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

Abstract

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.

Full text

RESEARCH
Sustaining reductions in catheter related bloodstream
infections in Michigan intensive care units: observational
study
Peter J Pronovost, professor,
1
Christine A Goeschel, director, patient safety and quality initiatives,
1
Elizabeth Colantuoni, assistant professor,
1
Sam Watson, senior vice president, patient safety and quality,
2
Lisa H Lubomski, assistant professor,
1
Sean M Berenholtz, associate professor,
1
David A Thompson, assistant
professor,
1
David J Sinopoli, instructor,
3
Sara Cosgrove, assistant professor,
4
J Bryan Sexton, associate
professor,
1
Jill A Marsteller, assistant professor,
5
Robert C Hyzy, associate professor,
6
Robert Welsh, chief,
7
Patricia Posa, special project coordinator,
8
Kathy Schumacher, director, quality, safety, standards and
outcomes,
9
Dale Needham, assistant professor
10
ABSTRACT
Objectives 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.
Setting Intensive care units predominantly in Michigan,
USA.
Intervention 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.
Main outcome measures Quarterly rate of catheter related
bloodstream infections per 1000 catheter days during the
sustainability period (19-36 months after implementation
of the intervention).
Results 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%).
Conclusions 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.
INTRODUCTION
Catheter related bloodstream infections cause consid-
erable morbidity, mortality, and healthcare costs.
12
An
estimated 82 000 catheter related bloodstream infec-
tions and up to 28 000 attributable deaths occur in
intensive care units annually,
3
and each infection
costs about $45 000 (£28 000; €31 000).
4
In an ongoing
quality improvement project, known as the Michigan
Health & Hospital Association (MHA) Keystone ICU
project, these infections were substantially reduced in
103 participating intensive care units.
5
The median
infection rate per 1000 catheter days dropped from
2.7 at baseline to 0 within three months after imple-
mentation of an evidence based intervention. Eighteen
months after implementation, infection rates had
decreased by 66% from baseline. However, whether
these initial results were sustained was not known.
Limited evidence assessing the sustainability of qual-
ity improvement projects beyond the initial implemen-
tation and evaluation period is available.
67
To evaluate
sustainability, a quality improvement project must
have an adequate infrastructure to sustain activities
beyond its initial phase. After the 18 month post-imple-
mentation evaluation period, most hospitals participat-
ing in the Keystone ICU project continued to submit
data on infection rates. The objective of this study was
to evaluate the extent to which intensive care units par-
ticipating in the initial Keystone ICU project sustained
reductions in rates of catheter related bloodstream
1
Quality and Safety Research
Group, Department of
Anesthesiology and Critical Care
Medicine, Johns Hopkins University,
1909 Thames Street, Baltimore,
MD 21231, USA
2
Michigan Health and Hospital
Association Keystone Center,
6215 West St, Jose ph, Lansing, MI
48917, USA
3
Carey Business School, Johns
Hopkins University, 10 North
Charles Street, Baltimore, MD
21201-3707
4
Division of Infectious Diseases,
615 N Wolfe Street, Osler 425,
Baltimore, MD 21287
5
Department of Health Policy and
Management, 624 N Broadway,
Hampton House 433, Baltimore,
MD 21205
6
Department of Internal Medicine,
Division of Pulmonary and Critical
Care Medicine, University of
Michigan, 3916 Taubman Center ,
AnnArbor,MI48109,USA
7
Thoracic Surgery, William
Beaumont Hospital, 3601 W 13
Mile Road, Royal Oak, MI, USA
8
St Joseph Mercy Health System,
5301 East Huron River Drive, P O
Box 995, Ann Arbor, MI, 48106-
0995
9
William Beaumont Hospital
10
Division of Pulmonary and
Critical Care Medicine, 615 N
Wolfe Street, Baltimore
Correspondence to: P J Pronovost
ppronovo@jhmi.edu
Cite this as:
BMJ
2010;340:c309
doi:10.1136/bmj.c309
BMJ | ONLINE FIRST | bmj.com page 1 of 6

infection. We hypothesised that the bloodstream infec-
tion rate would remain low during the sustainability
period relative to baseline.
