Using real-time problem solving to eliminate central line infections
Shannon RP, Frndak D, Grunden N, et al. Using real-time problem solving to eliminate central line infections. Joint Commission Journal on Quality and Patient Safety. 2006 Sep;32(9):479-487.
This article describes how two intensive care units (ICUs) redefined the processes of care through system redesign to deliver reliable outcomes. The ICUs implemented Toyota Production System principles to central line placement and maintenance, and within a year CLABs decreased from 49 to 6 (10.5 to 1.2 infections/1,000 line-days). Mortality also decreased from 19 to 1 (51 percent to 16 percent) despite an increase in the use of central lines and number of line-days.
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