Abstract
In September 2024, at a 17-hospital Midwest United States healthcare system, quality assurance and nursing staff identified that a standardized system-wide central line-associated bloodstream infection (CLABSI) prevention and maintenance policy did not exist. This revelation occurred after an investigation noted an increase in CLABSIs, an issue compounded as each of the organization's hospitals were without system-level guidance on the prevention of CLABSIs. Therefore, using the PICOT question “In high-risk patients (P), how do system-wide best practices/strategies (I) compared to current practice (C) affect CLABSI (O)?, a systematic review of the published literature was conducted using CINAHL, PubMed, Scopus, and Embase in addition to internet web searches of organizations like Centers for Disease Control, The Joint Commission, and the World Health Organization to determine the best evidence-based practice for the creation of a system-wide CLABSI prevention policy.
The project leader, the initiative’s co-lead, will create the system-wide policy and implementation plan for the incremental rollout and evaluate the rollout response. This initiative began in October 2024 by conducting online meetings with the health systems multidisciplinary CLABSI task force. There are four operational work groups devoted to this work on the system level: a team dedicated to reviewing total parenteral nutrition central line use, a team dedicated to reviewing central line maintenance, a team dedicated to reviewing blood culture bottle contamination, and finally a team dedicated to blood culture stewardship. A review of current hospital and system policies surrounding the issue of CLABSIs was completed and key intervention/best practice strategies were identified. CLABSI prevention evidence-based best practices will be deployed to several units in one hospital within the system to test the efficacy of the intervention. If its effectiveness is confirmed, this policy will be deployed to the rest of the hospitals within the system. Pre- and post-implementation surveys will be deployed to unit staff and the CLABSI task force members to evaluate and guide future action. This Implementation will occur in December 2024 and January 2025 with completion of the new system-wide policy by Spring 2025.
Notes
Reference list included in attached slide deck.
Sigma Membership
Epsilon
Type
Presentation
Format Type
Text-based Document
Study Design/Type
Other
Research Approach
Translational Research/Evidence-based Practice
Keywords:
Policy and Advocacy, Acute Care, Academic-clinical Partnership, Central Line-Associated Bloodstream Infection, CLABSI, Catheter-Related Bloodstream Infections, CRBSI, Best Practices, Guidelines, Interventions
Recommended Citation
Martin, Daniel; Beckett, Cindy; Martini, Kady; Tussing, Todd; and Kociba, Emma, "Seeking Zero: Development of a System-Wide CLABSI Prevention Policy" (2025). Biennial Convention (CONV). 115.
https://www.sigmarepository.org/convention/2025/presentations_2025/115
Conference Name
48th Biennial Convention
Conference Host
Sigma Theta Tau International
Conference Location
Indianapolis, Indiana, USA
Conference Year
2025
Rights Holder
All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.
Review Type
Abstract Review Only: Reviewed by Event Host
Acquisition
Proxy-submission
Date of Issue
2025-11-27
Seeking Zero: Development of a System-Wide CLABSI Prevention Policy
Indianapolis, Indiana, USA
In September 2024, at a 17-hospital Midwest United States healthcare system, quality assurance and nursing staff identified that a standardized system-wide central line-associated bloodstream infection (CLABSI) prevention and maintenance policy did not exist. This revelation occurred after an investigation noted an increase in CLABSIs, an issue compounded as each of the organization's hospitals were without system-level guidance on the prevention of CLABSIs. Therefore, using the PICOT question “In high-risk patients (P), how do system-wide best practices/strategies (I) compared to current practice (C) affect CLABSI (O)?, a systematic review of the published literature was conducted using CINAHL, PubMed, Scopus, and Embase in addition to internet web searches of organizations like Centers for Disease Control, The Joint Commission, and the World Health Organization to determine the best evidence-based practice for the creation of a system-wide CLABSI prevention policy.
The project leader, the initiative’s co-lead, will create the system-wide policy and implementation plan for the incremental rollout and evaluate the rollout response. This initiative began in October 2024 by conducting online meetings with the health systems multidisciplinary CLABSI task force. There are four operational work groups devoted to this work on the system level: a team dedicated to reviewing total parenteral nutrition central line use, a team dedicated to reviewing central line maintenance, a team dedicated to reviewing blood culture bottle contamination, and finally a team dedicated to blood culture stewardship. A review of current hospital and system policies surrounding the issue of CLABSIs was completed and key intervention/best practice strategies were identified. CLABSI prevention evidence-based best practices will be deployed to several units in one hospital within the system to test the efficacy of the intervention. If its effectiveness is confirmed, this policy will be deployed to the rest of the hospitals within the system. Pre- and post-implementation surveys will be deployed to unit staff and the CLABSI task force members to evaluate and guide future action. This Implementation will occur in December 2024 and January 2025 with completion of the new system-wide policy by Spring 2025.
Description
An EB/QI initiative was created and deployed at a 17-hospital Midwestern United States healthcare system in an effort to decrease CLABSIs by creating a standardized system-wide CLABSI prevention policy after implementing evidence-based best practice CLABSI prevention guidelines in an incremental rollout to the entire system. Pre- and post-implementation surveys were deployed to hospital unit staff and CLABSI task force work group members to evaluate prior performance and guide future action.