needle. If using pressure-based
technique (see section M. below), advance small-bore catheter over
guidewire, withdraw guidewire, and then confirm venous placement.
M. Confirmation of intended venous placement must occur with at least one of
the below evidence-based techniques:
1) Passive manometry of small bore catheter via IV tubing (available in
central line insertion bundle)
2) Waveform analysis of small bore catheter via pressure transduction
probe (available in central line insertion bundle)
3) Direct visualization of guidewire in right atrium via transesophageal
echocardiogram or fluoroscopy
4) Ultrasound visualization of guidewire in central vein in two orthogonal
planes
5) Rapid opacification of right atrium (via ultrasonic visualization) after
injection of 10mL agitated isotonic fluid into the catheter
Method of secondary confirmation must be documented in the patient’s
chart.
Reduction in Risk of Retained Guidewire: the proceduralist and a 2nd
clinician (RN, provider) must VISUALLY confirm the guide-wire removal at the
end of the procedure and prior to disposing the used procedure tray.
N. Dilate vessel, insert catheter, check for blood return, flush ports with saline,
place sterile needleless end cap and secure catheter in place – use of an
external securement device is preferred.
O. Prior to connecting the infusate to the central line, scrub the IV access hub
with an alcohol swab for at least 10 seconds and allow to air dry.
P. In an emergency, the central venous catheter can be used initially with a
physician’s verbal order prior to confirmation . Appropriate confirmation
technique should be performed in a timely fashion after initial patient
stabilization to confirm placement (see Section M. above).
Q. Remove sterile drape, remove disposable sterile sheath from ultrasound
probe, and clean and disinfect the ultrasound probe with a hospital-approved
NewYork-Presbyterian Hospital
Sites: All Centers
Infection Prevention Policy and Procedure Manual
Number: IC-301
Page 5 of 10
disinfectant (e.g., PDI Sani Cloth Plus [red top])) post-procedure (see IC804)
R. Remove gloves and perform hand hygiene.
S. Don sterile gloves from dressing kit. Re-prep insertion site with 2% CHG and
70% isopropyl alcohol prep from kit. Allow 30 seconds to air dry.
T. Place an appropriately-sized sterile transparent CHG semipermeable dressing
over site for patients greater than two months of age. If patients have a
chlorhexidine allergy/sensitivity or are less than two months of age, a
sterile transparent semipermeable dressing can be used.
U. A gauze dressing is only used to absorb drainage following the initial
insertion. Replace within 48 hours of insertion.
V. Under routine conditions (including in the Operating Room), order a
portable chest radiograph or fluoroscopy to rule out pneumothorax
(subclavian and internal jugular sites). Portable chest radiograph can occur in
the PACU for a CVC placed in the operating room. Document the location of
the catheter tip placement. Note: for Electrocardiogram (ECG) placed PICC
lines, tip placement is confirmed by the ECG waveforms during insertion. This
confirmation indicates that the PICC placed with ECG is ‘ok to use’ and a
provider order indicating this is placed (refer to PROC 734 Peripherally
Inserted Central Catheter (PICC) Line Insertion Using Ultrasound and/or
Modified Seldinger Technique).
9. Maintenance of CVC
For guidelines pertaining to dressing changes, needleless valve cap changes, and
accessing a central line, see PROC 720 Central Venous Catheters Maintenance &
Removal.
A. Assess and document CVC necessity daily. Routine CVC changes are
generally not recommended
B. Remove CVC within 24 hours if it was not placed using sterile technique as
outlined above, when clinically appropriate
C. Promptly remove the CVC when it is no longer needed
D. Use clinical judgment to determine when to discontinue a central venous
catheter should the catheter be a suspected source of infection
E. Do not use guide wire exchanges routinely. Catheters that are suspected to
be infected should not be exchanged over a guidewire
F. When obtaining blood cultures and specimens, peripheral sets are preferred.
If it is necessary to obtain blood specimens from a CVC, collect blood in
accordance with Nursing Standards: PROC 728 Specimen Collection – Blood
and Blood Culture
NewYork-Presbyterian Hospital
Sites: All Centers
Infection Prevention Policy and Procedure Manual
Number: IC-301
Page 6 of 10
a. Only RNs or other professionals who have completed the required CVC
Blood Culture and Specimen Collection education can access central
venous catheters
b. MD/PA/NPs should only obtain specimens via central venous catheters
on initial insertion of the central line under sterile conditions, or in
emergent situations (such as cardiac arrest) when a trained nurse is
not immediately available. Anesthesiologists in the O.R. setting are
trained and permitted to utilize central lines for real time monitoring of
patient status.
