Project Information

CLABSI Reduction in the Pediatric Cardiac Intensive Care Unit (PCICU): A review of 2016 through 2017

Project Description: This project will compare CLAbsi incidence and introduction of nursing intervention on a timeline from 2016 through 2017 in a retrospective review. In February 2016, the PCICU began the process of random audits of compliance with our central line bundle via the “K Card” process. The bundle was developed using guidelines from the Solutions for Patient Safety network. This process entailed random monthly reviews of 10 patients with central lines. The results are posted in a central location in the unit for all staff to not only recognize areas for improvement, but to also celebrate improvements in bundle compliance. In September 2016, we introduced intravenous TPN tubing changes every 24 hours based on new evidence. In October 2016, the PCICU implemented the use of a manufactured sterile CVL cap changing kit. In November 2016, the process of charge nurses rounding on central lines daily was re-introduced. In December 2016, the PCICU Unit Practice Council (UPC) developed a practice to increase environmental cleanliness and reduction of clutter in patient rooms, also known as the “Sunday Purge”. In February 2017, the PCICU UPC also implemented daily bathing with soap and water before using the CHG bathing cloths. Due to observed variability in the practice of sterile cap changes, education was modified and required for all Children’s Hospital staff in June 2017. In July 2017, an update on the K Card process along with a video was developed and required for all Children’s Hospital staff.

QPI: Joshua, Campbell, (

Collaborators: Laurel, Barwick, (


UF Health Big Aims: Zero Harm None

MeSH Keywords: Chlorhexidine, Pediatric Nursing, Central Venous Catheters, Bloodstream infection, CLABSI