Eliminating CLABSI, A National Patient Safety Imperative: Final Report
After providing project background about the origins of On the CUSP: Stop BSI, this report is organized to answer three key questions:
- How did the project work?
- Did the project work?
- What did we learn?
A final section summarizes lessons on how to improve future national collaboratives. This section includes the sustainment plans that have been developed, or are being developed, by States/regions to continue to eliminate CLABSI.
In 2003, AHRQ funded a highly successful program to use evidence-based interventions and a patient safety model called the Comprehensive Unit-based Safety Program (CUSP) to prevent central line-associated blood stream infections (CLABSI) and ventilator-associated pneumonia, and to improve the culture of safety in 127 intensive care units (ICUs) across Michigan. MHA Keystone partnered with the Armstrong Institute on a 2-year initiative called the MHA Keystone: ICU project.
AHRQ heralded this effort as one of their most successful projects. The MHA Keystone: ICU project reduced CLABSI in the first 18 months by 66 percent. The median CLABSI rate was 2.7 at baseline and dropped to a median of 0.0 in that period. A follow-up study published in 2010 reported that this rate of reduction was sustained for more than 3 years.3 The MHA Keystone: ICU project achieved these results by using a patient safety platform developed by the Armstrong Institute called CUSP and an evidence-based change package to prevent CLABSI.
Based on this success, AHRQ contracted in fall 2008 with HRET to replicate this program nationally, starting with at least 10 hospitals in each of 10 States. The contract was expanded in fall 2009 to include all 50 States, the District of Columbia, and Puerto Rico. HRET's partners were the Armstrong Institute, MHA Keystone, and State and regional hospital associations, which in turn partnered with hospitals and units that they recruited into the program. HRET, the Armstrong Institute, and MHA Keystone staff comprised the national project team (NPT) which named the national initiative, On the CUSP: Stop BSI.
The AHRQ program goals were to: 1) reduce CLABSIs to a rate of no more than 1/1,000 central line days, and 2) to improve patient safety culture on hospital units. Each State and regional hospital association executive signed a letter committing to these goals, to assigning a staff member to serve as the State lead to coordinate the program in the State/region, to recruiting at least 10 hospitals, and to complying with data collection and performance monitoring requirements. Some States were unable to recruit 10 hospitals. For example, Delaware had only nine acute care hospitals in the State, and States in later cohorts had significant challenges recruiting hospitals because of previous work on CLABSI reduction and the perception that the On the CUSP: Stop BSI program would not be particularly beneficial. For larger States unable to recruit 10 hospitals, the NPT decided that it was preferable to include them in order to disseminate CUSP. This proved to be a valuable strategy as many of the States that are in the AHA/HRET Hospital Engagement Network have expressed interest in applying the CUSP model to their Partnership for Patients work to reduce hospital-acquired conditions.
AHRQ directed HRET and the NPT to work with States to recruit both ICUs and non-ICUs, include critical access hospitals, and to attempt to recruit all 50 States, the District of Columbia, and Puerto Rico.
In addition, AHRQ directed HRET to encourage participating hospital associations to coordinate their CLABSI prevention efforts with other regional stakeholders. HRET encouraged States/regions to develop consortia comprised of regional stakeholders such as the QIO, Department of Health, Patient Safety Organization (PSO), local infection prevention chapters, and other stakeholders. Many States used their regional HAI-prevention work groups developed as a result of the Centers for Disease Control and Prevention (CDC) American Recovery and Reinvestment Act (ARRA) grants or other mechanisms to inform key stakeholders of On the CUSP: Stop BSI activities and invite them to listen to teleconferences and attend in-person meetings. These included representatives from the State QIO, State health department, PSO, State infection prevention chapters, and in a few cases, private payers.
Over the course of the 4-year period, HRET recruited 44 States, the District of Columbia, and Puerto Rico. Alaska, California, Maine and Vermont chose not to participate in the program. Michigan was not included as a participating State given its role as a national partner. Rhode Island ICUs participated in an effort similar to the MHA Keystone: ICU project prior to the AHRQ expansion contract and succeeded in eliminating virtually all CLABSIs.4
In order to best accommodate the readiness of hospital associations and their members to participate and to manage available project resources, the project was rolled out in a total of six cohorts of States/regions over the 4-year contract period. Each State/region and their participating hospitals participated in the On the CUSP: Stop BSI program for approximately 24 months, with the exception of the last cohort of States, Cohort 6, which participated for approximately 20 months.
3. Pronovost PJ, Goeschel CA, Colantuoni E, Watson S., Lubomski LH, Berenholtz, SM, et al. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ 2010;340:c309.
4. DePalo VA, McNicoll L, Cornell M, Rocha JM, Adams L, Pronovost PJ. The Rhode Island ICU Collaborative: a model for reducing central line-associated bloodstream infection and ventilator-associated pneumonia statewide. Qual Saf Health Care 2010;19(6):555-61.