Background: Current guidelines to decrease the incident of CLABSI (Central Line Associated Blood Stream Infection) recommend daily assessment of line presence and clinical indication for the line (Odada et al., 2023). This helps decrease unnecessary line use and facilitates prompt line removal if not indicated. Daily line documentation including type of line, anatomical location of line, and clearly noted indication for use is considered best practice for the Baylor Hospitalist group. Chart review revealed that this standard was not met 21% of the time. Baylor St. Luke’s Medical Center (BSLMC) recorded 53 CLABSIs from June ’22-May ’23 and 68 CLABSIs from June ’23-May ’24 demonstrating a 28.3% increase in CLABSIs. At the beginning of the quality improvement project from June to July 2024, there were four CLABSIs cases assigned to the Baylor College of Medicine (BCM) Hospitalist group per the BSLMC Hospital-Acquired Infection (HAI) Committee based on National Healthcare Safety Network (NHSN) criteria. In response to this increase in CLABSI rate, the BCM hospitalist group wanted to implement hospitalist specific CLABSI prevention measures given that they care for approximately 64% of the patient population at BSLMC.
Purpose: This quality improvement project sought to increase physician documentation compliance by 15% and reduce the CLABSI rate for the BCM hospitalist group at BSLMC by 10% by September 2025.
Description: We developed a central line audit tool used by our quality nurse to track central line clinical indication and documentation for patients on the BCM hospitalist service. If a central line were present and through the audit tool was found to have no clinical indication or inadequate documentation of the line, the quality nurse would contact the hospitalist in real time to review clinical indication and documentation. The quality nurse would then monitor for updated documentation and/or removal of the line and update the Central Line Audit Tool accordingly. The Central Line Audit Tool was also used to monitor the BCM hospitalist group patients diagnosed with CLABSI. Through this real-time monitoring, we increased physician documentation and reduced CLABSI rate within our group.
Conclusions: Halfway through the quality improvement project, central line documentation compliance has improved by 4% from 79% to 83% compliant notes. The BCM Hospitalist group has decreased the number of CLABSI cases attributed to them every month since the project began. At baseline, the group had 4 CLABSI attributed to them in June 2024. Currently, the group has one CLABSI attributed to them for October 2024 and none in November 2024 to date. Although the change is not clinically significant yet, we are seeing a positive change in both documentation compliance and reduced CLABSI rate, which we hope will lead to achieving and sustaining our goal of 15% improvement in documentation compliance and 10% reduction in CLABSI rate for BCM Hospitalists patients at BSLMC. Each CLABSI can cost a hospital approximately $48,000 based on the Agency for Healthcare Research and Quality (AHRQ) estimate (Byshee et al., 2017). During FY24 there were 68 CLABSIs at BSLMC. Our goal is to reduce the rate of CLABSI by 10% during this fiscal year. This will result in savings of approximately $336,000 annually.
