157 - Bringing the Bedside Back to CLABSI

Publication Number: 3151.157

Lindsay Favors-Pratt, Rady Children's Health San Diego, San Diego, CA, United States; Megan Medina, Rady Children's Hospital San Diego, San Diego, CA, United States; Quinn Allen, Rady Children's Hospital San Diego, San Diego, CA, United States; Eman Alrabadi, Rady Children's Hospital - - San Diego, CA, San Diego, CA, United States; Laurel Moyer, Rady Children's Hospital San Diego, San Diego, CA, United States

Background: Between July 2020 and June 2022, our organization experienced an increase in Central Line-Associated Bloodstream Infections (CLABSIs). Chart reviews of maintenance bundle compliance revealed minimal opportunities for improvement in central line care using existing audit methods.

Objective: In July 2023, we set an organizational goal to reduce CLABSIs. To support this goal, we implemented a new organization-wide process to evaluate maintenance bundle compliance and identify actionable opportunities for quality improvement. This included transitioning from Electronic Health Record (EHR)-based audits to Safety Card Rounding using Kamishibai methodology.

Design/Methods: Utilizing a multidisciplinary task force, we developed Safety Cards and established a dedicated in-person rounding team comprised of nursing leadership, infection prevention, and quality management representatives. In December 2022, two units piloted safety card rounding which was spread to all participating units by April 2023. Data was discussed at monthly meetings and via unit-based Safety Boards to drive transparency and discussion regarding opportunities for improvement.

Results: Initial Safety Card Rounding revealed significantly lower compliance compared to EHR audit data. Since implementation, compliance has markedly improved (Figure 2), accompanied by a notable reduction in CLABSI rates (Figure 1).

Conclusion(s): Safety Card Rounding increased organizational awareness of central line care and the importance of adherence to evidence-based practices. Since full implementation in April 2023, CLABSI rates have decreased by 28%. Beginning January 2024, insights from rounding are driving unit-level Plan-Do-Study-Act (PDSA) cycles to further enhance bundle compliance. The Safety Card Rounding process is now being adapted to address other hospital-acquired conditions across the organization.

Overall Success with CLABSI Evidence-Based Bundle Elements
The chart illustrates organizational adherence to evidence-based CLABSI bundle elements through safety card rounding from February 2023 to August 2025. Success percentage improved rapidly during early implementation, rising from approximately 25% to over 70% by mid-2023. Following the initiation of a PDSA cycle focused on hub scrubbing in December 2023, performance stabilized near the mean of 87%, with recent data averaging 85%. Control limits indicate sustained process reliability and alignment with the desired upward trend.

CLABSI Rate Control Chart: Monitoring Improvement Over Time
This control chart displays CLABSI rates per 1,000 central line days from January 2020 through April 2025. The chart shows initial variability in rates, followed by a notable decrease after the introduction of Safety Card Rounding in mid-2022 and full unit participation in early 2023. The centerline reflects an overall downward trend, and control limits indicate improved process stability over time, suggesting a positive impact of the intervention on reducing CLABSI rates.