METHODS
Study design
The Keystone ICU project was designed as a prospec-
tive cohort study and used a collaborative model invol-
ving the Johns Hopkins Quality and Safety Research
Group, the MHA Keystone Center for Patient Safety
and Quality, and participating hospitals. All hospitals
in Michigan with an intensive care unit were invited to
participate in the project. To participate, they had to
form an intensive care unit team, agree to complete
the project work, and send a signed letter of commit-
ment from a senior hospital executive with a list of
team members. At a minimum, the team had to include
a senior executive, the intensive care unit director and
nurse manager, and a physician and nurse in the inten-
sive care units who could both dedicate 20% of their
effort to project activities. The initial implementation
and evaluation phase was funded by the Agency for
Healthcare Research and Quality. During this phase,
individual intensive care units implemented two cul-
tural interventions first and then two interventions tar-
geting patients’safety (in any order).
5
The four
interventions were implemented at three month inter-
vals. As a result, the intervention targeting catheter
related bloodstream infection had a staggered timing
for its implementation.
At the end of the initial funding, intensive care unit
teams were instructed to sustain the bloodstream infec-
tion intervention. They were to maintain a team, inte-
grate the intervention into staff orientation, continue
collecting monthly data on catheter related blood-
stream infections and catheter days in collaboration
with hospital infection control staff, and continue
reporting infection rates per 1000 catheter days to
appropriate stakeholders. We lacked funding to
formally evaluate any intensive care units’compliance
with each of these components. Informally, however,
nearly all units reported that they were continuing all of
these components. After the initial funding ended,
intensive care units paid MHA to continue working
with the Johns Hopkins team on new quality improve-
ment interventions not related to catheter related
bloodstream infections. Thirteen intensive care units
declined further participation specifically because of
the MHA fee. Compared with all intensive care units
that continued to participate, the 13 units that dropped
out of this project were more likely to be at a teaching
hospital (93% v65 %, P=0.04), but they did not vary in
the median number of hospital beds (383 v338,
P=0.70) and did not have significantly different rates
of catheter related bloodstream infection in the first
and final quarters of the initial 18 month post-imple-
mentation period or quarterly rates of improvement
over that period.
Intervention
We used a conceptual model to increase use of evi-
dence based interventions and improve safety culture.
This model has been described elsewhere.
8-10
The
intervention evaluated in this study targeted clinicians’
use of five evidence based recommendations to reduce
catheter related bloodstream infections from the Cen-
ters for Disease Control and Prevention (CDC).
25
Four
recommendations related to insertion of the catheter:
hand washing, using full barrier precautions, cleaning
the skin with chlorhexidine, and avoiding the femoral
site when possible. The fifth recommendation was to
remove unnecessary catheters. Strategies to increase
the use of these evidence based recommendations are
described elsewhere.
511
Teams reported all catheter
related bloodstream infections and number of days of
use of catheters (catheter days). For the remainder of
this paper we will use the term bloodstream infection to
indicate catheter related bloodstream infection.
Outcomes
The primary outcome was the quarterly rate of blood-
stream infections during the 18 month sustainability
period. To test sustainability of the intervention, we
analysed trends in infection rates for the 18 month
initial evaluation period compared with the 18 month
sustainability period. Specifically, a total of 103 inten-
sive care units from 67 hospitals contributed data to the
initial evaluation period. Some intensive care units did
not contribute to all time periods, and 13 of the 103
units declined to participate in the sustainability per-
iod, leaving 90 for which we evaluated the primary out-
come. All hospitals used standard definitions of
catheter related bloodstream infections provided by
the CDC.
12
Our analysis included hospital teaching
status (binary variable) and bed size (continuous vari-
able) to show any effect on distribution of catheter
days. These variables came from the American Hospi-
tal Association database.
