Teams also were eased into a requirement that they fill out an expansive checklist and make it part of their routine for every patient with a central line.
These checklists include the name of the person inserting the catheter, the name of the nurse who is observing, the type of catheter that was being inserted, how many minutes it took the inserter to do it, how many times they stuck the patient, and whether there were any breaks in technique.
Nurses were encouraged to write on the bottom of the checklist any comments about the insertion process, "such as 'had to remind resident to put on a sterile cap' or 'another doctor entered the room and had to tell him to put on garb if he was going to stay in the room,' " Dumigan says.
All nurses who insert PICCs were trained in insertion techniques. Nurses with the checklists were trained to know when something wasn't quite right about the process and to recognize breaks in insertion techniques. "They had the ability to stop procedures," Dumigan says.
The teams established a policy that required the placement of "avoid entering" signs outside the patient's door when a central line activity was under way to help prevent distractions for caregivers.
The teams established systems for rounding daily to reduce infections by looking at the dressing.
In March 2012, the hospital hired a simulation lab to continue on-site training of central line practices.
One surprising finding, Boyce explains, is that a few of what were thought to be infections were actually instances of contamination. In drawing blood for culture to determine infection, staff was often drawing it through the catheter instead of through a vein, which the CDC had recommended.