(02) Reducing CLABSI Rates by Improving the Utilization of CHG

Title: Reducing CLABSI by Increasing the Utilization of CHG

Abstract : Basis of Inquiry
The project aimed to obtain CLABSI-free status by increasing the CHG peer feedback baseline from 82% to 92% by the end of Dec 2024 in the Hematology/Oncology unit at NCH-FL.
Purpose
Chlorhexidine Gluconate (CHG) usage is required for all patients with a central line in the Hematology/Oncology unit at NCH-FL, according to hospital policy. Efforts to increase CHG compliance began last fall, and while there were initial improvements, further opportunities for enhancement remained. Currently, CHG compliance continues to be the most significant area of concern in the prevention of central line-associated bloodstream infections (CLABSI) throughout the hospital.
Methods
To enhance CHG compliance, a driver diagram was utilized to identify four primary drivers, with specific change ideas developed for each. Actions to improve daily CLABSI bundle compliance included peer feedback, in collaboration with clinical nurses, the Unit Council, and Leadership, focusing on assessing the knowledge of patients and their families. Technology optimization involved implementing the Epic Brain task for CHG, streamlining documentation and compliance tracking. Education and training efforts included the distribution of educational flyers to families regarding CHG treatment and providing documentation training for Clinical Registered Nurses and Patient Care Technicians (PCTs).
Findings
In December 2024, CHG auditing rates increased to 92.88%, demonstrating the initiative's success in enhancing compliance with CHG protocols and maintaining a CLABSI-free status for 6 months. Leadership patient safety rounds and core charge nurse involvement in the peer feedback process have improved team patient and family awareness, resulting in increased compliance. Future considerations include adding more associates to ensure Central Line bundle compliance, with the goal of sustaining and further improving compliance rates. Utilizing CLABSI bundle peer feedback alongside documentation audits provides valuable insights into CHG bathing compliance.