Clancy, Carolyn M. MD
Agency for Healthcare Research and Quality, Rockville, Maryland.
Correspondence: Carolyn M. Clancy, MD, Agency for Healthcare Research and Quality, 540 Gaither Rd, Rockville, MD 20850 (email@example.com).
This commentary on patient safety in nursing practice comes from the Agency for Healthcare Research and Quality.
The author declares no conflict of interest.
Accepted for publications: March 24, 2012.
THE NURSING PROFESSION has long been aware of the often-perilous effects of infections associated with the care a patient receives in the hospital. Health care–associated infections (HAIs) occur too often and at great expense to patients, health care providers, and payers. At any given time, about 1 in every 20 patients has an infection related to his or her hospital care. These infections cost the US health care system billions of dollars each year and lead to the loss of tens of thousands of lives.
For too long, HAIs were considered an inevitable consequence of a hospital stay. Today, health researchers have provided proof that these deadly and costly infections can be sharply reduced—and even eliminated—when clinicians, working in teams, adhere to a defined set of evidence-based practices. Ongoing findings from a multiyear national program to replicate these results in hospital intensive care units (ICUs) are encouraging, yet more work remains to achieve and maintain the results we now know are possible.
The Agency for Healthcare Research and Quality (AHRQ), a leading partner in Federal efforts to fight HAIs, is a long-time supporter of research on evidence-based protocols that reduce the rate of central line–associated bloodstream infections (CLABSIs). One of the most deadly types of HAIs, CLABSIs are typically present in ICUs, inpatient units, and outpatient hemodialysis clinics. CLABSIs are linked to mortality rates that range between 12% and 25%.1
FUNDING TO PREVENT HAIS
Efforts by the US Department of Health and Human Services were redoubled in 2009, with its announcement of an action plan to reduce the incidence of HAIs, including CLABSIs, by 2013. One year earlier, AHRQ expanded its support for the implementation of the Comprehensive Unit–based Safety Program (CUSP) by hospitals in 10 states. This approach was used in the Keystone Project beginning in 2003 to substantially cut the incidence of CLABSIs in more than 100 Michigan ICUs within 18 months, an endeavor that was credited with saving 1500 lives and $200 million.2
A major expansion of CUSP has allowed AHRQ to spread this effective model to hospitals in 46 states, extend it to other settings beyond ICUs, and focus on reducing other types of HAIs. It is taking place through an alliance that consists of AHRQ; the Health Research and Educational Trust, an affiliate of the American Hospital Association; the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, which developed the CUSP model; and the Michigan Health and Hospital Association's Keystone Center for Patient Safety and Quality, which successfully introduced the CUSP approach in that state's ICUs.3 AHRQ's ongoing work to prevent HAIs includes more than $10 million in funding for fiscal year 2011 to develop and implement CUSP protocols to reduce the incidence of catheter-associated urinary tract infections, surgical site infections, and ventilator-associated pneumonia, as well as CLABSI.
This effort also supports the goals of the US Department of Health and Human Services' Partnership for Patients initiative, a national partnership created with funding from the Affordable Care Act.4 To date, more than 6400 partners, including hospitals, medical groups, consumer groups, and employers, have signed on to support the initiative. One goal is to decrease preventable hospital-acquired conditions, a term that includes HAIs and other causes of harm to patients, such as falls, by 40% (compared with 2010 rates) by the end of 2013. Achieving this goal should result in approximately 1.8 million fewer injuries and illnesses to patients, saving more than 60 000 lives. In addition, the Partnership's efforts seek to reduce hospital readmissions by 20%. In total, the Partnership's initiatives have the potential to save up to $35 billion across the health care system, including up to $10 billion in Medicare savings.
NATIONAL IMPLEMENTATION OF CUSP
AHRQ's alliance, called On the CUSP: Stop BSI, requires states to identify a lead organization to work with hospitals on implementing the program's clinical and cultural changes. The CUSP includes assessing and improving the unit's culture of patient safety; using a checklist of evidence-based safety practices; improving teamwork and communication among nurses, physicians, and hospital leaders; and measuring infection rates in a consistent and standard manner.
After 3 years, 45 states' hospital associations and 1 umbrella group have recruited more than 1100 hospitals and 1800 hospital teams to participate in the program, according to findings from a new progress report.5 Participation in the initiative is on a rolling basis: in 2009, 23 states began the project; 14 states and the District of Columbia began their work in 2010; and 9 states and Puerto Rico began their efforts in 2011. Once states agreed to participate, they were placed into a project group, or cohort, along with other states beginning the project at the same time. Recruitment has been strongest among teaching hospitals and hospitals with more than 400 beds and lower among hospitals with fewer than 100 beds. More than 75% of units participating in the project are ICUs, with the majority consisting of adult ICUs.
Project evaluators focused on quarterly data from the hospital units that began participating in 2009 and 2010. Compared with a baseline CLABSI rate of 1.94 infections per 1000 central line days in these units, as of September 2011, hospital units have lowered their CLABSI rates to 1.18 infections per 1000 central line days, a reduction of 41%. The improvement occurred in the 10 to 12 months following the introduction of the CUSP protocol.
Hospital units that reported zero quarterly CLABSI rates increased from 29% at baseline to 68% at 1 year following the intervention.
AREAS FOR IMPROVEMENT
The progress by participating hospital ICUs in lowering the rate of CLABSIs by more than 40% is welcome news and reflects dedication by nurses, physicians, hospital leaders, and others. Nonetheless, key opportunities for improvement remain; 3 were identified by the national program team as most important:
1. Targeted interventions for high-rate units. Average CLABSI rates are above 1.0 per central line days because of a relatively small percentage of units with rates that exceed 3. In summer of 2011, the national project team identified these facilities, worked with state hospital associations to discuss the rates with them, and developed resources to help address their needs. Since the targeted effort began, about half of the identified units have dropped their rates.
2. Data submission. Nearly 75% of the hospital units have submitted CLABSI rate data in each of the reporting periods. Although submitting data does not directly lower CLABSI rates, continuous monitoring is necessary for clinicians to identify which processes may require improvement.
3. Sustainability. CLABSI rates among participating hospital units have decreased substantially during the project's first 2 years. Sustaining these lowered rates and driving them down even further requires a sustained commitment on the part of hospitals and states. Project leaders are focusing their efforts on the important work of sustaining improvements and extending them to other units in participating hospitals as well as those that have not taken part in the initial project.
CONTINUED PROGRESS IS ACHIEVABLE
Efforts by hospitals to reduce CLABSI rates have produced a significant amount of encouraging news. A recent report by the Centers for Disease Control and Prevention found that hospital ICUs lowered the number of CLABSI cases by 58%, from 43 000 in 2001 to 18 000 in 2009.1 The ongoing evaluation and positive results from the On the CUSP: Stop BSI Project support AHRQ's sense that this encouraging news is a sign of things to come. Better understanding of the root causes of CLABSIs that occur even in high-performing hospital units may lead to important insights that will sustain improvement over the long term. Although work on this initiative remains to be done, findings from the national implementation project provide strong evidence that by aggressively monitoring and intervening, CLABSIs can be dramatically lowered and eventually eliminated and their deadly and costly consequences averted.
1. Centers for Disease Control and Prevention. Vital signs: central line–associated blood stream infections—United States, 2001, 2008, 2009. MMWR Morb Mortal Wkly Rep. 2011;1:60. http://www.cdc.gov/mmwr/pdf/wk/mm60e0301.pdf
. Accessed March 23, 2012.
2. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725–2732.
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