Central Line Infection Management Case Study

The preferred state of hospital management of central line infections and central line care focuses on a variety of steps that are implemented throughout the hospital. To start, an infection control team would be established in order to prevent or mitigate infections. An infection control team is a dedicated department responsible for advising, educating, and working with all areas of a hospital to prevent and control infection (Bedford Hospital NHS, 2018). This team would consist of a director of the infection, infection control doctor, infection control nurse, administrator, and any other key collaborative members (Bedford Hospital NHS, 2018). The preferred state would have standard CVC maintenance bundles that are current with evidence base …show more content…
O’grady et al., (2011) recommend periodical assessment of knowledge for all personnel involved the in central line care, appropriate nursing staff levels in ICUs, and designated competent trained personnel for the insertion or maintenance in central catheters. According to the Center of Disease and Control (2017), “Observational studies suggest that a higher proportion of “pool nurses” or an elevated patient-to-nurse ratio is associated with CRBSI in ICUs where nurses are managing patients with CVCs”. Thus, in the ideal hospital, education and competency assessment would be enforced more than once a year, utilization of Surveillance form 2 on central lines, and safe 1-2 patient to nurse ratio level in the ICU would be mandated. In addition, communication plays an integral role in the preferred state of central line maintenance. As a result, a checklist in conjunction with a central line bundle helps communicate to healthcare personnel the standard of care in central lines and infection prevention (Sacks et al., …show more content…
According to AHRQ (2017) “RCA uses the systems approach to identify both active errors (Errors that occur between humans and a complex system) and latent errors (hidden problems within health systems that contribute to adverse events)”. The essentials of a root cause ultimately are to identify the sequence of events that resulted in the error and a plan to prevent it from happening again. In regards to a central line infection, the root cause would be to determine how and why the patient got infected with the sequence of events that took place. The data collected and reconstruction of events through record review and interviews could serve to analyze the cause or factors resulting in the error (AHRQ, 2017). Thus, once the factors or causation is identified, immediate changes are created as new protocols or regulations in order to prevent future errors. For example, if a central line infection occurred in hospital X because of cap changes not being changed every 72 hours, then the result would implement cap changes every 72 hours to prevent future