Sean M Berenholtz

Johns Hopkins Medicine, Baltimore, Maryland, United States

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Publications (97)421.62 Total impact

  • Michael Klompas, Sean M Berenholtz
    JAMA Internal Medicine 02/2015; 175(2):316-317. DOI:10.1001/jamainternmed.2014.7020 · 13.25 Impact Factor
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    ABSTRACT: This article describes the interventions that sustained low central line-associated bloodstream infection (CLABSI) rates in the Michigan Keystone ICU Project. This analysis included data from March 2004 to December 2013 for 121 intensive care units (ICUs) in 73 hospitals. The Keystone Project was a cohort collaborative with an improvement team in each ICU. During the sustainability period, teams integrated the intervention into staff orientation, collected and submitted monthly data, and reported infection rates to leaders. The annual mean rate of BSIs dropped from 2.5 infections/1000 catheter-days in 2004 to 0.76 in 2013. A subset analysis found nearly double the percentage of ICUs with a mean rate of <1 infection/1000 catheter-days in 2013 compared with baseline. Active involvement of hospital leaders and the Keystone Center as well as ongoing monitoring and feedback of performance were important in sustaining results. These findings suggest that large-scale improvement projects can be sustained, establishing a new normal for care. © The Author(s) 2015.
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    ABSTRACT: In this article, the authors describe an initiative that established an infrastructure to manage quality and safety efforts throughout a complex health care system and that improved performance on core measures for acute myocardial infarction, heart failure, pneumonia, surgical care, and children's asthma. The Johns Hopkins Medicine Board of Trustees created a governance structure to establish health care system-wide oversight and hospital accountability for quality and safety efforts throughout Johns Hopkins Medicine. The Armstrong Institute for Patient Safety and Quality was formed; institute leaders used a conceptual model nested in a fractal infrastructure to implement this initiative to improve performance at two academic medical centers and three community hospitals, starting in March 2012. The initiative aimed to achieve ≥ 96% compliance on seven inpatient process-of-care core measures and meet the requirements for the Delmarva Foundation and Joint Commission awards. The primary outcome measure was the percentage of patients at each hospital who received the recommended process of care. The authors compared health system and hospital performance before (2011) and after (2012, 2013) the initiative. The health system achieved ≥ 96% compliance on six of the seven targeted measures by 2013. Of the five hospitals, four received the Delmarva Foundation award and two received the Joint Commission award in 2013. The authors argue that, to improve quality and safety, health care systems should establish a system-wide governance structure and accountability process. They also should define and communicate goals and measures and build an infrastructure to support peer learning.
    Academic medicine: journal of the Association of American Medical Colleges 12/2014; DOI:10.1097/ACM.0000000000000610 · 2.34 Impact Factor
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    ABSTRACT: Much research has been conducted to describe medical mistakes resulting in patient harm using databases that capture these events for medical organizations. The objective of this study was to describe patients' perceptions regarding disclosure and their actions after harm.
    Journal of Patient Safety 11/2014; DOI:10.1097/PTS.0000000000000136 · 0.88 Impact Factor
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    ABSTRACT: Objective. To develop and field test an implementation assessment tool for assessing progress of hospital units in implementing improvements for the prevention of ventilator-associated pneumonia (VAP) in a two-state collaborative, including data on actions implemented by participating teams and contextual factors that may influence their efforts. Using the data collected, learn how implementation actions can be improved and analyze effects of implementation progress on outcome measures. Design. We developed the tool as an interview protocol that included quantitative and qualitative items addressing actions on the Comprehensive Unit-based Safety Program (CUSP) and clinical interventions for use in guiding data collection via telephone interviews. Setting. We conducted interviews with leaders of improvement teams from units participating in the two-state VAP prevention initiative. Methods. We collected data from 43 hospital units as they implemented actions for the VAP initiative and performed descriptive analyzes of the data with comparisons across the 2 states. Results. Early in the VAP prevention initiative, most units had made only moderate progress overall in using many of the CUSP actions known to support their improvement processes. For contextual factors, a relatively small number of barriers were found to have important negative effects on implementation progress (in particular, barriers related to workload and time issues). We modified coaching provided to the unit teams to reinforce training in weak spots that the interviews identified. Conclusion. These assessments provided important new knowledge regarding the implementation science of quality improvement projects, including feedback during implementation, and give a better understanding of which factors most affect implementation.
