Document Type
Poster
Original Publication Date
2023
Journal/Book/Conference Title
Virginia Organization for Nurse Leaders (VONL) Conference
Date of Submission
November 2023
Abstract
BACKGROUND or RATIONALE:
The Acute Care Surgery unit (ACS) is a General and Progressive level of care post-operative unit at VCU Health system. Between quarter four 2021 and quarter one of 2023, five Central line associated blood stream infections (CLABSIs) occurred. NDNQI data revealed ACS had a higher CLABSI rate per 1,000 patient days than the national average of other similar type units in other magnet hospitals.
STATEMENT OF THE PROBLEM:
A GAP analysis revealed ACS did not achieve the 80% CHG compliance goal set by VCU Health’s Infection Prevention Department in all six quarters that these five CLABSIs occurred. This goal was set based on evidence that higher CHG bathing compliance reduces hospital acquired infections, including CLABSIs. A quality improvement (QI) project was developed to improve and sustain CHG compliance to 80% or greater and reduce/prevent CLABSIs.
METHODOLOGY:
A literature review revealed several implementation science methods may be effective in improving CHG compliance. Methods for this QI project were selected to address gaps in knowledge of staff and patients contributing to higher patient refusals and less opportunities for patients to comply. Implementation Science methods used for this project included: Staff education outreach, printed educational material, daily and bimonthly Audit and Feedback, Patient education through providing and framing information. A quality improvement project was developed and implemented using Plan-Do-Study-Act (PDSA) format. Three PDSA cycles were completed between February 13- April 30, 2023
RESULTS:
Goal CHG compliance was exceeded in PDSA cycles 2 and 3. ACS has met or exceeded 80% CHG compliance for seven months in a row since PDSA cycle 2. ACS has had no CLABSIs since January 2023, before the PDSA project began.
CONCLUSIONS:
Using multifaceted implementation science interventions was effective in changing the knowledge, beliefs, and practice of non-ICU staff from being a barrier into a facilitator to achieving and sustaining goal CHG compliance to prevent CLABSIs
Rights
This poster is distributed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) License (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Is Part Of
VCU Health Nursing