Using Dynamite to Blow Up Infections

Finding the problem and fixing it wasn't easy, nor did it happen fast.

At first, the team did what most hospitals normally do when they discover they have a problem: They formed a committee, in this case a multidisciplinary quality improvement group, in 2009.

But a year later, "we looked at our infection rates again, and they were exactly the same as they were before. We'd made no real progress," Kliger says. It was a big surprise. They'd had the entire recommended CLABSI bundle in place, "but it hadn't solved the problem."

In October 2010, Kliger disassembled the old committee and started a new and much larger group that included "basically any discipline that touched the process. And we looked particularly at our challenges to find out who were the people who were getting infections at our institution.

"We did a thorough root cause analysis on every infection we found," he says, and what that revealed is that the IHI bundle and all the things it was doing "were insufficient."

This root cause analysis led to the creation of four subcommittees, each one dealing with a specific step in the process: central line preparation and insertion, line access, line maintenance, and line removal. Each committee identified key issues that impaired improvement. For example, the line removal group looked at gaps in knowledge about how long lines should stay in, while the line access committee looked at failure to "scrub the hub."

Over three short months, there was a flurry of activity, starting with the launch of a retraining in basic infection control practices and peripherally inserted central catheter lines, for physicians, nurses, and others, Dumigan and Kliger say.

Kliger says that the reeducation was incredibly basic and simple, focusing on things like " 'How do you get a gown on properly and tie it properly without contaminating yourself?' and 'How do you put gloves on?'—the nuts and bolts of sterile technique."

Were providers touching things in between without thinking about it?

"Yes," Kliger replies.