Using real-time problem solving to eliminate central line infections

Jt Comm J Qual Patient Saf. 2006 Sep;32(9):479-87. doi: 10.1016/s1553-7250(06)32063-6.


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 countermeasures 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.

Publication types

  • Evaluation Study

MeSH terms

  • Academic Medical Centers
  • Bacteremia / etiology
  • Bacteremia / prevention & control*
  • Catheterization, Central Venous / adverse effects
  • Catheters, Indwelling / adverse effects
  • Catheters, Indwelling / microbiology*
  • Cross Infection / prevention & control*
  • Drug Resistance, Multiple, Bacterial
  • Hospital Bed Capacity, 500 and over
  • Humans
  • Inservice Training
  • Intensive Care Units
  • Pennsylvania
  • Problem Solving*
  • Sentinel Surveillance
  • Total Quality Management / methods*