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

S:NO 1 Issues Klebsiella Pneumonia in Blood related to RT. Femoral CVC line for Patient Simon Mampallil causes Melena Action for implementation Instruct the staff for assessment of the necessity of Femoral CVC line on Daily basis Remind the doctors to change the site of line once patient stable. Reinforce the CDC recommendation for change of line protocol since it is inserted in A/E (change after 48hrs). Apply flexiseal continuous drainage system to avoid stool expulsion. Instruct staff about change of gloves and hand scrub between the clustering of care Periodic Observation of CVC site for redness & tendernesss. Make sure the seal of dressing is adequate as per recommendation. Review date

31.8.13

Non-compliance 2 Failure of Propofol line change for two days Forgot

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 and display at the bedside those who are on Propofol infusion.

Sustainability plan
CVC Dressing Refreshment of knowledge Prepared by Usha K Nair ward 26 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 31.8.13

all patients whom has CVC or Dialysis cath. CVC insertion technique Reminders Chlorehrxidine anti septics Motivation Display audit file at the bed side just before the time of insertion All PPE are clearly display in the trolley Monthly audit reports send to the head of the department for further reinforcement. Gentle reminder to the doctors by words Encourage the staff whom has taken the initiative to remove the line will be rewarded Periodic review of patient related to the necessity of line by team members and staffs. Always include notification of line removal decision during the consultant round Motivate the staffs for the use of chlorehexidine as per requirement Facilitate the adequate supply of chlorehexidine swap stick and wipes Motivates the staff with verbal rewards regarding the proper usage of chlorehexidine. Always initiate the process by the team members in front of the staffs. 31.8.13

Early removal of CVC or Dialysis line

Reminders

31.8.13

31.8.13

Prepared by Usha K Nair ward 26