In 2002, the Infection Control Team in the authors' hospital noticed a significant increase of catheter-related bloodstream infections (CRBSI) at the extended care facility. The rate had increased from 0.5 per 1000 patient days to 1.2 per 1000 patient days and fluctuated between high and low infection rates. A process improvement team met to discuss the processes. Key elements affecting the increase in CRBSIs included lack of both supplies and time for nursing staff to change initial gauze dressings. The process improvement included using reverse-tapered peripherally inserted central catheters (PICCs), placing a chlorhexidine patch on day of insertion, increasing supplies, and educating core staff.