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CLABSI Observations

Cheri Cole-Jenkins, RN, QOM

CBDI Clinic

CVC Team Members

CBDI

The team

The team

Hannah Reed, RNIII

Shawna Langworthy, RN

Clinical Director

Amy Hendrix, RN Clinical Manager

Megan Ewald,

RN II CVC Chair

Reenie Giesken, RNII

Kristy Feld

RN, Educator

Aubrie Schroer, RNII

Kelly Vu / RN

Tiffany Holt, RNII

Cheri Cole-Jenkins, RN

Quality Outcomes Manager

16 CLABSIs in FY 2016

~400 kids with CVC

When did the CLABSIs occur?

When did the CLABSIs occur?

July 2016 x1 skin

Jan 2017 Skin x2

Aug 2016 x2 Gut x2

Feb 2017

Env x1, Skin x 1, Gut x1, ENT x 1

Sept 2016 Enviromental x1

March 2017 0

April 2017 0

Oct 2016 Gut x2

May 2017 0

Nov 2016 Skin x1

June 2017 Gut x1

Dec 2016 Skin x2

What were the BUGS?

What were the BUGS?

6 gut bugs

(E. coli, enterbacter, Kelb Pneumo Strep Pneumo)

5 Skin bugs

(staph aureus, MRSA, moraxella)

4 Environmental bugs

( Pseudomonas, acinetobacter, paenibacillus)

1 ENT

(rothia mucilaginosa)

Observations

We need to improve our CLABSI Observation process

Barriers for observations

Barriers for observations

Staffing Issues

Lack of clarity of responsibility for completing

No timely feedback

Name / Job title

Experiences with Observations

Experiences with Observations

Learnings limited

Learnings not available to staff in real time

Name / Job title

K-Cards

Let's try something new

PICU K-Card Rounding

PICU K-Card Rounding

Column description

Column 1--- Perfect care map. If your loved one was in the bed, what key things should happen to prevent a hospital acquired condition

Column 2---The specific project or hospital acquired condition we are trying to improve

Columns 3-9--- Date of the week and the number of green or orange K-Cards each day. This should be updated by each person who performs a k-card

Column 10---The days since the last event occurred

Column 11---This will be updated weekly by each team lead, sharing the areas of focus for us to improve. We will need you to make these better. Please use the post-its to provide us ideas!!!

Notes on PICU K-Card Board

  • updated each time someone performs a K-card coaching and observation moment!

Green

= the system is performing as it should.

All communication and prevention standards were followed.

Orange

= an opportunity for improvement was identified during the K-Card observation and coaching.

The top one- three opportunities will be listed on the white board.

K-card concerns

Where to put it?

Daily update?

Roll out?

K-card concerns

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