Protocol for All: Smaller Hospitals Can Adopt Proven Strategies for Reducing Central-Line Infections

This commentary first appeared in the September 12, 2011, issue of Modern Healthcare.

Central line-associated bloodstream infections (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 and Hospital Association and Blue Cross 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 in 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 and 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 2-year progress report published by AHRQ. More than 75 percent of units participating in the project are ICUs, with the majority consisting of 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 percent.

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 percent at baseline to 69.5 percent.

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 mid-sized hospitals: Hospitals with more than 400 beds account for about 40 percent of the participants; those with 100 or fewer beds make up 14 percent. Even at lower volumes, small facilities can gain a lot through the CUSP protocol. Mid-sized 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 percent) mid-sized hospitals, on average, participate in the project. Small and mid-sized 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 dramatically lower, and even eliminate, CLABSIs and avert consequences once thought inevitable.