G. Use dedicated catheter port for TPN. For guidelines on administration of TPN,
see PROC 712 Administration of Parenteral Nutrition (PN) Via Peripheral and
Central Lines.
H. Flush CVC and assess patency per Flushing Guidelines for Adult and Pediatric
Patients.
1) For clotted CVC: Refer to PROC 730 Declotting of a Central Venous
Catheter (CVC) Using Alteplase (Cathflo/T-PA).
I. Change IV administration set and intravenous fluid per PROC 702
Intravenous (IV) Fluid Administration Using Tubing Sets
J. For CLABSI prevention, applicable patients should receive daily chlorhexidine
gluconate cleaning unless a contraindication exists, as per Hosp Policy C325
CHG Skin Treatment.
K. Removal of a CVC
1. A written Physician/NP/PA order is required for removal of Internal
Jugular Venous Catheters. RNs may discontinue non-tunneled central
venous catheters (CVCs) & PA catheters from the internal jugular site in
the ICU setting ONLY.
2. RNs may discontinue CVCs & PA catheters ONLY after successful
completion of Nursing Professional Development educational training and
verification of competency. Physicians/NPs/PAs may discontinue CVCs
after appropriate training and certification.
3. Catheters that may be removed by Nursing from the internal jugular site
following successful completion of educational training include: single and
multi-lumen CVCs, introducers/cordis, PA catheters, and double and triple
lumen dialysis catheters.
4. RN refers to Nursing Clinical Standards on CVC & PA catheter removal
procedures: PROC 720 Central Venous Catheter: Maintenance and
Removal, and CC 1225 Hemodynamic Monitoring.
NewYork-Presbyterian Hospital
Sites: All Centers
Infection Prevention Policy and Procedure Manual
Number: IC-301
Page 7 of 10
PROCEDURE:
1) Implement U100 Universal Protocol for “Correct” Patient, Procedure,
Site/Side Verification. If applicable, verify Physician/NP/PA written order
to discontinue the internal jugular catheters.
2) Review the patient’s coagulation profile (PT, INR, PTT, platelets) and
anticoagulation medication profile before removal of the catheter. If
coagulation profile outside of normal expected values, discuss with
treatment team.
3) Assess catheter site for signs of infection
4) Assess patient’s vital signs, pulse oximetry, and level of consciousness
before and after catheter is removed
5) Ensure all infusions are disconnected from the catheter, all CVC lumens
are clamped, and adequate venous access is available. If a
physician/NP/PA is removing catheter, discuss plan for CVC removal with
patient’s RN before removal.
6) Place patient supine in slight Trendelenburg’s position
7) Open suture removal kit and sterile gauze pads
8) Place impervious protective pad under the patient’s torso and another
close to the catheter site
9) Turn off central venous pressure line alarm and disconnect cable from
transducer. Clamp off central venous pressure tubing, if appropriate, and
discard. Have the patient turn head away from catheter site.
10) Put on clean gloves, remove dressing
11) Remove clean gloves, perform hand hygiene, and apply sterile gloves
12) Remove sutures, exercising caution to prevent accidental cutting of the
indwelling catheter
13) Ask patient to take a deep breath in and hold it. Withdraw the catheter,
pulling parallel to the skin with a steady motion. Instruct the patient to
breathe after the catheter is removed. If the patient is receiving positive
pressure ventilation, withdraw catheter during the inspiratory phase of
the respiratory cycle.
NewYork-Presbyterian Hospital
Sites: All Centers
Infection Prevention Policy and Procedure Manual
Number: IC-301
Page 8 of 10
Note: If resistance is met when withdrawing the catheter, do
not continue to remove it. Notify the treatment team
immediately.
