SHM Converge Scientific Abstract ePoster Gallery-Reducing Clabsis Through Central Line Audits With Real-Time Feedback and Collaborative Quality Improvement Efforts by Hospitalists and Their Quality Nurse in a Major Medical Center

Reducing Clabsis Through Central Line Audits With Real-Time Feedback and Collaborative Quality Improvement Efforts by Hospitalists and Their Quality Nurse in a Major Medical Center

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This quality improvement project addressed rising central line-associated bloodstream infections (CLABSIs) at Baylor St. Luke’s Medical Center (BSLMC) by focusing on Baylor College of Medicine (BCM) Hospitalists, who care for about 64% of the hospital’s patients. Baseline review showed daily central line documentation was incomplete 21% of the time, despite guidelines recommending routine assessment of line presence and clinical indication.<br /><br />To improve practice, the team created a Central Line Audit Tool and Dashboard to track line type, location, indication, documentation quality, and assigned CLABSI cases. A BCM quality nurse provided real-time feedback to hospitalists when documentation was missing or no clinical indication for the line was found, and followed up to encourage documentation updates or line removal when appropriate.<br /><br />After 10 months, documentation compliance improved from 79% to 82% and the BCM Hospitalist internal CLABSI rate declined steadily, with zero cases in several months. The team estimated that a 10% reduction in internal CLABSI cases could save the hospital approximately $336,000 annually, based on average CLABSI costs.<br /><br />The project had some limitations, including manual auditing workload and the fact that many CLABSIs at BSLMC occurred in ICUs, limiting the impact on the hospital-wide rate. Still, the initiative showed that physician-led documentation audits and immediate feedback can meaningfully improve central line management and reduce infection risk.<br /><br />Next steps include automating the auditing process, sustaining gains, expanding education efforts, and broadening similar quality improvement work to indwelling urinary catheters. The project was also awarded one of 10 Baylor ACE Grants.

Asset Subtitle

Ashley S. Vaughn

Meta Tag

Author List Allison Heinen, Ashley S. Vaughn, Jill Jacoby

Category Innovations

Concept Central Line Audit

Concept Physician Documentation Compliance

Concept Catheter-Related Bloodstream Infection

Concept Central Line Documentation

Concept Real-time Feedback

Distinguished Non-Finalist

Presenter Organization Baylor College of Medicine

Presenting Author Ashley S. Vaughn

Track Quality Improvement

Keywords

central line-associated bloodstream infections

CLABSI

quality improvement

hospitalists

documentation compliance

central line audit

real-time feedback

infection prevention

dashboard

Baylor St. Luke’s Medical Center

Central Line Audit

Physician Documentation Compliance

Catheter-Related Bloodstream Infection

Central Line Documentation

Real-time Feedback