Health care-associated infections
(HAIs) result in almost 100,000 deaths each year and cost the U.S. health
system $40 billion annually. Most of these deaths and costs are preventable.
The U.S. Department of Health and Human Services' National Initiative to Reduce
Healthcare-Associated Infections focuses on the need to dramatically reduce
these infections. As part of this initiative, the Agency for Healthcare
Research and Quality (AHRQ) funded a national effort to prevent central
line-associated bloodstream infections (CLABSI) in U.S. hospitals beginning in
2008: On the CUSP: Stop BSI. AHRQ designed this project to replicate a highly
successful State-based initiative in all 50 States, the District of Columbia
and Puerto Rico. AHRQ's project goals were the reduction of CLABSIs to 1 per
1,000 central line days and to improve unit safety culture in intensive care
units (ICUs) and non-ICUs. This final report summarizes project outcomes and
On the CUSP: Stop BSI was
led by a unique partnership—the Health Research & Educational Trust (HRET)
of the American Hospital Association, the Johns Hopkins Medicine Armstrong
Institute for Patient Safety and Quality1 (Armstrong Institute), and the Michigan Health & Hospital Association's
Keystone Center for Patient Safety & Quality (MHA Keystone). HRET managed
the national effort. The Armstrong Institute created an effective change
package that consisted of two components: technical, evidence-based practice;
and an adaptive, innovative, hospital unit-based patient safety program. MHA
Keystone originally applied this change package to dramatically reduce CLABSIs
in Michigan, and the Michigan experience formed the basis of On the CUSP:
Stop BSI. HRET, the Armstrong Institute, and MHA Keystone comprised the
National Project Team (NPT), which oversaw all aspects of the national program.
The national program was organized
and implemented as a State- or region-level collaborative, structured around
the hospital association in the State or region2, with
centralized education, data collection, and program management functions
provided by the NPT. Recruitment of States began in 2008. Once hospital
associations agreed to participate in the 2-year program, they were assigned to
a group or cohort with other States/regions that began the program at the same
time. At the State/regional level, hospital associations or State sponsors
recruited and coordinated efforts with member hospitals and assigned a lead
staff person, most often the senior quality manager in the association, to
become the "State lead" to work directly with ICU and non-ICU teams, as well as
the NPT. The State or regional association was also encouraged to invite State
health departments, Quality Improvement Organizations (QIOs) and other State-based
quality improvement and HAI prevention organizations to collaborate in the
program and to help ensure coordination of HAI reduction activities.
Participating in a total of 6
cohorts were 44 States, the District of Columbia, and Puerto Rico. Collectively,
these States and regions recruited more than 1,000 hospitals and 1,800 hospital
units to participate in the project. Twenty-three States began the project in
2009, 12 States and the District of Columbia began during 2010, and 9 States and
Puerto Rico began the effort in 2011.
On the CUSP: Stop BSI succeeded
in reducing CLABSI nationwide. Analysis of available adult ICU data indicates
that States reduced their rate from a baseline of 1.915 infections per 1,000
line days to one of 1.133 infections, or a relative reduction of 41 percent. The
percentage of units with zero CLABSIs for at least one quarter increased from 30
percent at baseline to 68 percent at quarter six. Participating non-ICU and
pediatric units had similar, impressive reductions in CLABSI rates. States
that started with low CLABSI rates achieved additional improvements, again
demonstrating that "getting to zero" was possible, a notion clinicians had not
accepted until recently.
Adult ICU CLABSI Rate Overall Over Time
Percentage of Reporting Units with CLABSI Rate of 0/1,000 or Less than 1/1,000 CL
On the CUSP: Stop BSI is estimated to have saved an estimated 290 to 605 deaths assuming a 12-25 percent CLABSI mortality rate and an estimated $36,194,850 to $40,034,450 in excess costs averted, based upon a Centers for Disease Control & Prevention (CDC) estimate of $16,550 per CLABSI. A systematic review of the cost of CLABSI was completed and found the per-CLABSI cost may be higher than the published CDC estimate. Utilizing data from the systematic review, an estimated $97,756,628 to $244,270,620 in excess costs may have been averted, figures that are projected to continue to increase over time.
Project Summary of CLABSIs Prevented, Deaths Prevented and Excess Costs Averted Using CDC Estimates*
||Excess Costs Averted*
Project Summary of Excess Costs Averted Using Literature Estimates
||Excess Costs Averted (in millions)
||290 - 605
||$97 M - $244 M|
Drawing from their experiences, the On the CUSP: Stop BSI national project team and the State leaders identified five key lessons learned about how to implement a large, national quality improvement project:
- Have well-defined, evidence-based interventions.
- Build a solid implementation structure and project plan.
- Collect and use timely, accurate, and actionable data to improve performance.
- Tailor national program for local and unit audiences.
- Evolve project strategies and emphases over time.
The lessons learned contributed to the project's success and can be applied to future large scale interventions.
1. Formerly known as the Johns Hopkins University Quality Safety & Research Group.
2. Sometimes, the program was structured around a State sponsor as in the case of Hawaii.
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