Initiative to cut catheter infections expands

The $23 million effort, backed by the federal government and private philanthropy, builds on success in Michigan ICUs.

By Kevin B. O’Reilly — Posted April 6, 2009

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Catheter-related bloodstream infections kill at least 30,000 patients in the intensive care unit each year, the Centers for Disease Control and Prevention estimates. About 250,000 hospital patients contract these infections annually, costing an estimated $9 billion in extra care.

Yet, within three months of implementing a simple set of interventions in 2004, more than 100 Michigan ICUs slashed their central-line associated bloodstream infection rates by 66%. The median infection rate dropped from 2.3 per 1,000 catheter days to near zero. The program, which focuses on using checklists of evidence-based interventions and changing hospital culture, was funded by the Agency for Healthcare Research and Quality.

From 2004 to 2008, nearly 1,800 lives were saved and 129,000 extra days in the hospital were avoided due to the patient-safety initiative, according to the Michigan Health & Hospital Assn.'s Keystone Center for Patient Safety & Quality. Each hospital spends about $120,000 in staff time to implement the safety changes.

After its success in Michigan, the program is going national. Twenty-eight state hospital associations and patient-safety organizations have been selected to take part in an initiative that will help them implement the changes that led to Michigan's achievement.

Last fall, AHRQ gave $3 million to the American Hospital Assn.'s Health Research & Educational Trust to coordinate efforts among 10 states over three years. AHRQ will receive another $10 million during fiscal year 2009 to help fund more work in this area, an agency spokeswoman said.

The Johns Hopkins Quality & Safety Research Group and the MHA Keystone Center are using about $10 million in grants from the Jewish Community Endowment Fund and the Sandler Foundation to help another 18 states implement the patient-safety initiative, called the Comprehensive Unit-based Safety Program.

The program includes five evidence-based procedures the CDC has recommended, such as including chlorhexidine in the central-line kits used in ICUs. The antiseptic is more effective than other agents because it dries more quickly.

Physician and nurse leaders will be appointed at each hospital to help educate colleagues about using checklists to ensure adherence to infection-control practices. They also will discuss, during daily rounds, removing unnecessary catheters.

Peter J. Pronovost, MD, MPH, who developed the safety program and is co-investigator of the new initiative, said the influx of cash to help spread life-saving interventions was long overdue.

"If there were a therapy tested at Johns Hopkins that prevented all of these deaths, and then it was successfully tested in the state of Michigan, if that therapy were a drug or a device, the free market would respond and [bloodstream infections] would all be eliminated. But because it's a checklist, the market fails," said Dr. Pronovost, who was awarded a $500,000 MacArthur Foundation "genius grant" last year for his work on patient safety.

"We've been hounding people to say, 'This is crazy. This is more lives saved than virtually any other medical therapy of the last quarter-century.' The return on investment is huge."

Spreading quality improvement

The initiative represents a shift in AHRQ's approach to improving health care quality, said James B. Battles, PhD, a senior service fellow at the agency's Center for Quality Improvement and Patient Safety.

"This is AHRQ's beginning attempt to say, 'When is the time to do a national distribution of things we know work, and who's there to do the help?' " Battles said. "We have not done projects of national scale at this kind of level. ...We want to see if, in fact, we can replicate the success we had in Michigan."

Each statewide organization is responsible for selecting hospitals and ensuring they have commitment from senior leadership, physicians and other clinicians to implement the program, Battles said. But money should not be a factor.

"We want to make sure we support all the hospitals that want to participate," he said. "We don't want to turn anybody away."

Battles said the key to successfully rolling out the program across the country will be to go beyond just properly measuring infection rates, and pestering doctors and nurses about following guidelines.

"It's not just the infection control nurse and someone coming around with a bunch of figures," he said. "It's not until everybody at the ICU and at the hospital owns the nature of the risk and is actively engaged in solving the problem; then you can get dramatic change."

Sam Watson, senior vice president of patient safety and quality at the MHA Keystone Center, said that a delicate combination of factors led to Michigan's breakthrough and this combination will need to be in place for other states to succeed.

The program "really stands out as a clear example of how dedicated professionals can change how care is delivered," Watson said. "We were able to demonstrate through the use of rigorous and valid data some real outcomes. And instead of just focusing on the change of an intervention, the focus was on a change in culture. That's what led to sustainability, and it is very different from how we've historically addressed improvement in health care."

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Successful infection control

More than 100 Michigan intensive care units reduced costly and deadly catheter-related bloodstream infections from a median rate of 2.7 infections per 1,000 catheter days to a rate of near zero after only three months. The success of the program, which started in 2004, has been sustained, according to the Michigan Health & Hospital Assn. Physicians and nurses at the participating Michigan ICUs implemented the following interventions:

  • Washing hands
  • Using full-barrier precautions during the insertion of central venous catheters
  • Cleaning the patient's skin with chlorhexidine, a long-lasting liquid antiseptic soap
  • Avoiding the femoral site for catheter insertion, when possible
  • Removing unnecessary catheters

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

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External links

"National Implementation of the Comprehensive Unit-Based Safety Program (CUSP) to Reduce Central Line Associated Blood Stream Infections (CLABSI) in the Intensive Care Unit," American Hospital Assn. Health Research & Educational Trust (link)

Michigan Health & Hospital Assn.'s Keystone: ICU project (link)

"An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU," New England Journal of Medicine, Dec. 28, 2006, abstract (link)

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