Time after implementation (months)
Catheter related bloodstream infection rate
(per 1000 catheter days)
Baseline
During implementation
0-3
4-6
7-9
10-12
13-15
16-18
19-21
22-24
25-27
28-30
31-33
34-36
0
10
15
25
20
5
Catheter related bloodstream infection rate as a function of time. Circles represent mean
infection rate per quarter; thick blue line represents estimated mean rate of infection modelled
as a linear-spline function in which rate of change in mean infection rate is allowed to change
after 16-18 month period; thin red lines represent changes in observed infection rates over
time within a random sample of 50 intensive care units
RESEARCH
page 2 of 6 BMJ | ONLINE FIRST | bmj.com

Statistical analysis
We summarised rates of bloodstream infection as med-
ians and interquartile ranges and as means and stan-
dard deviations. We used generalised linear latent
and mixed models,
13 14
with a Poisson distribution, to
compare the quarterly bloodstream infection rate from
baseline to the end of the initial 16-18 month evalua-
tion period and for the subsequent 18 month sustain-
ability period (from 19-21 months to 33-36 months
post-implementation). In the models, we used robust
estimation of variance, adjusted for hospital teaching
status and bed number, and included two level random
effects to account for nested clustering within the
data
13 15
: intensive care units over time and hospitals
within regions. We also evaluated whether the relative
change in quarterly bloodstream infection rate was dif-
ferent during the initial evaluation period compared
with the sustainability period by using a linear spline
model, which allowed the relative change in quarterly
infection rate to change at the end of the initial
18 month period.
16
To assess the sensitivity of our results to missing data
and to potential non-reporting bias, we replicated the
analysis including only those 43 intensive care units
that reported continuous data from baseline to the
end of the sustainability period. To assess the sensitiv-
ity of our results to a few units that reported quarters
with large rates of bloodstream infections (primarily
driven by small numbers of catheter days), we repli-
cated the analysis excluding the quarters of data in
which catheter days were in the lowest 10% across all
quarters. Finally, we replicated our models assuming
an over-dispersed Poisson distribution (known as a
negative binomial distribution) for the number of
bloodstream infections to assess the sensitivity of our
results to the Poisson assumption. All P values are two
sided; we considered a P value of ≤0.05 to be statisti-
cally significant. We used Stata (version 9.1) for all ana-
lyses.
RESULTS
During the sustainability period, 90 (87%) of the origi-
nal 103 intensive care units from 61 (91%) of the origi-
nal 67 hospitals reported 1532 intensive care unit
months of data and 300 310 catheter days. Thirteen
units dropped out because they chose not to pay the
MHA’s fee. The distribution of total catheter days by
hospital teaching status and bed number was consistent
between the initial evaluation period and the sustain-
ability period (table 1).
Overall, 1394 possible quarters of bloodstream
infection data existed for the entire study (baseline
data for 55 intensive care units, plus 13 subsequent
quarters for the three month implementation period
and the 36 month post-implementation period for
103 units) (table 2). Seventy-eight quarters (roughly
5%) of data were lost when the 13 units left the colla-
boration, and 65 quarters (roughly 5%) of bloodstream
infection rates were missing for the remaining units.
Total catheter days were consistent during each
quarter in the initial evaluation period and the sustain-
ability period. The mean and median rates of blood-
stream infection decreased from 7.7 and 2.7
(interquartile range 0.6-4.8) per 1000 catheter days at
baseline to 2.3 and 0 (0.0-3.0) at 0-3 months after imple-
mentation of the intervention and to 1.3 and 0 (0-2.4) at
16-18 months after implementation, and they were sus-
tained at 1.1 and 0 (0.0-1.2) at 34-36 months post-
implementation (table 2). The multilevel Poisson
regression model showed a significant decrease in
bloodstream infection rates during all study periods
compared with baseline rates; 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 after implementation, with a sustained
improvement of 0.34 (0.24 to 0.48) at 34-36 months
(table 2).
From baseline to the end of the initial 18 month eva-
luation period, the mean rate of bloodstream infection
decreased significantly by 12% (95% confidence inter-
val 9% to 15%) per quarter (figure). During the
19-36 month sustainability period, the quarterly blood-
stream infection rate did not significantly change from
the rate achieved at the end of the initial evaluation
period (1% decrease, 95% confidence interval 9%
decrease to 7% increase).
