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