By Debra Wood, RN, contributor
Dec. 10, 2009 - Aiming to end health care-associated infections, the Agency for Healthcare Research and Quality (AHRQ) granted nearly $7 million to a Health Research & Educational Trust-led initiative that will expand the Michigan Health & Hospital Association (MHA) Keystone Center Project ― which has significantly reduced catheter-associated bloodstream infections ― to all 50 states, the District of Columbia and Puerto Rico.
“The goal is to eliminate these infections,” said Chris Goeschel, RN, MPA, MPS, ScD (candidate), director of patient safety and quality initiatives and manager of operations at the Johns Hopkins University School of Medicine’s Quality and Safety Research Group in Baltimore, one of the project partners. “The project, On the CUSP: Stop BSI, is a national implementation of work Hopkins and the MHA did in Michigan hospitals.”
Health care-associated infections result in 1.7 million infections and 99,000 deaths each year, costing between $28 billion and $33 billion annually, according to the AHRQ. This new funding is the latest effort to further the Department of Health and Human Services’ Action Plan to Prevent Healthcare-Associated Infections, which was released in January and calls for significant reductions in health care-associated infections nationwide within five years.
The Centers for Disease Control and Prevention (CDC) estimates 250,000 catheter-associated bloodstream infections (BSIs) occur annually and between 30,000 and 62,000 infected patients die.
The Health Research & Educational Trust (HRET), an affiliate of the American Hospital Association (AHA), will lead the On the CUSP: Stop BSI project in partnership with the Johns Hopkins Quality and Safety Research Group (QSRG) and the Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality.
The model combines the Comprehensive Unit-based Safety Program (CUSP), developed by Johns Hopkins University, with measurable, evidence-based interventions proven to decrease infection rates.
Goeschel says the program depends on successful implementation of both components.
The MHA Keystone Center for Patient Safety & Quality began in 2003, with funding from AHRQ, and has demonstrated stunning results, essentially decreasing the central line-associated bloodstream infection rate from 4 percent to zero and maintaining that rate, saving an estimated 1,500 lives and $200 million. In addition, it has increased the hand hygiene compliance rate to 86 percent in the 120 participating intensive care units in 74 hospitals, compared to a national average of 40 percent.
John Combes said CUSP empowers frontline staff and transforms the culture of the unit to achieve demonstrable improvements.
“The lessons learned through Michigan hospitals’ voluntary and sustained patient safety efforts are replicable nationwide,” said Spencer Johnson, president of the MHA, in a written statement. “Hospitals across the country participating in these types of programs continue to exemplify extraordinary commitment to improving patient safety and lowering health care costs.”
AHRQ funded HRET in 2008 to create coalitions in 10 additional states, led by the state hospital association and recruit 10 hospitals in each of those states to the project, with a goal of reducing central line-associated bloodstream infections by 80 percent and improving culture by 50 percent, said John Combes, president and chief operating officer of the American Hospital Association’s Center for Health Care Governance and the principal investigator for the CUSP initiative. In addition, Johns Hopkins was working with 18 states with funding from a private donor.
Washington State, North Carolina, Pennsylvania, Massachusetts, Florida and Ohio have begun the program, working with HRET. In North Carolina, nearly all of the state’s hospitals are participating.
“The recruitment has gone well,” Combes said. “We spend a lot of time up front teaching the CUSP methodology.”
Sam Watson reported that catheter-associated bloodstream infection rates have remained down in Michigan hospitals participating in the MHA Keystone project.
The five-step CUSP combines communication, teamwork and leadership to create a harm-free patient-care environment. It begins with safety training, followed by a written survey to identify defects based on unit reports, liability claims and sentinel events. Then a senior hospital official joins with the unit to improve communication and promote leadership. Staff members learn from the unit defects and use tools developed by Johns Hopkins to improve teamwork, communication and other work systems.
“We’re changing behaviors,” said Sam Watson, executive director of the MHA Keystone Center for Patient Safety & Quality. “There were challenges, where you had physicians and nurses reticent to change practice and behaviors, and concerns of physicians about their autonomy and nurses reluctant to take responsibility for speaking up. But at the end, everyone realized the importance of working together to prevent infection.”
Combes added that CUSP helps clinicians understand that the infections are not inevitable.
“They are preventable complications that can be dealt with through clear processes, standardization of equipment and procedures, an attitude that will call people when they don’t do things according to the standard protocols, and a willingness to examine your progress through data collection,” Combes said. “It’s empowering the frontline people and transforming the culture of the unit to get demonstrable improvement results.”
The evidence-based interventions are based on recommendations by the CDC and include hand hygiene, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site when possible and removing unnecessary catheters.
“The checklist supports the team,” Combes said.
Several hospitals have implemented their own safety changes, so recruiting them may prove difficult.
“Hospitals are very busy with lots of improvement interventions and activities, and to get them to take on one more can be a challenge,” Combes said.
Goeschel added that hospitals must measure the results, since clinicians believe they are providing good care. Data can highlight deficiencies and successes, and physicians demand it.
“When you analyze [the data] rigorously, many of them had problems they were not aware of. They thought they had implemented the bundles,” Goeschel said.
Each facility will keep detailed records and report bloodstream infection rates monthly. MHA will compile data collected by the participating hospitals, and Johns Hopkins will analyze it. The hospitals will receive mentoring and expert guidance.
“There is great opportunity for the bulk of hospitals to move forward with this,” Watson said. “The benefits to patients and to potential cost savings are real.”
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