Date of Graduation

Spring 5-22-2015

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Melissa Vandeveer, PNP, CNL, PhD

Second Advisor



The aim of this project is to reduce the rate of central line associated blood stream infection (CLABSI) occurrence in oncology ICU by 50% by the last quarter of 2015. This study was conducted in ICU to assess adherence to the facility’s hand hygiene (HH) protocol among the staff nurses and allied healthcare workers. The facility is best known as a non-profit cancer treatment center and designated as a Comprehensive Cancer Center. Evidence showed that hand hygiene is the most effective way of preventing CLABSI, one of the most common types of infection in ICU microsystem. The project utilized The Joint Commission’s Targeted Solutions Tool for Hand Hygiene as the framework to improve HH compliance and to reduce frequency of CLABSI occurrence. A multidisciplinary team approach was utilized that included four designated “Just In Time” coaches who have been trained to collect HH data via direct observation technique and positive reinforcement approach to improve compliance. The CNL student compiled and analyzed the data. Visual posters have also been installed in high traffic areas of ICU as reminders to HH protocol. The pilot period of six to twelve weeks is expected to improve the overall HH compliance among staff nurses at or above the 90% threshold. At the end of 2015, after several months of continuous aggressive implementation of coaching, positive reinforcement, and visual cues, the staff nurses and allied healthcare workers are expected to sustain performance and compliance to HH at or above 90% and meet the CLABSI occurrence threshold.