Effort cuts down catheter-related infections

The Michigan initiative was accomplished using relatively cheap, yet highly effective, interventions.

By Kevin B. O’Reilly — Posted Jan. 22, 2007

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In the first statewide program of its kind, Michigan hospitals cut their average catheter-related bloodstream infection rates by 66% and slashed the median infection rate to zero per 1,000 catheter days, compared with national rates as high as 5.2 infections per 1,000 catheter days.

The achievement, part of the Michigan Health and Hospital Assn.'s Keystone: ICU project, was documented in a study published in the Dec. 28, 2006, New England Journal of Medicine and shows that hospitals that engage physicians and nurses and make relatively cheap system changes can successfully tackle this patient safety hazard. Catheter-related bloodstream infections kill at least 17,000 patients every year, and the average cost of caring for an infected patient is $45,000, studies show.

"There's a lot of quality improvement stuff that's nothing short of marketing," said Peter J. Pronovost, MD, PhD, lead author of the study and consultant on the Keystone: ICU project. "We wanted to be able to tell citizens in Michigan that we're all safer now. That's a novel shift in that it is not just one or two hospitals doing well when 98% didn't do well."

More than 100 Michigan hospitals, accounting for 85% of the state's intensive-care unit beds, implemented the project's interventions. About half that number contributed baseline data to gauge how effective the changes were in reducing infections.

The changes included five evidence-based procedures that the Centers for Disease Control and Prevention has recommended because of their effectiveness and ease of implementation, such as convincing the majority of participating hospitals to include chlorhexidine in the central-line kits used in ICUs. The antiseptic is more effective than other agents because it dries more quickly.

Also, physician and nurse leaders were appointed at each hospital to help educate colleagues about using checklists to ensure adherence to infection-control practices, as well as discussing, during daily rounds, removing unnecessary catheters.

"We didn't dictate and say, 'You have to do it this way,' " said Dr. Pronovost, professor and director of adult critical care at the Johns Hopkins University's Schools of Medicine and Nursing in Baltimore. "Each hospital has its own culture and its own set of resources. We just asked, 'How are you going to make it happen?' "

The project, funded by the federal Agency for Healthcare Research and Quality, had a leg up on other patient-safety initiatives in that a lot of the infection-control infrastructure already is in place. Not only had the CDC recommended a set of relatively cheap interventions, but the agency's National Nosocomial Infections Surveillance System also provided a staff of independent hospital-based infection control experts to collect data and agreed-upon criteria for what constitutes a catheter-related bloodstream infection.

But Dr. Pronovost said it is possible that greater focus on the issue rather than the specific interventions was responsible for the outcome.

In an editorial accompanying the NEJM study, Richard P. Wenzel, MD, and Michael B. Edmond, MD, both at the Virginia Commonwealth University Dept. of Internal Medicine, write that the Keystone: ICU story "is compelling and the costs and efforts so relatively minor that the five components of the intervention should be widely adopted."

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Infection control

More than 100 Michigan intensive care units were able to reduce costly and deadly catheter-related bloodstream infections from a median rate of 2.7 infections per 1,000 catheter days to a rate of zero after only three months. Physicians and nurses at the participating Michigan ICUs implemented the following interventions:

  • Hand washing
  • Using full-barrier precautions during the insertion of central venous catheters
  • Cleaning the skin with chlorhexidine, a long-lasting liquid antiseptic soap
  • Avoiding the femoral site for catheter insertion, if possible
  • Removing unnecessary catheters

Source: "An Intervention to Decrease Catheter-Related Bloodstream Infections," New England Journal of Medicine, Dec. 28, 2006

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