Eliminating CLABSI: A National Patient Safety Imperative
State Participation. Recruitment to the project was an ongoing process that began in fall 2008 and ended in summer 2011. Lead organizations in States were encouraged to recruit as many teams of participants as they could. The ongoing success of this program, awareness of impending Centers for Medicare & Medicaid Services (CMS) public reporting of central line-associated bloodstream infections (CLABSI) rates, and the 2011 requirement that hospitals submit CLABSI data into National Healthcare Safety Network (NHSN) encouraged additional hospitals to enroll. 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. At present, 6 cohorts, including 44 States, the District of Columbia, and Puerto Rico are participating in the project. Because some State hospital associations recruited hospitals at different periods, more than one cohort can participate in a State at a given time. Figure 1 illustrates the current status of State recruitment efforts.
Forty-four States, plus the District of Columbia and Puerto Rico, are participating in one of the six cohorts. Although Michigan is not listed as a formal project participant, Michigan hospitals continue to work with the MHA Keystone Center on sustaining the exceptionally low CLABSI rates they achieved in the initial Keystone Project.3,4
Levels of participation within States vary substantially. Table 1 provides a breakdown of the number of participating hospitals and teams by State. Because some States have a higher percentage of very small hospitals that do not have an intensive care unit (ICU) or insert central lines, some variation in the percentage of hospitals in each State that could benefit from project participation is to be expected. Alabama, Delaware, Hawaii, Maryland, and Washington all have more than 50 percent of their hospitals participating in the project.
Hospital Participation. Because CLABSIs can occur in all sizes and types of hospitals in which central lines are used, this project has encouraged each State lead organization to enlist the participation of all hospitals that use central lines. Figure 2 summarizes the participation of hospitals in this project based on their size (defined by the number of hospital beds). Percentages were based on the number of hospitals with an adult ICU of each size participating in the project divided by the total number of hospitals of each size with an adult medical or surgical ICU (based on data in the 2009 American Hospital Association [AHA] Annual Survey).
Thus far, project recruitment has been strongest among hospitals with more than 400 beds and weakest among hospitals with fewer than 100 beds. Although small hospitals insert central lines in their ICUs, the number of insertions is often very low; this perhaps has made CLABSI prevention a lower priority for these hospitals.
Figure 3 summarizes the recruitment levels for hospitals with a range of characteristics. More than 33 percent of teaching hospitals with ICUs are participating in the project. The involvement of rural referral hospitals, hospitals from the 100 largest cities, and hospitals that are part of hospital systems is slightly lower.
The list of participating hospitals maintained on the project Web site at http://www.onthecuspstophai.org provides the best source of current information on which hospitals have chosen to participate. Ohio and Washington have not provided the names of participating hospitals, so those are not included. While the list on the Web site includes every hospital that has been enrolled in the national project database, some hospitals on this list may not be continuing to submit CLABSI data or participating in scheduled project activities on a regular basis.
Unit Team Participation. Because the vast majority of central lines are placed in patients in an ICU, recruiting ICU teams has been the project's primary focus. However, some central lines are placed and maintained in non-ICU units. Thus, teams representing these units are also participating. At present, some pediatric or neonatal ICUs are participating in the project; the Health Research & Educational Trust (HRET) is working with other organizations that specialize in pediatric care to provide focused guidance to hospitals seeking to prevent CLABSIs in neonatal ICUs. Figure 4 illustrates the range of units participating in cohorts 1 through 6 of the On the CUSP: Stop BSI initiative.
More than 75 percent of units participating in the project are ICUs; the majority are adult ICUs.
While participation of hospitals is critical, the ultimate measure of success is the reduction of CLABSI rates. Table 2 summarizes the impact of the project on CLABSI rates from baseline through the first 12 months of the intervention period. The table includes units (N=883) that reported data in one or more (but not necessarily all) of the first four reporting periods for the first four cohorts participating in the project. Table 2 indicates CLABSI rates have dropped from an average of 1.87 infections per 1,000 central line days to 1.25 infections per 1,000 central line days, an overall relative reduction of 33 percent.
Figure 5 presents the percentage of units (N=660) who achieved a zero percent CLABSI rate in each reporting period. This percentage has increased 154 percent since baseline, from 27.3 percent to 69.6 percent. Working to assist units that have not achieved this rate remains a top project priority.
Examining the data at the hospital level (rather than the unit level) indicates that the largest hospitals (400 beds or more) had the greatest drop in CLABSI rates from baseline to period 4 at 44 percent. Hospitals with a bed size between 176 and 250 had the next greatest drop at 41.8 percent. The smallest hospitals with 100 or fewer beds had the lowest decrease in CLABSI rates at 10 percent (Figure 6).
Figure 7 indicates that all types of hospitals decreased their CLABSI rates over time. Referral hospitals' CLABSI rates dropped 69 percent from the baseline period to period 4. Teaching hospitals and hospitals in systems decreased their CLABSI rates by 42 percent and 41 percent respectively over 12 months. Critical-access hospitals decreased their CLABSI rates by 100 percent, although data were available for only 12 hospitals in this category. Further investigation on the performance of smaller hospitals is warranted.
The third project objective is the improvement in safety culture in participating units. Significant and sustained improvement in a clinical outcome such as CLABSI requires a culture in which all staff members understand and can be held accountable for ensuring the safety of patients. To assess progress in culture change, participating units are asked to complete the Hospital Survey on Patient Safety Culture (HSOPS) survey at the start and end of the project. The followup surveys are administered at 18 months, which may not be enough time to capture the change in culture.
Clinical changes require and reinforce changes in safety culture. The HSOPS is a staff survey designed to help hospitals assess the culture of safety in their institutions. Units are expected to both reduce BSIs and improve HSOPS scores. Each unit was asked to administer HSOPS at baseline and at followup. Since many units are still participating in the project and have not remeasured their safety cultures, we compared the scores for 156 units that have baseline and remeasurement results. Baseline and follow up response rates for those units included in the analysis are 72.13 percent and 58.83 percent, respectively.
Figure 8 indicates that for these units, there was little change in attitudes between the baseline (response rate of 72.13 percent) and followup surveys (response rate of 58.83 percent). Feedback and communication about errors continues to be the area where the most improvement is needed in patient safety culture, followed by staffing issues and teamwork across units. Because units have far fewer HSOPS respondents than hospitals, interpreting unit-level results is challenging. Future analyses based on a larger number of participating units will be needed to determine whether HSOPS data is useful at the unit level and whether the project affected staff perceptions of safety culture.
3. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006 Dec 28;355(26):2725-32.
4. Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reductions in catheter-related bloodstream infections in Michigan intensive care units: an observational study. BMJ 2010 Feb 4;340:c309.