1. Frist Avila, Patricia MSN, RN, NE-BC, OCN, AOCNS
  2. Twibell, K. Renee PhD, RN, CNE
  3. Demaree, Heather MSN, RN, CMSRN


Background: The management of health care associated infections (HAIs) challenges acute care facilities due to variability in practices. The purpose of this quality improvement project was to decrease central line-associated bloodstream infection, catheter-associated urinary tract infection, and Clostridioides difficile infection in a high acuity care environment using a visual management (VM) tool to address practice variations.


Local Problem: An acute care unit experienced increasing HAIs.


Methods: An interprofessional team used Lean methodology to implement a VM tool reflective of evidence-based HAI prevention practices that staff had frequently omitted.


Interventions: A VM tool called the Safety Tracker was created.


Results: In 12 months, HAIs decreased from 9 events to 1, with a corresponding reduction in indwelling urinary catheter utilization and central line utilization. More than $160 000 were avoided in health care costs.


Conclusions: Creating an interprofessional VM Safety Tracker could significantly reduce HAIs.