Forty-three intensive care units reported data con-
tinuously from baseline to the end of the sustainability
Table 1
|
Number of intensive care units (ICUs) and catheter days by hospital type and size for each study period
Hospital type/size
Baseline period before
implementation of intervention
During implementation of
intervention (3 months)
Initial evaluation period
(18 months)
Sustainability period
(18 months)
No of ICUs* Catheter days (%) No of ICUs Catheter days (%) No of ICUs Catheter days (%) No of ICUs Catheter days (%)
All hospitals 55 41 506 (100) 96 57 033 (100) 103 300 175 (100) 90 300 310 (100)
Teaching status:
Teaching 33 29 407 (71) 66 44 752 (78) 71 231 595 (77) 60 230 836 (77)
Non-teaching 22 12 099 (29) 30 12 281 (22) 32 68 580 (23) 30 69 474 (23)
No of beds:
<200 13 3 266 (8) 17 3 066 (5) 19 16 349(5) 17 16 398 (5)
200-299 12 13 321 (32) 19 10 792 (19) 23 67 970 (23) 22 59 122 (20)
300-399 12 10 531 (25) 20 12 314 (22) 20 66 765 (22) 17 63 650 (21)
≥
400 18 14 388 (35) 40 30 861 (54) 41 149 091 (50) 34 161 140 (54)
*Of 103 ICUs participating in initial evaluation, 48 did not contribute baseline data
—
40 implemented intervention during baseline period of study; 8 did not report baseline data.
RESEARCH
BMJ | ONLINE FIRST | bmj.com page 3 of 6

period. A sensitivity analysis including only these 43
units resulted in similar findings to our main analysis
including all units: an estimated 13% (9% to 16%)
decrease in the mean rate of bloodstream infection
per quarter during the initial evaluation period fol-
lowed by a less than 1% decrease (4% decrease to 5%
increase) per quarter during the sustainability period.
The primary results were not substantially changed by
exclusion of infection data for quarters in which the
total catheter days were in the lowest 10% (<67 days).
Finally, the results changed little when we used regres-
sion models assuming an over-dispersed Poisson dis-
tribution for the number of infections.
DISCUSSION
Our findings show that the markedly reduced rates of
bloodstream infection achieved in the initial evalua-
tion period of the Keystone ICU project were sustained
for an additional 18 months. The median rate of infec-
tion remained at zero for the entire 18 month sustain-
ability period, with a greater than 60% reduction in
infection rates from baseline sustained at the end of the
36 month period.
Our project is one of relatively few robustly designed
and evaluated large scale quality improvement pro-
jects that have shown substantial improvements.
Even fewer projects have evaluated the sustainability
of such results. Achieving sustainability has been a
major challenge for the quality improvement
field.
17-19
The Keystone ICU project coupled a formal
model to translate evidence into practice with a com-
prehensive patient safety intervention to improve cul-
ture, educate staff, learn from mistakes, and involve
senior leaders.
810
During interviews, intensive care
unit teams noted several factors that were important
in sustaining this project, including continued feed-
back of infection data that the team perceived as
valid, improvements in safety culture that occurred as
part of the overall Keystone ICU project, an unremit-
ting belief in the preventability of bloodstream infec-
tions, involvement of senior leaders who reviewed
infection data and provided teams with the resources
needed, and a shared goal rather than a competition to
reduce infection rates throughout the state of Michi-
gan. Other studies describe similar methods to facili-
tate sustainability, such as active support from leaders
and an infrastructure that supports quality improve-
ment methods, training of staff, involving key internal
and external stakeholders,
6 20-23
alignment of project
and organisational goals,
21
multidisciplinary teams and
collaborations,
6
and inclusion of change management
that also encourages local adaptation and rewards
innovation and change.
21
Quality improvement initia-
tives that demonstrate value are more likely to be
sustained.
21 24
We did not formally evaluate the factors
associated with continued improvement. However,
the quality improvement model used in the Keystone
ICU project and our recommendations to teams at the
end of the initial evaluation period to maintain a team,
orient new staff, collect monthly data, and report infec-
tion rates to appropriate stakeholders target many of
the recommendations described in the literature.
