Zero CLABSI Quality Aim

King Faisal Specialist Hospital & Research Center – Riyadh

Zero CLABSI Quality Aim

Contact Info

Name Maya Sinno

Phone: 00966114647272

Email: msinno@kfshrc.edu.sa

Position: Director, Quality Managment

Organization Name: King Faisal Specialist Hospital & Research Center – Riyadh

Organization Address:
Zahrawi St, Al Maather , Al Maazer, Al Riyadh
Riyadh, 12713 Saudi Arabia


Participants:

  • Nawarh Faran, Coordinator Quality managment
  • Khalid Alhamdan, Coordinator Quality managment

APSS

Have you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes

What Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated blood-stream infections (CLABSI)

How Many Hospitals Will This Commitment Represent?
1

Commitment Name:
Zero CLABSI Quality Aim

Commitment Details

Commitment Summary:
This Commitment is to reach to Zero CLABSI over a period of Three years. Considering reduction of 20% over the first year, 30% on the second year and 50% for the third year. the project started from Jan 2018 to achieve this goal.

Action Plan:
1-Standardize the hospital policies and procedures related to the insertion, maintenance and removal of the central lines 2-Standardize the central lines products utilized in the hospital and ensure availability of antimicrobial impregnated lines for pediatrics and adults patients 3-Introduce midlines to avoid unnecessary use of central lines 4-Introduce physicians training by simulation for lines insertion 5-Introduce Ultrasound guided insertion 6- Ensure nurses training for lines maintenance as per the updated CDC guidelines 7- Build electronic bundles checklist to evaluate insertion and maintenance bundles compliance. Produce regular reports for bundles compliance and share with various departments 8-Initiate hand hygiene promotion campaign that involved production of educational videos and elevator posters ....etc.. 9- Initiate staff recognition program (Golden Cards) for staff who demonstrate significant and continuous compliance with hand hygiene standards 10- Activated unit based CLABSI nursing champions with clear accountability and charges to ensure implantation of the needed measure to achieve the goal of Zero CLABSI in the units

Impact Details

Lives Saved

Tell us about your baseline level of harm:
144

Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
111

Lives Saved:
33

Lives Spared Harm:
33

Methodology for Determining Lives Saved:
As per our journey for Zero harm and being High reliability organization, harm is monitored at the level of individuals. Above indicator is set based on the number of identified cases of CLABSI over the year. (Baseline year)2017= 144 2018= 111 2019= it will be calculated end of the year, however the indicator is published on a monthly basis Note: please note the rate of CLABSI is also monitored based on the line utilization for different units. This rate also guides the improvement efforts and the focus on the units that reports high CLABSI vs. low utilization of the lines