Problem & Purpose: Increased prevalence of central line-associated bloodstream infections (CLABSIs) was identified in the intensive care unit (ICU) at a large community hospital. Verifiable data consists of two CLABSIs in 2023-2024, while the ICU’s goal is zero. The hospital has a central line (CL) maintenance compliance goal of 92% per intervention. However, CL maintenance deficits were present. 20% of CLs had improper utilization of Curos caps, 20% of tubing/fluid labels were expired, 35% of CLs were not indicated, and 20% of CL dressings were expired. The purpose of this quality improvement (QI) project was to reduce CLABSIs and promote CL maintenance compliance among adult patients with CLs in the ICU by implementing the Agency for Healthcare Research and Quality (AHRQ) Safety Program for ICUs: Preventing CLABSI Toolkit, utilizing the Comprehensive Unit-based Safety Program (CUSP) and the implementation of the Central Venous Catheter Maintenance Module (CVCMM). The initiative was implemented over 16 weeks. Methods: The project lead (PL) conducted CVCMM educational sessions with the CUSP team and the ICU nursing staff during the first week of implementation. CVCMM implementation began the second week, ensuring all patients with CLs in the ICU received the module’s specified CL maintenance interventions as recommended in the toolkit. Audits were conducted by the ICU leadership staff during daily bedside rounds. Data was collected via Quick Response codes to determine daily toolkit compliance and CLABSI incidence. Data was disseminated to the staff monthly, and improvement discussions were conducted based on the recommendations within the CVCMM by the AHRQ. Approximately 50 patients in the ICU were expected to benefit from the implementation. Stakeholders consisted of 93 ICU nurses and the 10 CUSP members. Results: 635 audits were completed during the implementation. Zero incidences of CLABSI were

reported. Based on cumulative findings, daily toolkit compliance ranged from 70.0%-100.0% with a mean of 96.9%. Cumulative averaged findings of CVCMM intervention adherence averaged 98.4%. Conclusions: Findings suggest the implementation of the AHRQ Safety Program for ICUs: Preventing CLABSI Toolkit produced the desired practice change. The toolkit implementation resulted in improved CL maintenance compliance and zero CLABSI occurrences.