NR 584NP Week 7 Assignment_Applying Quality Improvement (QI) to Clinical Practice - Central Line-Associated Bloodstream Infections (CLABSI)

infection by maintaining sterility and minimizing the time a line remains in place. This policy follows national recommendations and aligns with best practices for infection prevention in hospitalized patients. • What inconsistencies exist between your facility’s current policies, actual nursing practice, and best evidence related to your assigned topic? What evidence (data, observation, incident reports) suggests a need for improvement? Even though a policy exists within the facility, there are some gaps between expected procedures and daily nursing procedures. Some nurses fail to record daily line checks, and others delay dressing changes due to limited staf케ng. During audits, it was noted that aseptic technique was not always maintained, especially when accessing the catheter hub. Besides, incident reports show four CLABSI cases in the past three months, which is above the target benchmark of one case per 1000 catheter days. According to Rajandra et al. (2025), poor compliance with the central venous catheter care bundle increases the risks of infection. In this case, the study found that only 65% adherence among ICU staff (Rajandra et al., 2025). Therefore, this inconsistency between policy and practice supports the need for additional staff training, regular audits, and feedback to maintain full compliance with infection prevention standards. Section 2: Analyze • Review national safety resources related to your topic. Name at least two national organizations or initiatives (e.g., Centers for Medicare & Medicaid Services (CMS), Agency for Healthcare Research and Quality (AHRQ), Centers for Disease Control and Prevention (CDC), Institute for Health (IHI), National Patient Safety Goals (NPSG)) and summarize the guidance they provide related to your topic. There are two national safety resources related to the topic, including the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ). The CDC provides detailed recommendations for preventing CLABSIs. Among its recommendations are the use of chlorhexidine for skin antisepsis and removing central lines as soon as they are no longer needed. The CDC advises using alcohol-based chlorhexidine for skin cleaning before insertion to lower the risk of infections. It also recommends limiting the number of catheter lumens to the patient’s clinical needs. The AHRQ also emphasizes adherence to insertion and maintenance bundles, use of standardized checklists, and continuous staff training to sustain compliance. Both organizations indicate that consistent use of techniques and early line © 2025. Chamberlain University LLC. All rights reserved. verification mandatory will promote accountability, reduce skipped steps, and promote standardized infection prevention practices across all units. • Which evidence-based strategies support your proposed changes? Include at least one scholarly source to support your plan. The main strategy to support this change is regular staff competency training on bundle compliance. Odada et al. (2023) found that hospitals that provided ongoing training for nurses and physicians achieved lower CLABSI rates because staff followed care bundles more consistently. As such, each session will focus on correct hand hygiene, sterile barrier use, and central line maintenance techniques. Through repeated practice, staff will build their confidence and accuracy in performing these