14) Place the catheter on the impervious protective pad. Check to ensure
that the entire catheter has been removed
15) Apply firm direct pressure on the insertion site with the gauze pad until
bleeding has stopped. If patient is on anticoagulant, direct digital
pressure must be applied for at least 15 minutes
16) Apply an occlusive sterile dressing at the site
17) Re-assess site every 15 minutes X 2, then every 30 minutes x 2, and
then 1 hour later for bleeding and/or hematoma
18) Maintain the patient in the supine position for 30 minutes after catheter
removal
19) If signs and symptoms of air embolus are present, immediately place
patient in left lateral Trendelenburg’s position, administer 100% oxygen,
and notify treatment team. This position prevents the air from passing to
the left side of the heart and into the systemic arterial circulation.
Note: Signs and symptoms of air embolus include abnormal
vital signs, shortness of breath, tachypnea/respiratory
distress, gasping, hypoxia, mental status changes, chest pain,
dysrhythmias, and sucking sound near the catheter insertion
site.
20) Remove dressing and assess for site closure after 24 hours.
11. Documentation
A. CVC Insertion: The MD/NP/PA documents a post-procedure note in the
medical record immediately following the procedure, at a minimum to
include the following information:
1) Date and time of progress note
2) Indication for insertion of central venous catheter
3) Universal protocol implemented, including patient identification, informed
consent, and Time Out
4) Procedure performed
5) Site of procedure and type and size of the central venous catheter used
6) Personnel who participated in the procedure
NewYork-Presbyterian Hospital
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Infection Prevention Policy and Procedure Manual
Number: IC-301
Page 9 of 10
7) Sedation used, including medication and route of administration
8) Chest radiograph, if ordered for confirmation of catheter placement, or
clinical confirmation of placement
9) Condition of the patient at the conclusion of the procedure
10) Complications, if any
11) Signature of personnel completing the note, including date and time
B. For maintenance of CVC refer to Nursing Standards: PROC 720 Central
Venous Catheters: Maintenance & Removal.
1) Document the assessment and dressing change for each central line in
the Lines parameter of the Treatment Flowsheet in the electronic medical
record
2) Enter a Central Line Dressing Change note in the electronic medical
record for every dressing change
3) Document compliance with CHG bath once per day. If CHG bathing was
not done, document rationale. If patient refuses CHG bathing, nursing
staff should escalate the refusal to the provider team.
C. CVC removal: The provider removing the CVC should document successful
catheter line removal in the patient’s medical record on central line removal
note including:
1) Site
2) Reason for discontinuation of the catheter
3) Removal of sutures, if present
4) Length of catheter removed
5) Dressing applied to site
6) Patient’s response to procedure
12. Quality and Performance Improvement
A. Significant complications related to central venous catheters must be
reported through KEEPSAFE
B. CLABSI will be adjudicated, monitored, and reported by the Department of
Infection Prevention & Control (IP&C)
NewYork-Presbyterian Hospital
Sites: All Centers
Infection Prevention Policy and Procedure Manual
Number: IC-301
Page 10 of 10
REFERENCES:
Ling ML, Apisarnthanarak A, Jaggi N, Harrington G, Morikane K, Thu le TA, Ching
P, Villanueva V, Zong Z, Jeong JS, Lee CM (2016). APSIC guide for prevention of
Central Line Associated Bloodstream Infections (CLABSI). Antimicrob Resist Infect
Control, 5:16.
Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O’Grady NP, Pettis AM, Rupp
ME, Sandora T, Maragakis LL, Yokoe DS; Society for Healthcare Epidemiology of
America (2014). Strategies to prevent central line-associated bloodstream
infections in acute care hospitals: 2014 update.
Infect Control Hosp Epidemiol. 35(7):753-71.
Centers for Disease Control and Prevention (CDC). (2011). Guidelines for the
prevention of intravascular catheter-related infections. Recommendation Update,
July 2017. http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf.
Guideline for hand hygiene in health-care settings. MMWR 2002; 51 No. RR-16.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm.
A Compendium of Strategies to Prevent Healthcare-Associated Infection in Acute
Care Hospitals: 2014 Updates. Infection Control Hospital Epidemiology (ICHE) 2014
Aug; 35(8): 967–977.
