Date of Graduation

Summer 8-31-2026

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

Program

Kaiser cohort MSN capstone

First Advisor

Liesel Buchner

Abstract

Problem: Central line-associated bloodstream infections (CLABSIs) remain a significant and preventable patient safety concern in acute care settings, contributing to increased morbidity, mortality, prolonged hospitalization, and substantial healthcare costs.

Context: At Hospital A, a tertiary referral center in Northern California, six adult CLABSIs were identified between June and December 2025 following an eight-month CLABSI-free period. Four events occurred in adult medical surgical telemetry. All peripherally inserted central catheter (PICC) line CLABSIs were attributed to gaps in maintenance bundle adherence and the lack of a standardized, real-time tracking mechanism for the PICC Team.

Interventions: A PICC Team Tracker was implemented as a frontline-driven, electronic surveillance tool embedded with existing electronic health record infrastructure. The tracker consolidated maintenance bundle elements, including chlorhexidine (CHG) bath compliance, dressing change tracking, and line necessity review, into a standardized workflow supported by iterative PDSA cycles, audit-and-feedback processes, and a staff nurse champion model.

Measures: Outcome and process measures were obtained from the National Healthcare Safety Network (NHSN) Hospital Acquired Infection Data Scorecard and the Nursing Sensitive Indicator (NSI) Dashboard. The primary outcome measure was the all Adult CLABSI Standardized Infection Ratio (SIR), with a target of ≤ 0.67. Process measures included CHG bath compliance, timely dressing change compliance, and daily line necessity assessment compliance, each with a target of ≥ 90%.

Results: The all Adult CLABSI SIR decreased from a baseline of 0.83 to 0.64 by February 28, 2026 and sustained below the project target of ≤ 0.67 through July 31, 2026. CHG bath compliance increased from 81.4% to 90.5%, timely dressing change compliance reached 100%, and daily line necessity assessment compliance reached 99.3% by May 2026, sustaining above 3 target through June and July 2026.

Conclusions: A structured, frontline-driven surveillance tool can translate evidence into measurable patient safety improvement, with each prevented CLABSI event representing an estimated $113,493.60 in avoided costs and 29.3 excess bed days. The PICC Team Tracker offers a scalable, low-cost model for CLABSI prevention that is replicable across microsystems and integrated healthcare systems.

Keywords: central line-associated bloodstream infection, CLABSI prevention, peripherally inserted central catheter, PICC team, maintenance bundle adherence, standardized infection ratio, frontline engagement, electronic surveillance, clinical nurse leader

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