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American Family Children's Hospital

Reducing Hospital-Acquired Infections

By Linda Stevens, DNP, RN-BC, CPHQ, CSPHP; Lyndsy Huser, MS, RN, ACNS-BC; Amy Marver, MSN, RN, CCRN


Many initiatives are underway to reduce hospital-acquired infections (HAIs) at UW Health, but how do we know if these initiatives and changes are working?


Infection control practitioners review infections reported by the laboratory to see if they meet criteria for an HAI. Two of these HAIs— catheter-associated urinary tract infections (CAUTI) and central line-associated blood stream infections (CLABSI)—have gotten a lot of attention this past year and efforts have been underway to make improvements. Both of these infections have an interdisciplinary team that meets regularly to review the data and make recommendations to improve these outcomes.


The CLABSI interdisciplinary team now meets twice a month and completes a gap analysis between recommended evidence-based practices and current UW Hospital and Clinics practice. This analysis will help us identify future areas to focus on. Top priorities already identified are to evaluate the use of midline catheters versus peripherally inserted central catheter (PICC) lines, discontinuing unnecessary central lines, and to investigate having two RNs present at central line dressing changes.


Unit-based CLABSI champions completed eight hours of central line training in FY14 and are monitoring central lines and their dressings on their units. They are also responsible for educating other staff on their units. New products have been added to central supply to assist with better line care, including an alternative to the bio patch that assists with hemostasis and a better, larger dressing for larger central lines.


The CAUTI workgroup also meets twice a month and has joined the 2014 CAUTI Improvement Collaborative through the University Health System Consortium (UHC). The past year's initiatives to reduce CAUTI have included:

  • Standardization of catheter kits with urine meters and size on all units throughout the organization
  • Use of indwelling urinary catheter checklist for all indwelling catheter insertions on inpatient units, including the emergency department • Ongoing education of all staff on proper catheter care that is to occur twice daily
  • CAUTI champion education
  • Daily evaluation of the necessity of the indwelling catheter
  • Formation of a pediatric specific CAUTI subgroup