    Infection Control and Hospital Epidemiology 10/2014; 35(S3):S116-S123. DOI:10.1086/677832 · 3.94 Impact Factor
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    Infection Control and Hospital Epidemiology 08/2014; 35(8):915-936. DOI:10.1086/677144 · 3.94 Impact Factor
  • Nishi Rawat, Sean Berenholtz
    Critical Care Medicine 08/2014; 42(8):1940-1941. DOI:10.1097/CCM.0000000000000433 · 6.15 Impact Factor
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    ABSTRACT: Background. Ventilator-associated pneumonia (VAP) is among the most lethal of all healthcare-associated infections. Guidelines summarize interventions to prevent VAP, but translating recommendations into practice is an art unto itself. Objective. Summarize strategies to enhance adoption of VAP prevention interventions. Methods. We conducted a systematic literature review of articles in the MEDLINE database published between 2002 and 2012. We selected articles on the basis of specific inclusion criteria. We used structured forms to abstract implementation strategies and inserted them into the "engage, educate, execute, and evaluate" framework. Results. Twenty-seven articles met our inclusion criteria. Engagement strategies included multidisciplinary teamwork, involvement of local champions, and networking among peers. Educational strategies included training sessions and developing succinct summaries of the evidence. Execution strategies included standardization of care processes and building redundancies into routine care. Evaluation strategies included measuring performance and providing feedback to staff. Conclusion. We summarized and organized practical implementation strategies in a framework to enhance adoption of recommended evidence-based practices. We believe this work fills an important void in most clinical practice guidelines, and broad use of these strategies may expedite VAP reduction efforts.
    Infection Control and Hospital Epidemiology 08/2014; 35(8):998-1004. DOI:10.1086/677152 · 3.94 Impact Factor
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    ABSTRACT: Background Despite evidence supporting restrictive red blood cell (RBC) transfusion thresholds and the associated clinical practice guidelines, clinical practice has been slow to change in the intensive care unit (ICU). Our aim was to identify barriers to conservative transfusion practice adherence.Study Design and MethodsA mixed-methods study involving observation of prescriber (i.e., physicians, physician assistants, nurse practitioners) and bedside nurse daily bedside rounds, provider survey, and medical record abstraction was conducted in one cardiac surgical ICU (CSICU) and one surgical ICU (SICU) in an academic hospital in Baltimore, Maryland.ResultsOf 52 patient encounters observed during bedside rounds, 38 (73%) involved patients without evidence of active bleeding or cardiac ischemia. Surveys were completed by 52 (93%) of the 56 providers participating in rounds. Prescribers in the CSICU and SICU (87 and 90%, respectively) indicated the ideal pretransfusion hemoglobin (Hb) to be not more than 7 g/dL in nonbleeding and/or nonischemic patients compared to a minority of nurses (8% [p = 0.002] and 42% [p = 0.015], respectively). Prescribers and nurses in both ICUs overestimated the typical pretransfusion Hb in their units (CSICU, p < 0.001; SICU, p = 0.019). During rounds, providers infrequently explicitly discussed Hb monitoring or transfusion thresholds (33%) despite most (60%) reporting significant variation in transfusion thresholds between individual prescribers.Conclusions Our study identified several provider and system barriers to evidence-based transfusion practices including knowledge differences, overly optimistic estimates of current practice, and heterogeneous transfusion practice in each ICU. Further work is necessary to develop targeted interventions to improve evidence-based RBC transfusion practices.
    Transfusion 06/2014; 54(10). DOI:10.1111/trf.12718 · 3.57 Impact Factor
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    ABSTRACT: Preventing healthcare-associated infections (HAIs) is a national priority. Although substantial progress has been achieved, considerable deficiencies remain in our ability to efficiently and effectively translate existing knowledge about HAI prevention into reliable, sustainable, widespread practice. "A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Updates" is the product of a highly collaborative endeavor designed to support hospitals' efforts to implement and sustain HAI prevention strategies.
