Project Information

Standardization of Needleless Valve Changes for CLABSI Reduction: Shared Successes from Staff-Drive Initiatives

Project Description: Central line-associated bloodstream infection (CLABSI) rates (CLABSI per 1000 device days) on 64MS were increasing over a period of two quarters and underperforming National Database of Nursing Quality Indicators® (NDNQI®) benchmarks (Qtr4 2015: 1.66 vs 1.01; Qtr1 2016: 5.52 vs 1.07). As such, the unit’s newly formed Unit Practice Council (UPC) embraced CLABSI reduction as their first official project under the guidance of their Clinical Leader (CL) and Nurse Specialist (NS) advisors. During the unit’s annual skills fair anecdotal evidence surfaced that needleless connectors were not being changed according to hospital policy and staff responses suggested variability in routine line maintenance practices, specific to use of needleless connectors. Similar findings were discussed at the Nursing Department’s Safety Huddles where several units shared success with standardization of practice around routine needleless connector changes. In response, the CL and NS brought these strategies to the UPC for consideration. The UPC, in collaboration with the CL and NS critiqued current practice and suggested practice changes against the Infusion Nurses Society (INS) recommendations and came to consensus that its first CLABSI reduction initiative would be to standardize practice with regards to changing needleless connectors, replicating the process used with success on 7W.

QPI: Linda, Allen, (

Collaborators: Kelly, Jacobitz, (


UF Health Big Aims: Zero Harm None

MeSH Keywords: