Project Information

Multidisciplinary CLABSI Reduction Initiative: UF Health's Path Toward Achieving Zero Infections

Project Description: Central-line associated bloodstream infections (also known as CLABSIs) are serious, life-threatening infections in which organisms enter the bloodstream due to poor insertion technique or improper maintenance of central venous catheters. These purely preventable infections have been associated with increased healthcare costs, length of stay and mortality. The National Healthcare Safety Network (NHSN) reports that in 2015, 26,029 CLABSI events occurred across the 3,550 participating acute care hospitals. Based upon this data, NHSN conducted a re-baseline in which all-future standardized infection ratios (SIR), a summary measure used to track HAIs at a national, state, or local level over time, would be based upon going forward. In 2016 UF Health Shands hospital saw an increase in their CLABSI rate and as a result a ~25% increase in their SIR (from 0.897 to 1.109). As a result, a multidisciplinary team composed of nursing leaders, infection preventionists and infectious disease physicians regrouped in October 2016 in response to the increasing CLABSI rates. The goal of this CLABSI Committee was to develop interventions targeted at preventing these events from occurring and monitor outcomes. Interventions included the development and implementation of: 1) An electronic drilldown tool to track and trend contributing factors when a CLABSI occurs to create future interventions 2) A CLABSI Bundle for standardization of insertion and care of central venous catheters 3) Kamishibai Cards (K-Cards) for monitoring compliance with bundle 4) A patient education brochure for CLABSI prevention and 5) Targeted interventions in select patient populations at high risk of CLABSIs as identified from the CLABSI drilldown trend data

QPI: John, Delano, (

Collaborators: Angela, Larson, (; Jamie, Dees, (; Scott, Brown, (; (; Nicole, Iovine, (


UF Health Big Aims: Zero Harm None

MeSH Keywords: Catheterization, Central Venous, Infection Control, CLABSI, Infection Prevention