The 3 P's of CLABSI Reduction

It's no coincidence that it has been more than two years since Carolinas Hospital System recorded a central-line associated blood stream infection in its surgical intensive care unit.

But before things got better, they had to get worse. In 2010 and 2011, 420-bed CHS in Florence, S.C., noticed an increase in its CLABSI rates. "We acknowledged it was an issue," says Costa Cockfield, the hospital's CNO. "We weren't proud of it." So, the hospital started making changes in earnest in 2011 to reduce its CLABSI rates.

Part of the hospital's success can be attributed to its participation in the CLABSI Target Zero Learning and Action Network through The Carolinas Center for Medical Excellence. The rest of the changes were centralized around products, processes and personnel — coined the three p's. The following is a detailed look at all three.


CHS switched several of the products used in the SICU in an effort to reduce CLABSI rates there. For instance, according to Ann North, RN, the director of infection prevention control, the organization changed to a new type of dressing with the antiseptic chlorhexidine gluconate. This "took potential user error" out of the dressing equation, which led to fewer infections, she explained.

Further, after analyzing data from 2010 and 2011, Ms. North and others noticed that dialysis patients' central lines tended to cause a problem. "That seemed to be specifically where our problem areas were," she says. As a result, a team put together an infection prevention bundle for dialysis patients. The bundle includes bathing patients with CHG and using a different dressing — different than even the newly adopted dressing used throughout rest of the unit.CHS building


Throughout the development of CHS' culture of safety and journey to zero CLABSIs, many new processes were put into place. "As we continued down this journey, [there were] many things that needed to be improved upon with processes," says Ms. Cockfield.

For instance, staff now perform daily safety huddles, during which they are always asked if they have patients with central lines. When the daily huddles first started, most of the conversations were around events that had already occurred. Now, that's changed, and the huddles focus on precursor events. "That tells a little about our evolution with our high reliability journey," Ms. Cockfield says.

To aid in keeping central line dressings clean and fresh, the hospital established a day of the week that all patients would get their central line dressings changed. "Rather than waiting for the dressings to look like they needed to be changed, we chose Tuesday to be our day to change the dressings," says Ms. North.

Other new processes include limiting blood draws from central lines — this is now only prompted by a physician order — and placing a sign outside a door when a central line is being inserted so no one accidently enters while the sterile procedure is being performed.


One of the biggest personnel changes at CHS involved bringing in two new, specialized nurses. "We committed the resources to have specialists handling the central lines and being responsible for their care," explains Darcy Craven, CEO of CHS. "Their only job is to insert…and care for the lines."

Aside from the addition of specialized nurses, the rest of the staff had to be trained and buy into the culture of safety and high reliability being created at CHS. "It was a very formal education," says Ms. Cockfield. She stresses the importance of keeping training standardized so everyone hears the same message. Part of that message is the significance of hand hygiene and speaking up if someone sees a colleague fail to wash their hands.

Beyond the three p's, another important aspect of keeping CLABSI rates at zero is celebrating success, says Ms. Cockfield. In recognition of its consistence with keeping CLABSI rates at zero since January 2012, CHS received a Certified Zero Harm Award from the South Carolina Hospital Association in April. The SICU team was invited to a senior leadership meeting, at which they were recognized as a unit for their great accomplishment. "That keeps them motivated to want to do better," says Ms. Cockfield.

But that doesn't mean the infection control team at CHS is resting on its laurels. Indeed, the hospital is still progressing toward its main goal. "The ultimate goal is zero healthcare associated infections, period," Mr. Craven says.

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