    Infection Control and Hospital Epidemiology 05/2014; 35(5):460-3. DOI:10.1086/675820 · 4.02 Impact Factor
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    ABSTRACT: IMPORTANCE Regular oral care with chlorhexidine gluconate is standard of care for patients receiving mechanical ventilation in most hospitals. This policy is predicated on meta-analyses suggesting decreased risk of ventilator-associated pneumonia, but these meta-analyses may be misleading because of lack of distinction between cardiac surgery and non-cardiac surgery studies, conflation of open-label vs double-blind investigations, and insufficient emphasis on patient-centered outcomes such as duration of mechanical ventilation, length of stay, and mortality. OBJECTIVE To evaluate the impact of routine oral care with chlorhexidine on patient-centered outcomes in patients receiving mechanical ventilation. DATA SOURCES PubMed, Embase, CINAHL, and Web of Science from inception until July 2013 without limits on date or language. STUDY SELECTION Randomized clinical trials comparing chlorhexidine vs placebo in adults receiving mechanical ventilation. Of 171 unique citations, 16 studies including 3630 patients met inclusion criteria. DATA EXTRACTION AND SYNTHESIS Eligible trials were independently identified, evaluated for risk of bias, and extracted by 2 investigators. Differences were resolved by consensus. We stratified studies into cardiac surgery vs non-cardiac surgery and open-label vs double-blind investigations. Eligible studies were pooled using random-effects meta-analysis. MAIN OUTCOMES AND MEASURES Ventilator-associated pneumonia, mortality, duration of mechanical ventilation, intensive care unit and hospital length of stay, antibiotic prescribing. RESULTS There were fewer lower respiratory tract infections in cardiac surgery patients randomized to chlorhexidine (relative risk [RR], 0.56 [95% CI, 0.41-0.77]) but no significant difference in ventilator-associated pneumonia risk in double-blind studies of non-cardiac surgery patients (RR, 0.88 [95% CI, 0.66-1.16]). There was no significant mortality difference between chlorhexidine and placebo in cardiac surgery studies (RR, 0.88 [95% CI, 0.25-2.14]) and nonsignificantly increased mortality in non-cardiac surgery studies (RR, 1.13 [95% CI, 0.99-1.29]). There were no significant differences in mean duration of mechanical ventilation or intensive care length of stay. Data on hospital length of stay and antibiotic prescribing were limited. CONCLUSIONS AND RELEVANCE Routine oral care with chlorhexidine prevents nosocomial pneumonia in cardiac surgery patients but may not decrease ventilator-associated pneumonia risk in non-cardiac surgery patients. Chlorhexidine use does not affect patient-centered outcomes in either population. Policies encouraging routine oral care with chlorhexidine for non-cardiac surgery patients merit reevaluation.
    JAMA Internal Medicine 03/2014; 174(5). DOI:10.1001/jamainternmed.2014.359 · 13.25 Impact Factor
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    ABSTRACT: Objective. Diagnosing ventilator-associated pneumonia (VAP) is difficult, and misdiagnosis can lead to unnecessary and prolonged antibiotic treatment. We sought to quantify and characterize unjustified antimicrobial use for VAP and identify risk factors for continuation of antibiotics in patients without VAP after 3 days. Methods. Patients suspected of having VAP were identified in 6 adult intensive care units (ICUs) over 1 year. A multidisciplinary adjudication committee determined whether the ICU team's VAP diagnosis and therapy were justified, using clinical, microbiologic, and radiographic data at diagnosis and on day 3. Outcomes included the proportion of VAP events misdiagnosed as and treated for VAP on days 1 and 3 and risk factors for the continuation of antibiotics in patients without VAP after day 3. Results. Two hundred thirty-one events were identified as possible VAP by the ICUs. On day 1, 135 (58.4%) of them were determined to not have VAP by the committee. Antibiotics were continued for 120 (76%) of 158 events without VAP on day 3. After adjusting for acute physiology and chronic health evaluation II score and requiring vasopressors on day 1, sputum culture collection on day 3 was significantly associated with antibiotic continuation in patients without VAP. Patients without VAP or other infection received 1,183 excess days of antibiotics during the study. Conclusions. Overdiagnosis and treatment of VAP was common in this study and led to 1,183 excess days of antibiotics in patients with no indication for antibiotics. Clinical differences between non-VAP patients who had antibiotics continued or discontinued were minimal, suggesting that clinician preferences and behaviors contribute to unnecessary prescribing.
