Infection checklist effort expands, but national rates unchanged

Some hospitals have virtually eliminated deadly catheter-related bloodstream infections by implementing a checklist of simple preventive measures, yet an initiative to spread the success nationwide has run into some resistance.

A project funded by the Agency for Healthcare Research and Quality, On the CUSP: Stop BSI, has attracted the participation of at least 400 hospitals in 27 states. The project seeks to build on the success in Michigan, where intensive care units at more than 100 hospitals cut their median central-line infection rate to zero per 1,000 catheter days, compared with a national average of 5.2.

The achievement was due to improvements in hand washing, using full-barrier precautions when inserting central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site for insertion and removing unnecessary catheters. Physicians, nurses and others were encouraged to speak up when they saw colleagues failing to follow the prevention checklist.

Yet not enough hospitals are measuring their performance and implementing the changes needed to prevent these bloodstream infections, said Peter J. Pronovost, MD, PhD, leader of the On the CUSP initiative. An April AHRQ report found that, nationally, hospitals have not improved on the rate of catheter-related bloodstream infections.

"These infections kill 31,000 people a year. That's a 747 crashing every three days," said Dr. Pronovost, director of the Quality and Safety Research Group at Johns Hopkins Hospital in Maryland.

"There's substantial uncertainty about how accurately we can measure harm and the extent to which harm is preventable," he said. "But in this area, we're there -- we can measure these infections accurately, and we have substantial evidence on how to improve. Yet in most states, only 15% of the hospitals are signing up for this initiative."

Dr. Pronovost spoke at an April 14 event sponsored by the Commonwealth Fund, a nonprofit devoted to improving health care quality. The group announced that it will list hospitals' performance on catheter-related bloodstream infections on its Web site. Nearly 900 hospitals are now publicly volunteering their rates of such infections, which are posted at quality-tracking Web sites run by Consumers Union and the Leapfrog Group.

"It's important to track trends, to figure out where we need to improve to target and how to prioritize among different areas," said Anne-Marie J. Audet, MD, vice president of the Commonwealth Fund's Program on Quality Improvement and Efficiency. "For central-line associated bloodstream infections, the benchmark is zero, and that is achievable and sustainable."

According to Consumers Union, 34 hospitals in 10 states have gone more than 1,000 days without a central-line infection.

Cultural barriers

Lucian L. Leape, MD, adjunct professor at the Harvard School of Public Health's Dept. of Health Policy and Management in Massachusetts, said fear of discussing missteps makes it difficult to improve care.

"Patient safety is about changing the health care culture that is, in all but a few organizations, incredibly dysfunctional," said Dr. Leape, widely recognized as a pioneer in the field of patient safety research. "Most places are still hierarchical, where respect is expected, but not given. Too often it's not OK to talk about mistakes."

Hospitals implementing the bloodstream infection-prevention checklist have had to come up with clever ways to enable health professionals to speak up when the guidelines are not being followed.

Beth Israel Medical Center in New York implemented a system of so-called red rules in which anyone at any time can pull out a red card to stop what is happening, according to Brian S. Koll, MD, the medical center's chief of infection prevention. The professionals in the room must then discuss what prompted the red card and resolve any issues before proceeding with, say, placement of a catheter.

"We tried to emphasize that people were not correcting each other, but helping each other, if there was a lapse," Dr. Koll said. Beth Israel achieved 100% compliance with the checklist within months of starting the project in 2004, cutting its infection rate to two per 1,000 central-line days. Now, its rate is 0.5.

Dr. Pronovost said that using checklists and encouraging health professionals to speak up when something goes wrong are simply ways of counteracting human frailty.

"We have permission to make mistakes and to forget, but we don't have permission to unnecessarily put patients at risk," he said.