To decrease central line-associated bloodstream infections (CLABs)by 90 percent in the Coronary Care Unit (CCU) / Medical Intensive Care Unit (MICU) in the first year of our project.

The number of central line-associated blood stream infections in the CCU and MICU before and after implementing standardization and education measures.

We performed a retrospective review of the previous year’s central line infections and compared the infection rates of the Coronary Care Unit (CCU) and the Medical Intensive Care Unit (MICU) against the national infection rates and the rates for the Pittsburgh area and defined the problems with benchmarking the difference between reporting and actionable data. We began real time monitoring of the infection rates to determine root causes and complications associated with central line-associated bloodstream infections (CLABs) that led to implementing the following process changes: 

• Implemented a CLAB team consisting of a physician champion, nursing champions and infection control partners.
• Developed our countermeasures based upon real time observations of central line placement and care.
• Began fostering an “Is this line necessary?” approach to each individual patient.
• Changed the culture among the staff so that each CLAB was associated with a real patient who had a real family (not just one of the line infections per 1,000 line days).
• Applied the principles of the Toyota Production System to our CLAB infections.
• Reported data in real time every day instead of looking at a chart of results at the end of the month.
• Acted on data with a team approach every time a patient developed positive blood cultures or had a high-risk line.
• Solicited ideas and opinions from the bedside nursing staff.
• Standardized our line insertion kits.
• Standardized our dressing change kits.
• Educated the nurses on the proper technique for dressing and maintaining central lines.
• Developed an online nursing education module.
• Educated physicians about proper techniques for inserting central lines and choosing appropriate sites.
• Developed a simulation lab and an online physician education module.
• Established standards for central lines such as all lines present on hospital admission are removed, the subclavian site is preferred, and lines are not to be re-wired.
• Developed a policy that states any femoral line must be removed within 12 hours of insertion.
• Developed and implemented a line data sheet to be hung on each patient’s door so that the staff can recognize a patient’s central lines at a glance.
• Purchased new antimicrobial catheters and peripherally inserted central catheters.
• Standardized our barrier precautions and site preparation.
• Developed an insertion documentation sticker so that all line insertions were documented in the same manner.
• Purchased and implemented the use of a chlorhexidine coated wafer at the insertion site.
• Purchased and utilized ultrasound technology for line insertions.
• Implemented a “Hmmm” bulletin board in the MICU and CCU to review each infection in a manner in which the staff knows which patient is infected, what happened, what went wrong and what we could have done to prevent the infection.
• Empowered nurses to be the patient guardians of this project.
• Developed a help chain for the nursing staff to utilize in the event that a problem arises.
• Communicated one-on-one to individual staff members.
• Kept the staff energized by constantly reminding them of our success and celebrating it with luncheons, posters, and QI data results.
• Educated every new resident and fellow that rotated through our unit each month.
• Involved senior leadership since their buy-in is essential to the success of the project.

We reduced central line bloodstream infections by 90 percent in the CCU/MICU in the first year of implementing measures from the Perfecting Patient Care (PPC) University (a Toyota Production System model for improving healthcare) by standardizing the work, developing training modules that eliminate variation, and taking a humanistic approach to each individual patient with an infection.

The number of CLAB infections decreased to zero within 3 months and we decreased our overall percentage of CLABs by 90 percent within one year. Work standardization and education are the necessary tools needed to eliminate variation in the achievement of our goal to eliminate CLABs. It is also essential to change the culture of the way we think about infections so that we realize every infection is not just a number on a graph but a patient’s life. 

• Implementing a physician champion and obtaining staff member buy-in was critical to the project’s success and it is necessary to always keep the staff energized so that we may continue to strive for ZERO CLAB infections for our patients. 
• Use real time observations and act on data when it happens. Looking retrospectively at infections will not yield the answers that you need in order to achieve your goal.
• Standardize the care so that everyone is doing the work the same way. Variation will lead to failure.
• Set up clear and specific guidelines so that everybody has the direction and answers to the role they play in the project.
• Constantly give feedback to staff members: discuss setbacks as well as successes and give the feedback in a variety of ways so that everyone is updated.
• Learn from each mistake: do not place blame and establish an emotionally and professionally safe environment to learn in.
• Communicate one-on-one with the staff and always develop countermeasures with the people who are actually doing the work.
• Don’t reinvent the wheel, learn from others and share your ideas too!
• Educate, educate, educate: training is the essential mechanism necessary to achieve positive results.

Kimberly Hicks RN, BSN, Unit Facilitator, Coronary Care Unit
Allegheny General Hospital
khicks@wpahs.org

[Storyboard presentation at IHI's National Forum, December 2005]