Facilities Involved in HAI Blood Stream Infection (BSI) QIA

Network 1 Network 2 Network 6 Network 9

The goals for this project are to reduce the number of BSIs at the facility and Network levels

2016 Facility and Network Activities

Network 6 Adjusted Timeline


Facilities return project agreements/contracts to the Network

Facilities begin performing three CDC Audits and reporting these in the National Health Safety Network (NHSN) from January through March, in addition to monthly infection data, by the 5th of the following month (i.e. Feb 5 for Jan)

  1. A minimum of 10 hand washing opportunity observations
  2. A minimum of 5 catheter connection and/or disconnection observations
  3. A minimum of 5 cannulation observations


  • The Network will provide a template for evaluating the root cause analysis of the infections identified during the first six months of 2015, potential interventions based on cause category, and a  summary form for Facility reporting to the Network from March through the end of October
  • Facilities begin using either the provided RCA template or other tool available at the facility with similar information to review infections with the interdisciplinary team during QAPI meetings. A summary of the RCA and discussion will be sent to the Network by March 5, 2016
  • Facilities (1) identify three CDC interventions to implement and the methods to implement these from March through September and (2) provide these choices to the Network by March 5, 2016 – review these plans during monthly QAPI meetings

March – October

Facilities implement CDC interventions on a monthly basis and:

  • Provide a  summary report to the Network including 3 successes, 3 challenges, and any key observations discussed during monthly QAPI about infections by either email or fax
  • Report infections in NHSN and to the Network, perform a RCA (“autopsy”) of any new infections including notifying the Network of any change in intervention plans because of the identified RCA (for example if an infection is the result of poor technique by a staff member, describe what and when remediation might occur with this staff member)
  • Report infections and any audits performed in NHSN by the 5th of the following month (i.e. April 5 for March)

All facilities in the project are encouraged to participate in the quarterly Learning and Action Network (LAN) activities as well, to improve understanding, share best practices, and work through barriers identified during the project. Call Schedule to be posted shortly.

HAI LAN Webinar Schedule - Click Here to Register for the Webinar:

  • February 10, 2016-9AM-10AM
    Presentation: Slides and Recording
  • May 11, 2016 - 9AM - 10 AM
    Presentation:   Slides and Recording
  • August 10, 2016 - 9AM - 10 AM
  • November - TBD
HAI Blood Stream Infection (BSI) QIA

Initiative Contacts

Network 1 (CT, MA, ME, NH, RI, VT)
Heather Camilleri, CCHT
Quality Improvement Coordinator

Network 2 (NY)
Carol Lyden, RN, BSN, MS, CNN
Quality Improvement Director

Network 6 (GA, NC, SC)
 Wambui Kungu, BS, HSM
 Quality Improvement Coordinator

Network 9 (IN, KY, OH)
 Deborah DeWalt, RN, MSN
 Quality Improvement Director