ITS 79 - Successful Implementation of a Novel, Web-based Application Used to Collect, Trend and Act upon Root Cause Data of Central Line Associated Blood Stream Infections in a Large, Academic Medical Center

Background: An academic medical center was experiencing increased incidences of central line associated blood stream infections (CLABSI). Traditional line lists were proving ineffective in identifying root causes. In an effort to better understand data, and to engage the bedside staff, a web-based application was implemented for a more efficient way to collect and collate CLABSI data and identify trends.

Methods: The data collection application is utilized for all CLABSI infections. When the Infection Preventionist (IP) identifies a CLABSI, a scripted email, which includes a link to the application, is sent to all key stakeholders. Bedside staff complete the electronic form, and present the case study, with potential root causes, at the monthly CLABSI committee. Additionally, the collected data is collated in real- time to identify actionable trends such as organism, line type, line site, and other relevant information. This data is used to formulate CLABSI prevention action plans based upon root causes.

Results: There were 55 CLABSIs identified for the year. Approximately, a third of the 55 infections had the line accessed for drawing blood. This prompted the committee to revise the central line policy to restrict blood draws. CLABSIs occurred most frequently (18 CLABSIs) for the year in hemodialysis (HD) lines, prompting review of best practices and re-education in HD areas. Other important actionable findings included where the majority of infections occurred (critical care), organism (gram-positive), and line location (internal jugular). Our first quarter Standardized Infection Ratio (SIR) post project roll out met aggressive Value Based Purchasing metrics.

Conclusions: Web-based applications can be very useful tools in preventing CLABSIs when fully operationalized. Although our facility used this same web-based platform for many years, we did not achieve success, or fully benefit from its capabilities, until we developed an ongoing process for analyzing the collected data to drive continued improvement in CLABSI prevention.