    Infection Control and Hospital Epidemiology 03/2014; 35(3):278-84. DOI:10.1086/675279 · 4.02 Impact Factor
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    ABSTRACT: Background. Several studies demonstrating that central line-associated bloodstream infections (CLABSIs) are preventable prompted a national initiative to reduce the incidence of these infections. Methods. We conducted a collaborative cohort study to evaluate the impact of the national "On the CUSP: Stop BSI" program on CLABSI rates among participating adult intensive care units (ICUs). The program goal was to achieve a unit-level mean CLABSI rate of less than 1 case per 1,000 catheter-days using standardized definitions from the National Healthcare Safety Network. Multilevel Poisson regression modeling compared infection rates before, during, and up to 18 months after the intervention was implemented. Results. A total of 1,071 ICUs from 44 states, the District of Columbia, and Puerto Rico, reporting 27,153 ICU-months and 4,454,324 catheter-days of data, were included in the analysis. The overall mean CLABSI rate significantly decreased from 1.96 cases per 1,000 catheter-days at baseline to 1.15 at 16-18 months after implementation. CLABSI rates decreased during all observation periods compared with baseline, with adjusted incidence rate ratios steadily decreasing to 0.57 (95% confidence intervals, 0.50-0.65) at 16-18 months after implementation. Conclusion. Coincident with the implementation of the national "On the CUSP: Stop BSI" program was a significant and sustained decrease in CLABSIs among a large and diverse cohort of ICUs, demonstrating an overall 43% decrease and suggesting the majority of ICUs in the United States can achieve additional reductions in CLABSI rates.
    Infection Control and Hospital Epidemiology 01/2014; 35(1):56-62. DOI:10.1086/674384 · 4.02 Impact Factor
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    ABSTRACT: Patients continue to suffer preventable harm from the omission of evidence-based therapies. To remedy this, The Joint Commission developed core measures for therapies with strong evidence and, through the Top Performer on Key Quality Measures program, recognize hospitals that deliver those therapies to 95% of patients. The Johns Hopkins Medicine board of trustees committed to high reliability and to providing > or = 96% of patients with the recommended therapies. The Armstrong Institute for Patient Safety and Quality coordinated the core measures initiative, which targeted nine process measures for the 96% performance goal: eight Joint Commission accountability measures and one Delmarva Foundation core measure. A conceptual model for this initiative included communicating goals, building capacity with Lean Sigma methods, transparently reporting performance and establishing an accountability plan, and developing a sustainability plan. Clinicians and quality improvement staff formed one team for each targeted process measure, and Armstrong Institute staff supported the teams work. The primary performance measure was the percentage of patients who received the recommended process of care, as defined by the specifications for each of The Joint Commission's accountability measures. The > or = 96% performance goal was achieved for 82% of the measures in 2011 and 95% of the measures in 2012. With support from leadership and a conceptual model to communicate goals, use robust improvement methods, and ensure accountability, The Johns Hopkins Hospital achieved high reliability for The Joint Commission accountability measures.
    Joint Commission journal on quality and patient safety / Joint Commission Resources 12/2013; 39(12):531-44.
