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):2725-2732.
For practicing clinicians, quality improvement (QI) is a difficult and important task. There can be requirements for extra steps, additional forms, or new safety procedures when caring for patients; there is also the promise of improved clinical outcomes. This tradeoff can be justified when solid, evidence-based techniques are implemented, but—unfortunately—definitive evidence is not always available. Public reporting of a variety of quality indicators, now mandated by the Centers for Medicare and Medicaid Services (CMS), is likely to boost calls for changes in clinical medicine, and the pressure to adopt new safety practices is likely to increase.
Fortunately, this article by Pronovost and colleagues provides a test of state-of-the-art QI theory applied to an important QI target, catheter-related bloodstream infections (CR-BSI). Annually there are 80,000 CR-BSI in the United States, causing about 28,000 deaths in ICU patients; the medical costs to treat these infections is estimated at $2.3 billion. There have been numerous published and unpublished trials of QI methods that have reduced the incidence of such infections, but none have been as large as this one, a state-wide ICU trial conducted in Michigan and funded by the Agency for Healthcare Research and Quality (AHRQ).
One-hundred-three ICUs, representing 85% of ICU beds in the state, participated in the study. In addition to the intervention to reduce CR-BSI, a comprehensive program aimed at instilling a culture of safety was implemented, including the creation of a QI team with a physician and nurse as team leaders, use of a daily goals sheet to enhance clinician-clinician communication, an intervention to reduce ventilator-associated pneumonia, and a comprehensive safety program designed to improve the culture of safety.
The study intervention was designed to improve clinicians’ use of five evidence-based procedures recommended by the Centers for Disease Control and Prevention (CDC):
- Use of full barrier precautions;
- Use of chlorhexidine antiseptic;
- Avoidance of femoral line placement; and
- Removal of unnecessary catheters.
The strategies used to encourage these practices were technologically simple and easy to implement. They included the use of a central line kit with a procedure checklist, the termination of any procedure for failure to follow protocol, and daily discussions of line removal on rounds. Additionally, at regular meetings, all clinicians received feedback regarding numbers and rates of CR-BSI.
The results were impressive: The overall rate of CR-BSI decreased from a baseline median of 2.7 (mean, 7.7) infections per 1,000 catheter-days to 0 (mean, 2.3) during the first three-month period after implementation of the intervention (P<0.002). During the 18 months of follow-up, this reduction was sustained at 0 (mean, 1.4). The results applied in both academic and non-teaching hospitals, regardless of size.
Even with such simple methods, managing a statewide implementation of a comprehensive QI program is a feat of organization, as anyone who has implemented even small-scale projects knows. An accompanying editorial praised the effort, noting the magnitude of the accomplishment and recommending widespread adoption of these simple yet effective techniques. Given the push toward the adoption of similar methods, this demonstration is welcome and makes the wholesale acceptance of such measures not only easier but also imperative.
Quality Performance Measures across the Nation
Landon BE, Normand SL, Lessler A, et al. Quality of care for the treatment of acute medical conditions in US hospitals. Arch Intern Med. 2006 Dec 11;166(22):2511-2517.