Pro­to­col for all

Smaller hos­pi­tals can adopt proven tools for re­duc­ing cen­tral-line in­fec­tions

Modern Healthcare - - Opinions Commentary - Dr. Carolyn Clancy Dr. Carolyn Clancy is di­rec­tor of the Agency for Health­care Re­search and Qual­ity, Rockville, Md.

Like death and taxes, health­care-as­so­ci­ated in­fec­tions have long been con­sid­ered one of those un­pleas­ant, but in­evitable, things in life. No longer. Years of re­search have yielded solid proof that these deadly and costly in­fec­tions can be sharply re­duced, and even elim­i­nated, by ad­her­ing to a set of ev­i­dence-based prac­tices. Find­ings from a national pro­gram to repli­cate these re­sults in U.S. hos­pi­tals is en­cour­ag­ing, with HAIS drop­ping by an av­er­age of onethird. But more par­tic­i­pa­tion by small and mid­sized hos­pi­tals is needed.

The stakes are high for pa­tients and hos­pi­tals. At any one time, about one in ev­ery 20 pa­tients has an in­fec­tion re­lated to his or her hos­pi­tal care, lead­ing to longer stays, com­pli­ca­tions and tens of thou­sands of deaths. HAIS are es­ti­mated to cost the U.S. health­care sys­tem bil­lions of dol­lars each year, a cost for which hos­pi­tals are in­creas­ingly re­spon­si­ble un­der Medi­care pay­ment pol­icy.

My agency, the Agency for Health­care Re­search and Qual­ity, has long sup­ported re­search on ev­i­dence-based pro­to­cols that re­duce the rate of cen­tral line-as­so­ci­ated blood­stream in­fec­tions. One of the most deadly types of HAIS, CLABSIS are typ­i­cally present in hos­pi­tal in­ten­sive-care units, in­pa­tient units and out­pa­tient he­modial­y­sis clin­ics. CLABSIS are linked to mor­tal­ity rates be­tween 12% and 25%, ac­cord­ing to the Cen­ters for Dis­ease Con­trol and Pre­ven­tion.

CLABSIS are preva­lent and deadly, but are they in­evitable? To find out, re­searchers at Johns Hop­kins Univer­sity used AHRQ fund­ing in 2003 to im­ple­ment the Com­pre­hen­sive Unit-based Safety Pro­gram, or CUSP. The CUSP pro­to­col in­cludes us­ing a check­list of ev­i­dence-based safety prac­tices; im­prov­ing team­work among doc­tors, nurses, and hos­pi­tal lead­ers; and mea­sur­ing in­fec­tion rates in a con­sis­tent and stan­dard man­ner.

Johns Hop­kins teamed up with the Michi­gan Health & Hos­pi­tal As­so­ci­a­tion and Blue Cross and Blue Shield of Michi­gan to test the pro­gram’s ef­fec­tive­ness in re­duc­ing CLABSIS in more than 100 Michi­gan ICUS. Those ICUS sub­stan­tially cut the in­ci­dence of CLABSIS within 18 months and saved an es­ti­mated 1,500 lives and $200 mil­lion.

As these re­sults il­lus­trate, the CUSP pro­to­col helped hos­pi­tals pre­vent these in­fec­tions, saved sub­stan­tial costs and made care safer for pa­tients. In 2008, AHRQ ex­panded its sup­port for the pro­to­col to 10 more states.

Be­gin­ning in 2009, AHRQ scaled up the pro­gram to in­clude hos­pi­tals in all 50 states, set­tings out­side of ICUs and other types of HAIs. Part­ners in this new national project con­sist of AHRQ; the Health Re­search and Ed­u­ca­tional Trust, an af­fil­i­ate of the Amer­i­can Hos­pi­tal As­so­ci­a­tion; Johns Hop­kins; and the Michi­gan Health & Hos­pi­tal As­so­ci­a­tion. The national im­ple­men­ta­tion project, called “On the CUSP: Stop BSI,” re­quires states to iden­tify a lead or­ga­ni­za­tion to work with hos­pi­tals on im­ple­ment­ing the pro­to­col’s clin­i­cal and cul­tural changes.

As of June, 46 state hos­pi­tal as­so­ci­a­tions and one other um­brella group had re­cruited more than 1,055 hos­pi­tals and 1,775 hos­pi­tal teams to the pro­gram, ac­cord­ing to a two-year progress re­port pub­lished by AHRQ. More than 75% of units par­tic­i­pat­ing in the project are ICUs, with the ma­jor­ity be­ing adult ICUs.

To de­ter­mine im­pact, project eval­u­a­tors an­a­lyzed quar­terly data from the first two co­horts of hos­pi­tal units that be­gan par­tic­i­pat­ing in the project. Com­pared with a base­line CLABSI rate of 1.87 in­fec­tions per 1,000 cen­tral-line days in these units, hos­pi­tal units in these two co­horts have low­ered their CLABSI rates to 1.25 in­fec­tions per 1,000 days, a re­duc­tion of 33%. One year af­ter the in­ter­ven­tion be­gan, the per­cent­age of hos­pi­tal units that re­ported zero quar­terly CLABSI rates per 1,000 cen­tral-line days more than dou­bled— from 27.3% at base­line to 69.5%.

The progress that hos­pi­tals have made in low­er­ing the rate of CLABSIs by one-third is wel­come news. None­the­less, op­por­tu­ni­ties for im­prove­ment re­main, in­clud­ing:

More par­tic­i­pa­tion among small and mid­sized hos­pi­tals: Hos­pi­tals with more than 400 beds ac­count for about 40% of the par­tic­i­pants; those with 100 or fewer beds make up 14%. Even at lower vol­umes, small fa­cil­i­ties can gain a lot through the CUSP pro­to­col. Mid­sized hos­pi­tals (be­tween 176 and 325 beds) are more likely than small hos­pi­tals to in­sert cen­tral lines on a reg­u­lar ba­sis. Slightly more than 1 in 4 (27.7%) mid­sized hos­pi­tals, on av­er­age, par­tic­i­pate in the project. Small and mid­sized hos­pi­tals saw CLABSI rates drop as sig­nif­i­cantly as large hos­pi­tals in the orig­i­nal Key­stone Project.

Tar­geted in­ter­ven­tions for high-rate units: A rel­a­tively small per­cent­age of units that have CLABSI rates over 5 per 1,000 cen­tral line days are the pri­mary rea­son that av­er­age national rates ex­ceed 1.0. State hos­pi­tal as­so­ci­a­tions work­ing with the national project team have iden­ti­fied these fa­cil­i­ties and are work­ing with them to ad­dress their needs.

Sus­tain­abil­ity: CLABSI rates among par­tic­i­pat­ing hos­pi­tal units have dropped sub­stan­tially dur­ing the project’s first year. How­ever, sus­tain­ing these rates and im­prov­ing them re­quires a sus­tained com­mit­ment on the part of hos­pi­tals and states.

The on­go­ing eval­u­a­tion of the project con­firms our be­lief that the ev­i­dence-based pro­to­cols to lower CLABSI rates can be im­ple­mented suc­cess­fully across the coun­try. Death and taxes aren’t go­ing away, but through ag­gres­sive mon­i­tor­ing and in­ter­ven­tion, hos­pi­tals can sig­nif­i­cantly lower, and even elim­i­nate, in­fec­tions once thought in­evitable.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.