Date on Paper


Document Type

Doctoral Paper

Degree Name




Committee Chair

Harrington, Candace

Committee Member

Christian, Becky


Background: Central-line associated blood stream infections (CLABSI) are a major threat to patient morbidity and mortality. Kentucky Continue Care Hospital (KCCH), a long-term acute care hospital, experienced a significant increase in CLABSI in 2018; therefore, implementation of a central-line bundle to reduce CLABSI was identified as a quality improvement priority. Methods: This author used the Quality Improvement Model to plan, study, and evaluate the implementation of a central line bundle in KCCH following University of Louisville Institutional Review Board (ULIRB) approval, staff were educated on the new process and the audit tool using a self-study module over a 2-week period before implementation. Chart audits were done over a six-week period to identify changes for ongoing implementation strategies. The goal for this first PDSA cycle was 20% compliance. Results: Outcome objectives determined overall compliance with all central line bundle interventions improved by 19.7%. There was a 22.2% demonstration of positive change from pre-implementation to post-implementation. Outcome objectives were met, overall compliance improved by 19.7% more often and staff were meeting the objectives 22.2% more of the time. Barriers included lack of standardized documentation and difficulty in identifying which patients needed daily chlorhexidine bathing.

Included in

Nursing Commons