Reduction of Central Line-Associated Bloodstream Infections on a Transplant Unit

Background: Central line-associated bloodstream infection (CLABSI) is a preventable complication of central venous catheters (CVC) that can result in prolonged hospitalization, increased cost, and mortality. Local problem: CLABSI rates in a solid organ transplant unit were above the National Database of Nursing Quality Indicators target. Methods: Evidence-based CLABSI prevention interventions were implemented using the Plan-Do-Study-Act process. Interventions: A stepwise approach was used to implement CVC maintenance bundle pole cards, chlorhexidine gluconate (CHG) bathing treatments, and Kamishibai card (K-card) door tag processes for all patients with CVCs. Results: The unit achieved and sustained >90% compliance with both CHG bathing treatments and K-card door tag processes. The CLABSI rate decreased from 2.15 to 0.41, an 81% reduction. Conclusions: CLABSI reduction in a transplant unit can be achieved through the systematic implementation of evidence-based practices.