here is my executive summary regarding the project
Introduction
Within the hospital there are several intravascular devices used for various treatments. Catheters utilized currently in the organization are tunneled/non-tunneled central venous catheters, dialysis catheters, peripherally inserted central catheters and implanted ports. A hospital acquired central line associated bloodstream infection (CLABSI) is never event in this organization. When a central catheter infection occurs it reflects that we have caused harm to our patients due to lack of adherence to the processes that we have in place as an organization, lack of knowledge of processes, or need for process improvements. CLABSI cans lead to an increased length of stay for the patient’s admitted to the hospital. This causes an increased expense to both the patient and the organization. The cost to treat a CLABSI is estimated at $1.9 billion per year. Increased cost to the organization is estimated to be greater than $45,000 per instance of hospital acquired infection. Mortality rates increase in patients with a central line associated bloodstream infection. Patients with a central line in place in addition to underlying immunocompromising conditions are at increased risk of developing a blood stream infection. A multi-layered approach should be taken to assist in preventing a CLABSI. A review of our current practice regarding CLABSI prevention is important to understand current state. This includes review of compliance to current CLABSI bundle with a focus on the use of alcohol impregnated caps to cover exposed ports for patient with Central lines, current standard work and policies related to CLABSI prevention and ease of access to information. Description of care coordination A multidisciplinary approach will be taken to engage the key stakeholders in improved compliance to the CLABSI bundle. A survey of staff is completed to assess current knowledge of the bundle. The key stakeholders include: the bedside nurse, the patient care technician, the physician, the patient, the vascular access team, and the unit-based educators. Delivery of services The plan to increase compliance of the CLABSI bundle within a specific unit, with a focus on the use of alcohol impregnated green caps will include re-education of staff on the importance of compliance by providing actual patient case-studies specific to patient outcomes related to a CLABSI infection. Audit compliance of all patients within the unit that have a central line and provide real-time coaching related to gaps. Include staff in auditing each other’s patients and provide coaching to their peers. Ensure education is provided to the patient regarding CLABSI prevention and the use of alcohol impregnated caps and documented in the patient’s medical record. Benefits to target population Increased compliance to the CLABSI bundle will assist in the reduction of instances of a hospital acquired bloodstream infection. Increasing bundle compliance will assist in reducing length of stay in patients with central lines and a reduction in patient harm. Patients with central lines will have a greater understanding of how to prevent central line infections. Finances for the program There is minimal cost to implementation of this project. I am requesting $5000 for implementation of this project. Financial cost will include printing cost of education materials, education pay for staff required to participate in re-education, education time for project owner for data collection, implementation, and SWOT analysis. Pay for unit educator to re-educate staff. Projected outcomes Goals of this project are aimed at increasing the healthcare providers knowledge of the current bundle and reasons why 100% compliance is important. Daily shift audits performed until compliance reaches 100%. Spot audits will take place weekly thereafter. Ensuring knowledge is hardwired with staff and new staff will have the bundle hardwired within their orientation period. Survey performed within 90 days of project initiation to confirm staff’s understanding of the CLABSI bundle. Benefits to the system There is a cost savings that comes with increasing compliance to the CLABSI bundle that will benefit the organization. A reduction in the cost of care of patients with central lines is a factor and the result of increased compliance. CMS reimbursement for care of patients with central lines will not be affected. An increase in the ability to meet the quality metrics of the organization related to CLABSI and hospital acquired infections.