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    ABSTRACT: Improving surgical quality is a priority, but building a business case for the efforts could be challenging. Bridging the gap between the clinicians and hospital leaders is the first step to align quality and financial priorities within health care. The aim of this study was to evaluate the financial impact of the surgical comprehensive unit-based safety program on colorectal surgery procedures. This a retrospective cohort study. This study was conducted at a university-based tertiary care hospital. All patients undergoing colectomy or proctectomy between July 2010 and June 2012 were included. A comprehensive unit-based safety program focused on colorectal surgical site infection reduction was implemented. Three surgeons participated in the program in year 1, and 5 surgeons participated in year 2. Patients were categorized as participating or nonparticipating based on the surgeon who performed the procedure. Resource utilization and cost were the main outcome measures. During the 2 years, there were 626 patients who met the selection criteria. Participating surgeons operated on 444 patients (70.9%), and the nonparticipating surgeons operated on 182 patients (29.1%). After adjusting for covariates, the variable direct cost was significantly lower for the participating surgeons in laboratory work by $191 (p = 0.009), operating room utilization by $149 (p = 0.05), and supplies by $615 (p = 0.003). The surgical site infection rates, need for an intensive care unit stay, and length of stay were not significantly different between the 2 groups. The multiple biases related to surgeon self-selection for program participation and surgeon training and clinical skills were not addressed in this study owing to the limitations in sample size and data collection. A comprehensive unit-based safety program implementation, including dedicated frontline providers who focused on the standardization of protocols, was able to reduce the variation in resource utilization and costs in comparison with a control group.
    Diseases of the Colon & Rectum 11/2013; 56(11):1298-1303. DOI:10.1097/DCR.0b013e3182a4b973 · 3.20 Impact Factor
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    ABSTRACT: Ventilator-associated pneumonia (VAP) is common, lethal, and expensive. Little is known about optimal strategies to evaluate process measures for VAP prevention. The authors conducted a prospective study of different sampling strategies for evaluating head of bed (HOB) elevation and oral care. There was no significant difference between morning and evening shift HOB elevation compliance rates (P = .47). If oral care was performed at least once during a 12-hour shift, there was an 87% probability that it also was performed at least twice. If oral care was performed at least twice during a 12-hour shift, then there was a 93% probability that chlorhexidine oral care was performed at least once. The results of this study suggest that sampling HOB elevation twice as compared with once daily is unlikely to change the estimate of performance, oral care need not be frequently sampled, and high oral care compliance may predict chlorhexidine oral care compliance.
    American Journal of Medical Quality 09/2013; 29(5). DOI:10.1177/1062860613503707 · 1.78 Impact Factor
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    ABSTRACT: Increasing evidence, including publication of the Transfusion Requirements in Critical Care trial in 1999, supports a lower hemoglobin threshold for RBC transfusion in ICU patients. However, little is known regarding the influence of this evidence on clinical practice over time in a large population-based cohort. Retrospective population-based cohort study. Thirty-five Maryland hospitals. Seventy-three thousand three hundred eighty-five nonsurgical adults with an ICU stay greater than 1 day between 1994 and 2007. None. The unadjusted odds of patients receiving an RBC transfusion increased from 7.9% during the pre-Transfusion Requirements in Critical Care baseline period (1994-1998) to 14.7% during the post-Transfusion Requirements in Critical Care period (1999-2007). A logistic regression model, including 40 relevant patient and hospital characteristics, compared the annual trend in the adjusted odds of RBC transfusion during the pre- versus post-Transfusion Requirements in Critical Care periods. During the pre-Transfusion Requirements in Critical Care period, the trend in the adjusted odds of RBC transfusion did not differ between hospitals averaging > 200 annual ICU discharges and hospitals averaging ≤ 200 annual ICU discharges (odds ratio, 1.07 [95% CI, 1.01-1.13] annually and 1.03 [95% CI, 0.99-1.07] annually, respectively; p = 0.401). However, during the post-Transfusion Requirements in Critical Care period, the adjusted odds of RBC transfusion decreased over time in higher ICU volume hospitals (odds ratio, 0.96 [95% CI, 0.93-0.98] annually) but continued to increase in lower ICU volume hospitals (odds ratio, 1.10 [95% CI, 1.08-1.13] annually), p < 0.001. In this population-based cohort of ICU patients, the unadjusted odds of RBC transfusion increased in both higher and lower ICU volume hospitals both before and after Transfusion Requirements in Critical Care publication. After adjusting for relevant characteristics, the odds continued to increase in lower ICU volume hospitals in the post-Transfusion Requirements in Critical Care period, but it decreased in higher ICU volume hospitals. This suggests that evidence supporting restrictive RBC transfusion thresholds may not be uniformly translated into practice in different hospital settings.
