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

David Ainsworth

Abstract

Background: Central line-associated bloodstream infections (CLABSIs) remain among the most serious and costly healthcare-associated infections in acute care settings, with each event associated with significant excess mortality, prolonged hospital stays, and avoidable healthcare costs. At Hospital A, a 239-bed acute care facility, two of six total CLABSI events over a 12-month period were associated with peripherally inserted central catheters (PICCs), representing 33% of all facility CLABSIs and exposing a critical gap in standardized PICC line surveillance and maintenance bundle monitoring.

Problem: The PICC team lacked a systematic, real-time tracking mechanism to monitor central line maintenance bundle adherence across seven adult non-intensive care inpatient units, resulting in person-dependent handoff communication, inconsistent documentation, and missed opportunities for early intervention and CLABSI prevention.

Interventions: Three sequential Plan-Do-Study-Act cycles were used to implement a comprehensive PICC team tracker, standardize an audit-and-feedback process through dashboard visibility, and establish a nurse champion education and engagement program to embed the tracker into daily standard work.

Outcome Measures: The primary outcome measure is the All Adult Non-ICU CLABSI Standardized Infection Ratio (SIR), tracked monthly using NHSN surveillance data, with a goal of ≤ 0.67 by July 31, 2026.

Results: From January to April 2026, the All Adult Non-ICU CLABSI SIR declined from a baseline of 0.83 to 0.63, crossing below the project goal of ≤ 0.67 by February 2026 and sustaining that threshold through April 2026. All three process measures including CHG bath compliance, timely dressing change compliance, and daily line necessity assessment, demonstrated upward trends across the implementation period, with CHG bath compliance reaching the 90% goal by July 2026. Final results are pending project completion in July 2026.

Conclusion: Early findings suggest that implementing a standardized PICC Team Tracker supported by real-time data visibility, frontline champion engagement, and sequential PDSA testing is a feasible and effective approach to improving CLABSI prevention bundle adherence and reducing infection rates in adult non-ICU inpatient settings. Sustainability and potential for spread across the health system will be evaluated upon completion of the full implementation period.

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