Sustaining Reductions in Catheter Related Bloodstream Infections in Michigan Intensive Care Units: Observational Study

Quality and Safety Research Group, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 1909 Thames Street, Baltimore, MD 21231, USA.
BMJ (online) (Impact Factor: 17.45). 02/2010; 340(feb04 1):c309. DOI: 10.1136/bmj.c309
Source: PubMed


To evaluate the extent to which intensive care units participating in the initial Keystone ICU project sustained reductions in rates of catheter related bloodstream infections. Design Collaborative cohort study to implement and evaluate interventions to improve patients' safety.
Intensive care units predominantly in Michigan, USA.
Conceptual model aimed at improving clinicians' use of five evidence based recommendations to reduce rates of catheter related bloodstream infections rates, with measurement and feedback of infection rates. During the sustainability period, intensive care unit teams were instructed to integrate this intervention into staff orientation, collect monthly data from hospital infection control staff, and report infection rates to appropriate stakeholders.
Quarterly rate of catheter related bloodstream infections per 1000 catheter days during the sustainability period (19-36 months after implementation of the intervention).
Ninety (87%) of the original 103 intensive care units participated, reporting 1532 intensive care unit months of data and 300 310 catheter days during the sustainability period. The mean and median rates of catheter related bloodstream infection decreased from 7.7 and 2.7 (interquartile range 0.6-4.8) at baseline to 1.3 and 0 (0-2.4) at 16-18 months and to 1.1 and 0 (0.0-1.2) at 34-36 months post-implementation. Multilevel regression analysis showed that incidence rate ratios decreased from 0.68 (95% confidence interval 0.53 to 0.88) at 0-3 months to 0.38 (0.26 to 0.56) at 16-18 months and 0.34 (0.24-0.48) at 34-36 months post-implementation. During the sustainability period, the mean bloodstream infection rate did not significantly change from the initial 18 month post-implementation period (-1%, 95% confidence interval -9% to 7%).
The reduced rates of catheter related bloodstream infection achieved in the initial 18 month post-implementation period were sustained for an additional 18 months as participating intensive care units integrated the intervention into practice. Broad use of this intervention with achievement of similar results could substantially reduce the morbidity and costs associated with catheter related bloodstream infections.

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Available from: Christine A Goeschel
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    • "While used in other hazardous industries for decades, checklists have found their way into healthcare given successful efforts in reducing bloodstream infections in the intensive care unit, in reducing surgical morbidity and mortality in diverse global settings, and in re-engineering the hospital discharge process to decrease avoidable rehospitalisations.31–35 More recently, papers have appeared calling for the further exploration of their use in diagnostic work.36 "
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    ABSTRACT: Despite the relatively slow start in treating diagnostic error as an amenable research topic at the beginning of the patient safety movement, interest has steadily increased over the past few years in the form of solicitations for research, regularly scheduled conferences, an expanding literature and even a new professional society. Yet improving diagnostic performance increasingly is recognised as a multifaceted challenge. With the aid of a human factors perspective, this paper addresses a few of these challenges, including questions that focus on who owns the problem, treating cognitive and system shortcomings as separate issues, why knowledge in the head is not enough, and what we are learning from health information technology (IT) and the use of checklists. To encourage empirical testing of interventions that aim to improve diagnostic performance, a systems engineering approach making use of rapid-cycle prototyping and simulation is proposed. To gain a fuller understanding of the complexity of the sociotechnical space where diagnostic work is performed, a final note calls for the formation of substantive partnerships with those in disciplines beyond the clinical domain.
    Full-text · Article · May 2013 · BMJ quality & safety
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    • "Ensuring compliance with guidelines is a vast and complex field of research [11-13]. Common to any improvement strategy is the need for measurement; this serves evaluation purposes, measurement can also be the intervention, or a major component of it [14-16]. In a survey on infection control practices in the US, ICUs were only able to reduce heathcare-associated infection rates (including VAP), when they had a written policy, monitored compliance, and achieved a ≥95% compliance to all elements included in the local care bundle [11,17]. "
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    ABSTRACT: Background On average 7% of patients admitted to intensive-care units (ICUs) suffer from a potentially preventable ventilator-associated pneumonia (VAP). Our objective was to survey attitudes and practices of ICUs doctors in the field of VAP prevention. Methods A questionnaire was made available online in 6 languages from April, 1st to September 1st, 2012 and disseminated through international and national ICU societies. We investigated reported practices as regards (1) established clinical guidelines for VAP prevention, and (2) measurement of process and outcomes, under the assumption “if you cannot measure it, you cannot improve it”; as well as attitudes towards the implementation of a measurement system. Weighted estimations for Europe were computed based on countries for which at least 10 completed replies were available, using total country population as a weight. Data from other countries were pooled together. Detailed country-specific results are presented in an online additional file. Results A total of 1730 replies were received from 77 countries; 1281 from 16 countries were used to compute weighted European estimates, as follows: care for intubated patients, combined with a measure of compliance to this guideline at least once a year, was reported by 57% of the respondents (95% CI: 54–60) for hand hygiene, 28% (95% CI: 24–33) for systematic daily interruption of sedation and weaning protocol, and 27% (95%: 23–30) for oral care with chlorhexidine. Only 20% (95% CI: 17–22) were able to provide an estimation of outcome data (VAP rate) in their ICU, still 93% (95% CI: 91–94) agreed that “Monitoring of VAP-related measures stimulates quality improvement”. Results for 449 respondents from 61 countries not included in the European estimates are broadly comparable. Conclusions This study shows a low compliance with VAP prevention practices, as reported by ICU doctors in Europe and elsewhere, and identifies priorities for improvement.
    Full-text · Article · Mar 2013
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    • "Such forces will likely ensure adherence to minimum standards, but they will not promote innovation, optimise care or continuously improve. Internally motivated efforts have promoted innovation to increase the routine practice of recommended care and had significant success in reducing infection rates and mortality.13–15 A more formal internal effort is needed to evaluate system issues and improve safety, and the nuclear power industry may provide a model. "
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    Full-text · Article · May 2012 · BMJ quality & safety
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