Infusion Nurses Society (INS) Infusion therapy standards of practice. 2016 Journal
of Infusion Nursing, 39(1S), S1-159
O’Horo, JC, Silva, GL, Munoz-Price, LS, and Safdar, N, (2012). The effect of daily
bathing with Chlorhexidine for reducing healthcare-associated bloodstream
Infections: A Meta-analysis. Infect Control Hosp Epidemiology, 33(3): 257-267.
RESPONSBILITY:
Department of Infection Prevention & Control
Critical Care Medicine
Medical Board
Nursing Board
POLICY DATES:
Issued:
September 2008
Last Revised:
June 2022
Medical Board Approval:
July 2022
2023 QPS Goals Closeout &
2024 QPS Goals Preview
PCA
December 1, 2023
2023 QPS Goal Performance Summary
NYP
Goals Achieved
NYP-AH
9 of 10
NYP-BMH
10 of 10
NYP-CU
6 of 9
NYP-LMH
9 of 10
NYP-MSCH
7 of 8
NYP-W
9 of 10
NYP-WC
8 of 10
NYP-WBHC
2 of 2
NYPH
8 of 10
NYP-HVH
10 of 10
NYP-Q
9 of 10
NYP
9 of 10
2
2023 QPS Goals Scorecard
Goal
Goal 1: Achieve a target mortality index of ≤0.85
NYP
NYPH
NYP-AH
NYP-BMH
NYP-CU
NYP-LMH
NYP-MSCH
NYP-W
NYP-WC
NYP-WBHC
NYP-HVH
NYP-Q
0.73
0.76
0.68
0.69
0.82
0.64
N/A
0.72
0.83
N/A
0.66
0.62
N/A
64.42%
63.37%
N/A
72.11%
64.09%
54.34%
58.41%
70.29%
71.28%
0.85
Target
Goal 2: Improve adherence with the 3 hour surviving sepsis bundle
in the ED by 10%
65.36%
65.29%
75.12%
68.31%
58.21%
76.71%
Target
59.07%
53.46%
47.96%
54.01%
49.28%
58.96%
0.38
0.41
0.27
0.17
0.62
0.51
0.39
0.19
0.39
N/A
0.12
0.25
0.37
0.92
0.62
0.99
N/A
0.00
0.26
2.88
0.77
1.04
1.17
N/A
0.00
0.09
Goal 3: Achieve a target SIR of ≤0.55 for C. diff
0.55
SIR
Goal 4: Achieve a target SIR of ≤0.69 for CAUTI
0.71
0.83
0.79
0.07
1.03
0.69
SIR
Goal 5: Achieve a target SIR of ≤0.94 for CLABSI
0.91
0.98
0.39
0.52
0.97
0.94
SIR
Goal 6: Implement artificial intelligence fetal heart tracing
management system enterprise wide
Achieved
N/A
Achieved
N/A
Achieved
N/A
Achieved
Binary
Goal 7: Implement a standardized process for Screening of Social
Drivers of Health (SDH) upon admission and process to track
positive screens
Achieved
Binary
Goal 8: Creation of a standardized data review process for
OPPE/FPPE utilizing KEEPSAFE surgical complications and other
surgical data for the departments of surgery across the enterprise
Achieved
Binary
Goal 9: 90% compliance with elopement screening and
implementation of safety interventions for at risk patients
95%
94%
96%
93%
93%
96%
Target
94%
94%
96%
N/A
97%
96%
97%
95%
98%
96%
98%
96%
97%
90%
Target
Goal 10: Achieve 95% or greater compliance with Bar Code
Medication Administration (BCMA)
93%
96%
95%
98%
95%
95%
3
2024 Quality & Patient Safety Goals
#
2024 Goal
Executive Sponsor
1
Achieve a target mortality index of ≤0.70
2
Improve adherence with the 3-hour surviving sepsis bundle in the ED to 75% Jason Adelman
3
Achieve a target SIR of ≤0.27 for C.diff
Emily Jackson
4
Achieve a target SIR of ≤0.63 for CAUTI
Purvi Shah
5
Achieve a target SIR of ≤0.80 for CLABSI
Frank Volpicelli
6
10% reduction in Hospital Acquired Pressure Injuries stage 2 and greater
Christa Kleinschmidt
7
8
Implement standardized process for offering community resources to 80% of
patients who screen positive for health-related social needs
Optimize postpartum hemorrhage management with the goal of decreasing
postpartum hemorrhage rates (QBL>1000mL) by 10%
Peter Fleischut
Julia Iyasere
Steve Kernie
9
Attain 90% compliance with on-time KEEPSAFE closeouts (90% compliance
b.
