One year prior to the TAP Strategy the facility had 71 CLABSIs with a CLABSI SIR of 1.441 and 22 CAUTIs with a CAUTI SIR of 1.734. After the implementation, there were 65 CLABSIs with a CLABSI SIR of 1.328 and 14 CAUTIs with a CAUTI SIR of 1.164. The TAP Strategy is a framework for quality improvement that stands for Target, Assess, and Prevent created by the Centers for Disease Control and Prevention (CDC). The program uses data reported by healthcare facilities to the CDC’s National Healthcare Safety Network (NHSN) to identify healthcare facilities with an excess burden of healthcare-associated infections (HAIs) and provides an assessment tool to identify gaps in the infection prevention program. A comprehensive cancer center implemented the TAP Strategy from October 2021 to September 2022 to reduce the number of central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs).
Problem: Gaps in practice and policies related to CLABSI (central-line associated bloodstream infection) and CAUTI (catheter-associated urinary tract infection) and units with an excess burden of HAI (hospital-acquired infections)
Measurement: The unit with the highest CLABSI rate in the facility and the highest CAUTI rate were surveyed. The survey analyzed the staff’s understanding of education, practices, policies, etc. related to CLABSI and CAUTI. CAUTI and CLABSI rates were utilized to measure pre and post-interventions
Analysis: A gap analysis was conducted to identify gaps in the infection prevention program that needed to be reviewed. Gaps were addressed through aimed interventions from the CAUTI and CLABSI committees. HAI rates and SIRs (standardized infection ratios) were compared to determine the effectiveness of efforts before and after implementation
Implementation: Gaps identified included the need for physician champions for prevention efforts, policy and practice updates, and changes to documentation in the electronic medical records. All gaps were addressed through practice and policy changes directed by CAUTI and CLABSI committees. Others can learn to perform and address gaps to prevent HAIs
