The Transplant Program is part of the Support Program for Institutional Development of the Unified Health System (PROADI-SUS) with the objective of carrying out solid organ transplants (SOT), ensuring the quality, safety, universality and equity of care for people in queues of transplant.

The SOT Impatient Unit (IU) and Intensive Care Unit (ICU) unitscame to Einstein Morumbi in 2021 and the structure of individual rooms needed to be adapted to a two-bed ward and ICU-hall to accommodate the number of beds necessary, 40 from IU and 10 from ICU.

From August 2022 onwards, there was an increase in cases ofcentral line-associated bloodstream infections (CLABSI) in these units, with an average of one case of CLABSIevery 26 days. Data from the literature point to a negative impact, with unfavorable outcomes associated with CLABSI in general, and these may be even worse in transplant patients, due to immunosuppression.

The aim of the project is to improve processes to reduce CLABSI and reduce the CLABSI rate by 40%, going from 2.90/1000 Central line-day to 1. 74 from July 2023 to August 2024 and increase the adherence to insertion, central line (CL) maintenance and hand hygiene (HH) bundles to 95%.

All patients admitted to the two units using CL were included in the scope of the project. Meetings were held with representatives of the multidisciplinary team to raise problems and define priorities based on a risk matrix, with a description of a driver diagram with ideas for proposed changes to enable their implementation.

The improvement model was used to carry out the project and tools such as PDSA (plan, do, check, act), fishbone diagrams and TWI (Training Within Industry). Bundles are created with immediate educational feedback and monitoring of results by sector coordination.

In seven months of the project there was a reduction in the CLABSI rate from 2.9 to 0.57/1000 C