Central Line Maintenance Processes
IP&C and Quality & Patient Safety (QPS) staff perform weekly “device rounds” to
assess adherence to standard CL maintenance practices (see Figure 2).
11
Methodology:
IP&C and QPS staff perform weekly “device rounds” to assess adherence to
standard CL maintenance practices. “Target Units” (those that did not meet the
CLABSI SIR target for the previous six months) are visited on a weekly basis and all
patients with CLs are reviewed. Other units are visited at least once per quarter. A
standardized survey tool is used to collect data for each patient with a CL.
Data Source:
Data is captured by the IP&C and/or QPS team during device rounds. Data are
entered into an electronic database.
Time period: February – December 2022
Expected outcome: >90% compliance
c.
CLABSI Mini Root-Cause Analysis (RCA)
A mini root cause analysis (RCA) will be performed for all inpatient CLABSIs identified
by IP&C. A multidisciplinary unit-based team completes the mini RCA form within 7
days of notification of the infection (see Figure 3).
12
Time Frame
Jan – Dec 2021
Cases
Submitted
5
Cases
Completed
5
Completion
Compliance
100%
Methodology:
Multi-disciplinary unit-based teams to complete mini RCA form within 7 days of
notification of the infection by IP&C to learn about potential contributing factors for
CLABSI.to learn about potential contributing factors for CLABSI.
Data Source:
Mini RCA forms in KEEPSAFE
Time period: January – December 2022
Indicator:
All inpatient CLABSIs
Expected outcome: ≥90% compliance
3. Assessment of impact of previous year’s (2021) prevention activities:
a. Key CLABSI prevention strategies implemented in 2021 included:
Weekly device rounds: In June 2021, IP&C staff began conducting weekly device
rounds for patients with indwelling urinary catheters (IUC) and central venous
catheters (CVC) on targeted units (e.g., units not meeting the QPS SIR goal for
CAUTI or CLABSI). A standardized data collection tool was developed and included
questions about proper care and maintenance of the devices and medical necessity
for the devices. The rounds were conducted in close collaboration with Nursing and
other unit staff. Opportunities for improvement were identified including the need to
promote an open dialogue about the necessity of the devices. Because of the
immediate success of the rounds, the rounds were expanded to include additional
units that were considered to be at risk for not meeting the CAUTI and/or CLABSI
goal. These additional rounds were conducted by the Quality and Patient Safety
(QPS) Department.
Optimize adherence to evidence-based strategies for catheter selection, insertion,
care and maintenance and for blood culture collection through education,
observation, data collection, and feedback.
4. Identification of Current (2022) Targeted Locations: A structured risk assessment is
used to identify hospital units that are most likely to need and benefit from additional
CLABSI prevention efforts. A combination of CLABSI SIR (a risk-adjusted assessment of
CLABSI rate) and CLABSI cumulative attributable difference (CAD) is used to identify
hospital units for which focused CLABSI prevention efforts will be implemented during
calendar year 2022. Specifically, units are considered to be units targeted for
improvement interventions if:
the unit-specific CLABSI SIR for the period of July-December 2021 had at least
two CLABSI and the SIR was > 1.00.
5. CLABSI Prevention Strategies for 2022:
13
CLABSI prevention strategies will include strategies that are implemented throughout
NYP-HVH and additional strategies that are focused on units identified as high risk, as
described above. Hospital-wide strategies include:
Daily Tier 3 huddle to discussed all line and tubes indication and necessity
Continue to collaborate with Nursing to conduct weekly CVC rounds focusing on
CVC maintenance and necessity
Provider engagement to optimize the process for critical daily review of central
venous catheter necessity with subsequent removal of catheters that are no
longer necessary.
