7/30/2019 Action Plan for CRBSI JUNE 2013

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Prepared by Usha K Nair ward 26

Action plan for catheter related blood steam in ward 26 June 2013

S:NO Issues causes Action for implementation Review

date

1

2

Klebsiella Pneumonia in Blood

related to RT. Femoral CVC

line for Patient Simon

Mampallil

Failure of Propofol line

change for two days

Melena

Non-compliance

Forgot

Instruct the staff for assessment of the necessity of FemoralCVC line on Daily basis

Remind the doctors to change the site of line once patientstable.

Reinforce the CDC recommendation for change of line protocolsince it is inserted in A/E (change after 48hrs).

Apply flexiseal continuous drainage system to avoid stoolexpulsion.

Instruct staff about change of gloves and hand scrub betweenthe clustering of care

Periodic Observation of CVC site for redness & tendernesss. Make sure the seal of dressing is adequate as per

recommendation.

Send email notification to all staff Failure of compliance report to C/N Feda with staff name

High light the Propofol line change interval in an A4 paper anddisplay at the bedside those who are on Propofol infusion.

31.8.13

Sustainability plan

CVC Dressing Refreshment of

knowledge

Display laminated copy of line protocol (soc)at bed side Strict observation of dressing technique and timely correction

from the team members

Periodic observation of CVC dressing changing time period Reinforce the staff for the strict use of Chlorehexidine wipe for

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7/30/2019 Action Plan for CRBSI JUNE 2013

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Prepared by Usha K Nair ward 26

all patients whom has CVC or Dialysis cath.

CVC insertion technique Reminders Display audit file at the bed side just before the time ofinsertion

All PPE are clearly display in the trolley Monthly audit reports send to the head of the department forfurther reinforcement. Gentle reminder to the doctors by words

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Early removal of CVC or

Dialysis line

Reminders Encourage the staff whom has taken the initiative to removethe line will be rewarded

Periodic review of patient related to the necessity of line byteam members and staffs.

Always include notification of line removal decision during theconsultant round

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Chlorehrxidine anti septics Motivation Motivate the staffs for the use of chlorehexidine as perrequirement

Facilitate the adequate supply of chlorehexidine swap stickand wipes

Motivates the staff with verbal rewards regarding the properusage of chlorehexidine.

Always initiate the process by the team members in front ofthe staffs.

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