• Rate of blood stream infections related to central venous devices per 1,000 patient device days
• Compliance with bundle (checklist of behaviors / procedural documentation audit)

• Revised organization policy to include maximum barrier protection
• Developed a “line cart” that had all necessary supplies
• Developed checklist for pre, during and post procedure standard work
• Transducer kit placed on all central line (CL) carts (used to prevent accidental arterial cannulation)
• Placed a picture flowsheet on all CL carts to highlight elements of Central Line Bundle
• Picture flowsheet for transducer/manometer application was developed and posted on CL carts
• Specified RN staff observer; procedural pause; “Stop the Line” Patient Safety Alert Process; documentation role (audit/checklist)
• Revised and taught proper use of new skin preparation (chlorhexidine)
• Perform monthly in-service for internal medicine house staff and as needed with surgery service (action by MD Medical Director)
• Standardize dressing care and changes; annual training competency (newly added)
• Access/maintenance of needleless device protocol (developed and reviewed by staff)
• Devised successive checks: Daily multidisciplinary goal sheet, safety walkrounds, and Charge RN report form
• Reviewed each line infection as sentinel event to assess patterns
• Spread improvement work to hospital-wide initiative level by providing standard work (checklist; cart; roles of staff – MD, RN; algorithm for CCU/non-CCU patients)
• Placed graphs depicting line infection in prominent locations
• Housewide education assisted by PowerPoint presentation (created by physician leader)
• Celebrated early and subsequent success at committee/staff meetings, or via organization’s newsletter, and posted “dashboards” of graphs/case studies
• Future work: Successive checks to be included in RN shift handoffs

• Removed barriers to operators using complete/proper supplies through the use of a “line cart” containing approved supplies, including chlorhexidine skin preparation. Prior to having the cart, house staff often used incomplete barrier precautions.
• Bundling evidenced-based elements of care carried improvement work to higher level of compliance in behavior, reliability in care, and reduced bad outcomes.
• Used fewer lines and removed them as soon as possible, prompted through the daily goal sheet reduces patient risk.
• "Getting it right" rather than auditing was forced by changing the line insertion check sheet from “Yes-No” to “Yes-Yes with reminder.”  Nurses were not policing, they were assuring patients were as safe as possible during line insertion.

Rosemary Tempel, RN, Project Manager
Virginia Mason Medical Center 
admrmt@vmmc.org

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