Optimize adherence to evidence-based strategies for catheter selection,
insertion, care and maintenance and for blood culture collection through
education, observation, data collection, and feedback.
Invigorate campus CLABSI teams to identify local barriers, opportunities, and
best practices that can inform prevention efforts
Enhance process measure reporting in Epic to monitor adherence to basic
prevention strategies including chlorhexidine bathing, catheter use and
maintenance practices, utilization of alternatives to central lines and blood culture
specimen sources.
Tableau dashboard to display CLABSI process measures data
6. Hospital-wide strategies
a. Enhanced data dissemination and accountability: CLABSI data will continue
to be streamlined and standardized among dashboards, reports and report cards
that include CLABSI data. Estimated progress toward the goal will be assessed
for each month and for year to date based on the estimated number of CLABSI
that each hospital can have and still achieve the SIR goal. An automated report
of compliance with CHG bathing documentation will be developed to allow for
frequent feedback of data to nursing units in order to drive adherence to CHG
bathing protocols.
b. CLABSI Workgroup: The Workgroup is comprised of an executive sponsor, two
process owners and representatives from Nursing Quality, Clinical Nursing,
Infection Prevention & Control (IPC), Quality & Patient Safety (QPS), Nursing
Procurement & Strategic Sourcing, and medical staff. This group meets monthly
to identify opportunities, prioritize interventions, enhance accountability for rapid
and consistent implementation of CLABSI prevention strategies, identify and
resolve barriers to implementation of and adherence to prevention strategies,
discuss potential new preventive measures, and review CLABSI data on a near
real-time basis to assess the impact of interventions and identify the need for
further intervention. Campus teams meet on a more frequent basis.
c. HAI Champions: The department of nursing on each campus has a HAI
Champion program. This group includes front-line clinical nurses who serve as
unit-based resources for HAI prevention education, intervention, and evaluation.
This group will meet on a regular basis to discuss HAI (including CLABSI) data,
interventions, challenges, and successes. In addition to their local, unit-based
activities, this group facilitates two-way communication between front-line nurses,
IPC, and hospital leadership.
14
7. Root Cause Analysis of All Non-MBI CLABSI Cases: A standardized “mini” root
cause analysis (RCA) is conducted for every non-MBI CLABSI case identified. These
RCAs are conducted by personnel involved in the care of the patient (e.g., unit-based
nursing leadership and clinical nurses, clinicians (e.g., MD, NP, PA), and representatives
of other departments as appropriate (e.g., IP&C). The RCA is submitted into a
centralized database (KEEPSAFE) and the findings of all CLABSI RCAs are aggregated
by IP&C on a quarterly basis. Notable findings from individual RCAs and the aggregate
RCA data will be discussed at the CLABSI Workgroup in order to share important
findings so that factors associated with CLABSIs can be avoided in future patients.
8. Focused Strategies for Targeted Units
Targeted units to provide an action plan and regular updates on initiatives and
improvement efforts to the CLABSI workgroup.
Targeted assessment of CHG bathing compliance and documentation on
targeted units
Weekly device rounds on targeted units for patients with CVC in place
B. Catheter-Associated Urinary Tract Infections (CAUTI)
Objectives:
Identify Standardized Infection Ratio (SIR) data for CAUTIs using CDC NHSN
aggregated data (see Figure 5)
Evaluate procedures, policies and practices looking for preventable risk factors when
infection trends are identified
Reduce infections by reducing risk factors
Methodology:
IP&C collects data on an ongoing basis
Data are provided monthly to key stakeholders (e.g. hospital leadership, CAUTI
Workgroup members, nursing, clinicians, unit staff, etc.)
Data are posted on Hospital’s’ Infonet
Data Sources:
Monthly report of number of indwelling urinary catheter (IUC) days
15
Daily microbiology report of urine culture reviews
Concurrent and/or retrospective chart review by Infection Preventionists and Medical
Director
Follow-up:
Reports are presented to the Infection Prevention and Control Committee, Patient Care
Services Leadership, ICU Committees, Medical
