SHM Converge Scientific Abstract ePoster Gallery-Mission Control: Engaging Clinical Teams to Prevent Bloodstream Infections Through the Timely Removal of Unnecessary Vascular Access Devices

Mission Control: Engaging Clinical Teams to Prevent Bloodstream Infections Through the Timely Removal of Unnecessary Vascular Access Devices

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UC San Diego Health developed “Mission Control – MC-CABSI,” a real-time intervention to reduce bloodstream infections by prompting clinical teams to remove unnecessary vascular access devices (VADs), including central venous catheters (CVCs) and peripheral IVs (PVCs). The project was motivated by evidence that many bloodstream infections occur outside the ICU and that PVC-related infections are increasingly important, especially as CDC surveillance is expected to shift in 2030 to a device-agnostic Hospital Onset Bacteremia (HOB) metric.<br /><br />The program uses daily EHR secure chat messages, powered by line data from flowsheets, and targets nurses plus the attending/primary physician. Five message types were created: central lines not infusing for 48 hours, units with high VAD density, patients with three or more PVCs, central lines documented as no longer necessary but still in place, and field-inserted PVCs that remain 24 hours after admission. The goal is to close the gap between recognizing a line is unnecessary and actually removing it.<br /><br />Results from the initial rollout showed 281 messages sent, a 58% response rate, and 163 patients with VADs removed. Hospital-wide median vascular access device density (VADD) decreased from 1.41 to 1.35 compared with the previous six months, suggesting improved device stewardship.<br /><br />Next steps include monitoring long-term infection and VADD trends, refining message triggers based on clinician feedback, expanding to other device types such as urinary catheters, increasing automation and EHR integration, and preparing for future CDC HOB surveillance requirements.

Asset Subtitle

Aryeh Feldheim

Meta Tag

Author List Aryeh Feldheim, Ian Jenkins, Kristyn Schumacher, Rahel Bahru, Robert El-Kareh

Category Innovations

Concept Catheter-Associated Bloodstream Infection

Concept Intravenous Access Device

Concept Intravascular Device

Concept Peripheral Intravenous Catheter

Concept Device Necessity

Distinguished Non-Finalist

Presenter Organization UC San Diego Health

Presenting Author Aryeh Feldheim

Track Quality Improvement

Keywords

UC San Diego Health

Mission Control MC-CABSI

bloodstream infections

vascular access devices

central venous catheters

peripheral IVs

EHR secure chat

device stewardship

vascular access device density

Hospital Onset Bacteremia

Catheter-Associated Bloodstream Infection

Intravenous Access Device

Intravascular Device

Peripheral Intravenous Catheter

Device Necessity