Using Real-Time Problem Solving to Eliminate Central Line Infections

Authors: Shannon, Richard P.; Frndak, Diane; Grunden, Naida; Lloyd, Jon C.; Herbert, Cheryl; Patel, Bhavin; Cummins, Daniel; Shannon, Alexander H.; O'Neill, Paul H.; Spear, Steven J.

Source: Joint Commission Journal on Quality and Patient Safety, Volume 32, Number 9, September 2006 , pp. 479-487(9)

Publisher: Joint Commission Resources

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Abstract:

Background: An estimated 200,000 Americans suffer central line-associated bloodstream infections (CLABs) each year, with 15%-20% mortality. Two intensive care units (ICUs) redefined the processes of care through system redesign to deliver reliable outcomes free of the variations that created the breeding ground for infection.

Methods: The ICUs, comprising 28 beds at Allegheny General Hospital, employed the principles of the Toyota Production System adapted to health care—Perfecting Patient Care^™—and applied them to central line placement and maintenance. Intensive observations, which revealed multiple variances from established practices, and root cause analyses of all CLABs empowered the workers to implement counter-measures designed to eliminate the defects in the processes of central line placement and maintenance.

Results: New processes were implemented within 90 days. Within a year CLABs decreased from 49 to 6 (10.5 to 1.2 infections/1,000 line-days), and mortalities from 19 to 1 (51% to 16%), despite an increase in the use of central lines and number of line-days. These results were sustained during a 34-month period.

Discussion: CLABs are not an inevitable product of complex ICU care but the result of highly variable and therefore unreliable care delivery that predisposes to infection.

Document Type: Research article

Publication date: 2006-09-01

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Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

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Using Real-Time Problem Solving to Eliminate Central Line Infections

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