Elizabeth S

  1. Evaluation Plan
    1. Measure Cumulative Progress
  1. How quickly did the MA hospitals and nursing staff adopt the new policy change?
  2. Utilization of the new implementation (quarterly)
    1. Use anonymous individual surveys to ask the nursing staff/ MA hospitals how they are liking the new implementation
    2. Suggestion box for obtaining feedback
  • How proficient are staff becoming with implementing the new policy?
  1. Compare before and after infection rates w/ new implemented plan in place
  2. Benchmarks
  3. Nurses are implanting the new policy successfully
    1. Should see a significant decrease in CLABSI rates with new implementation
  4. MA hospitals will be followed for 1 year
    1. Obtain accurate data
      1. Monthly checks for infection rates
      2. Check staff compliance
    2. Continue to gather data on CVC placement and line days
  • Continue to track admissions, discharges and CLABSI related deaths
    1. Follow up with patients who are d/c’d home with CVC lines
      1. Checking for patient compliance with CVC care
      2. Checking to see if infection occurred after discharge home with a CVC
      3. EMR should have information on CVC insertion and removal dates
    2. Determine if implementation is working
      1. Was there a reduction in CLABSI with new implementation?
      2. Drop in CLABSI rates over a 1-year period = success
      3. Success = keeping the new initiative in place
    3. Offer hospitals an incentive for CLABSI reduction
  1. Feedback
  2. Utilization of catheter caps
  3. Promote success by sharing data
  • Asking/ receiving nursing staff and MA hospital administrators and stakeholder input
  1. Providing information to patients and families about CVC care and new policies
    1. To ensure that they are aware of the process to promote change and reduce infection rates
    2. Assessing barriers
      1. Maintaining open communication
      2. Plan for any negative feedback or resistance
        1. Handle pushback by continuing to focus on the issue at hand
        2. Grow a culture of trust