Protect Every Line, Stop CLABSI

Project Topic:

Central Line Associated Bloodstream Infection (CLABSI) Prevention

Hospital, City and State:

Aurora St. Luke's Medical Center, Milwaukee, Wisconsin

Unit:

Cardiovascular Intensive Care Unit (CVICU)

CSI Participants:

• Amanda Grzebien, BSN, RN
• Brandon Tollefson, BSN, RN

Project Goals/Objectives:

1. Decrease CLABSI rate in CVICU 80%
2. 90% of Chlorohexidine Gluconate (CHG)/soap and water baths are performed every 24 hours
3. 90% of central line dressings comply with hospital policy
4. Increase the number of chart audits for the CLABSI prevention bundle 80%

Project Outcomes:

1. CLABSI rates stayed the same; all CLABSIs since starting the project had no nursing indicator identified.
2. Increased to 94% of Chlorohexidine Gluconate (CHG)/soap and water baths performed every 24 hours
3. Increased to 95% of central line dressings comply with hospital policy
4. Increased in CLABSI chart audits 217%, 109 to 345

Project Overview:

CLABSI rates in our unit have stayed the same since the start of the CSI Project initiative in September 2024. We had one CLABSI in January 2025 and two in April 2025. All 3 of the CLABSI cases were found to have no identifiable nursing opportunities. We have found that beside nurse-to-nurse feedback has sustainably helped decrease CLABSI that have no nursing identifiers.

During our kickoff in September, we helped re-educate staff by offering a new Workday module that explained CLABSI practices for prevention and showed correct central line dressing maintenance. Along with creating a CLABSI trivia wheel that quizzed staff on different central line-based questions, it helped bring awareness to central lines and their importance. In addition, during this time, we reeducated staff on the significance of chlorohexidine gluconate (CHG) baths on CLABSI prevention, which led to an increase in CHG bath compliance.

Furthermore, before starting the project, we averaged 11 audits per month. From September 2024 to now, we have averaged 33. This has been a huge increase for our unit. During audits, we have initiated nurse-to-nurse real-time feedback, which has been one of the most successful interventions. Due to this, we have increased nurses' confidence and expertise in central line dressing maintenance.

From auditing and staff feedback, we were able to identify that our SWAN cables' weight, dressing adherence for diaphoretic patients, and undated dressings were our biggest areas of improvement. In response, we helped create a CVOR and CVICU workgroup to address the overlapping tasks between departments, such as dating the dressing and improving dressing integrity. This group allows for multidisciplinary communication and creates a space to collaborate on ways to improve. We also were able to supply nurses with markers to attach to their badge reels to help aid in dating dressing after dressing changes. Moreover, we collaborated with management and met with a medical supply representative to add a new IV glue to our unit supply stock. The new glue product is a specific glue, used under dressings that has antimicrobial properties and a stronger adhesiveness to skin to aid in dressing adherence. With no nursing identifiers found in any of the CLABSI cases, we continued to find new ways to reduce future CLABSI.