SMCA Nurses Lead Successful Effort to Reduce Central Line Associated Bloodstream Infections (CLABSI)

nurses at seton medical center austin

From left: Chelsea Kilgore, BSN, RN; Patrick Kopacko, BSN, RN; and Sarah Deibert, BSN, RN


Beginning in March of 2016, nursing at Ascension Seton Medical Center Austin (SMCA)’s Intermediate Care Unit (IMC) noticed an increase in the incidence of central line bloodstream infection (CLABSI) on the unit. In response, the Intermediate Care Unit (IMC – step-down) Policy and Performance Improvement Council (PPI) determined that the unit should increase monitoring and education efforts to reduce the rate of these infections.


  • Chelsea Kilgore, BSN, RN and Patrick Kopacko, BSN, RN, worked with Unit Educator Jeff Bothof, BSN, RN on this safety initiative as part of their clinical ladder project. The team analyzed data to determine the various factors that contribute to increases in CLABSI rates.
  • Four main areas for improvement were identified:
    • Peer-to-peer accountability
    • Clearly defined audit processes that incorporate real-time feedback (to improve adherence to established policies
    • Clear communication of CLABSI outcomes
    • Standardized education and expectation communication to all team members regarding the care for central lines
  • In May 2016, the IMC unit began implementing standardized audit process to determine the educational needs of the unit. The team also provided real-time feedback to nurses who needed extra help and guidance on changing and maintaining dressings.
  • Between May and June 2016, nurses provided standardized education to all RNs in the unit on policies related to:
    • Central venous catheters
    • Blood cultures
    • Care of peripheral intravenous lines.


The CLABSI rate decreased from 5.87 prior to implementation to zero after implementation of the initiative.