    Critical care medicine 08/2013; 41(10). DOI:10.1097/CCM.0b013e31828e9a49 · 6.15 Impact Factor
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    ABSTRACT: Despite important progress in measuring the safety of health care delivery in a variety of health care settings, a comprehensive set of metrics for benchmarking is still lacking, especially for patient outcomes. Even in high-risk settings where similar procedures are performed daily, such as hospital intensive care units (ICUs), these measures largely do not exist. Yet we cannot compare safety or quality across institutions or regions, nor can we track whether safety is improving over time. To a large extent, ICU outcome measures deemed valid, important, and preventable by clinicians are unavailable, and abstracting clinical data from the medical record is excessively burdensome. Even if a set of outcomes garnered consensus, ensuring adequate risk adjustment to facilitate fair comparisons across institutions presents another challenge. This study reports on a consensus process to build 5 outcome measures for broad use to evaluate the quality of ICU care and inform quality improvement efforts.
    American Journal of Medical Quality 07/2013; DOI:10.1177/1062860613491823 · 1.78 Impact Factor
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    ABSTRACT: Our retrospective analysis of the Michigan Keystone intensive care unit (ICU) collaborative demonstrated that adult ICUs could achieve and sustain a zero rate of ventilator-associated pneumonia (VAP) for a considerable number of ventilator and calendar months. Moreover, the results highlight the importance of adjustment for ventilator-days before comparing VAP-free time among ICUs.
    Infection Control and Hospital Epidemiology 07/2013; 34(7):740-3. DOI:10.1086/670989 · 4.02 Impact Factor
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    ABSTRACT: Central-line-associated bloodstream infections (CLABSIs) are a significant cause of preventable harm. A collaborative project involving a multifaceted intervention was used in the Michigan Keystone Project and associated with significant reductions in these infections. This intervention included the Comprehensive Unit-based Safety Program, a multifaceted approach to CLABSI prevention, and the monitoring and reporting of infections. The purpose of this study was to determine whether the multifaceted intervention from the Michigan Keystone program could be implemented in Connecticut and to evaluate the impact on CLABSI rates in intensive care units (ICUs). The primary outcome was the NHSN-defined rate of CLABSI. Seventeen ICUs, representing 14 hospitals and 104,695 catheter days were analyzed. The study period included up to four quarters (12 months) of baseline data and seven quarters (21 months) of postintervention data. The overall mean (median) CLABSI rate decreased from 1.8 (1.8) infections per 1,000 catheter days at baseline to 1.1 (0) at seven quarters postimplementation of the intervention. This study demonstrated that the multifaceted intervention used in the Keystone program could be successfully implemented in another state and was associated with a reduction in CLABSI rates in Connecticut. Moreover, even though the statewide baseline CLABSI rate in Connecticut was low, rates were reduced even further and well below national benchmarks.
    Journal for Healthcare Quality 01/2013; DOI:10.1111/j.1945-1474.2012.00210.x

Publication Stats

4k Citations
421.62 Total Impact Points


  • 2010–2015
    • Johns Hopkins Medicine
      • Department of Anesthesiology and Critical Care Medicine
      Baltimore, Maryland, United States
  • 2001–2015
    • Johns Hopkins University
      • • Department of Anesthesiology and Critical Care Medicine
      • • Department of Surgery
      Baltimore, Maryland, United States
  • 2013
    • Beverly Hospital, Boston MA
      Beverly, Massachusetts, United States
  • 2011
    • Tulane University
      New Orleans, Louisiana, United States
  • 2002–2011
    • Johns Hopkins Bloomberg School of Public Health
      • Department of Health Policy and Management
      Baltimore, MD, United States