| Sumario: | Significance & Background: Central Line-Associated Bloodstream Infection (CLABSI) is a serious and often preventable infection occurring in patients with central venous catheters (CVCs). CLABSI remains a significant cause of morbidity and mortality in healthcare settings and can lead to increased healthcare costs. The CLABSI rate in our medical oncology unit began to see a trend in the wrong direction, which had previously maintained zero CLABSIs for the past two years. Purpose: Our unit goal was to achieve zero CLABSI by August 2024. This was achieved through the shared governance approach, centered on empowering and engaging staff to lead this initiative, thus fostering a culture of accountability and safety. Interventions: The Quality Outcomes Council led by the frontline nurses conducted the CLABSI prevention initiatives jointly with the leaders. Gaps in practice and barriers were identified by focus groups sessions. Root Cause Analysis and Kotter's Eight-Step Model were used to enhance bundle adherence. Our strategies involved targeted education on CVC care and hands-on skills checkoff for needleless connector change (January 2024). A standardized schedule for Intravenous (IV) tubing change also was introduced to improve consistency. The introduction of Chlorhexidine Gluconate (CHG) baths in February became a cornerstone of the bundle along with the biweekly audits to monitor compliance and provide feedback. Results: From November 2023 to August 2024, the unit remained CLABSI free. Ongoing audits showed notable improvement in needleless connector change from 82%(baseline) to 95% (post action). IV tubing compliance remained above 90% for both periods. Discussion: The council will continue to monitor abidance and provide peer feedback for sustained adherence and accountability. Staff Engagement was key in achieving the unit goal of zero CLABSI. This initiative also unveils the need for onboarding education and ongoing surveillance. The project highlights the positive impact of shared decision-making and staff commitment to nurse sensitive indicators like CLABSI.
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