Limitations of study
This research has several new limitations not reported
in our evaluation of the initial evaluation period.
5
Table 2
|
Catheter related bloodstream infection rates from baseline until 36 months after quality improvement intervention
Study period No of ICUs
Median (IQR) No of
infections Median (IQR) catheter days
Infection rate
Incidence rate ratio* (95% CI)Median (IQR) Mean (SD)
Baseline 55 2 (1-3) 551 (220-1091) 2.7 (0.6-4.8) 7.7 (28.9) Reference
During implementation 96 1 (0-2) 447 (237-710) 1.6 (0-4.4) 2.8 (4.0) 0.81 (0.61 to 1.08)
After implementation
—
initial
evaluation period:
0-3 months 95 0 (0-2) 436 (246-771) 0 (0-3.0) 2.3 (4.0) 0.68 (0.53 to 0.88)
4-6 months 95 0 (0-1) 460 (228-743) 0 (0-2.7) 1.8 (3.2) 0.62 (0.42 to 0.90)
7-9 months 96 0 (0-1) 467 (252-725) 0 (0-2.0) 1.4 (2.8) 0.52 (0.38 to 0.71)
10-12 months 95 0 (0-1) 431 (249-743) 0 (0-2.1) 1.2 (1.9) 0.48 (0.33 to 0.70)
13-15 months 95 0 (0-1) 404 (158-695) 0 (0-1.9) 1.5 (4.0) 0.48 (0.31 to 0.76)
16-18 months 95 0 (0-1) 367 (177-682) 0 (0-2.4) 1.3 (2.4) 0.38 (0.26 to 0.56)
After implementation
—
sustainability period:
19-21 months 89 0 (0-1) 399 (230-680) 0 (0-1.4) 1.8 (5.2) 0.34 (0.23 to 0.50)
22-24 months 89 0 (0-1) 450 (254-817) 0 (0-1.6) 1.4 (3.5) 0.33 (0.23 to 0.48)
25-27 months 88 0 (0-1) 481 (266-769) 0 (0-2.1) 1.6 (3.9) 0.44 (0.34 to 0.57)
28-30 months 90 0 (0-1) 479 (253-846) 0 (0-1.6) 1.3 (3.7) 0.40 (0.30 to 0.53)
31-33 months 88 0 (0-1) 495 (265-779) 0 (0-1.1) 0.9 (1.9) 0.31 (0.21 to 0.45)
34-36 months 85 0 (0-1) 456 (235-787) 0 (0-1.2) 1.1 (2.7) 0.34 (0.24 to 0.48)
ICU
=
intensive care units; IQR=interquartile range.
*
Calculated with use of generalised linear latent and mixed model,
13
with robust variance estimation and random effects to account for clustering of catheter related bloodstream infections
within ICUs over time and clustering of hospitals within geographical regions; rates of catheter related bloodstream infections during implementation, initial evaluation, and sustainability
periods compared with baseline (pre-implementation) values, adjusted for hospital
’
s teaching status and number of beds.
RESEARCH
page 4 of 6 BMJ | ONLINE FIRST | bmj.com

Firstly, we cannot evaluate whether the results would
have been sustainable if intensive care units were
blinded to their infection rates, because our model to
change practice included feedback of data so units
could evaluate their performance.
8
Secondly, we had
insufficient funds to formally evaluate mechanisms
that contributed to the success of this sustainability,
so we cannot evaluate the relative importance during
the sustainability phase of periodic meetings between
participating units and the Keystone Center. Although
these meetings focused on implementing new safety
interventions, they may have influenced the sustain-
ability of the bloodstream infection intervention. Also
unknown was the impact of Blue Cross Blue Shield of
Michigan’s quality payment incentive on a hospital’s
decision to continue to participate in the Keystone ICU
project. In the first year, hospitals received an incentive
payment if they submitted 90% of the required blood-
stream infection data. In subsequent years, the incen-
tive payment was based on performance thresholds
(statewide infection rate compared against CDC
pooled mean) for continued reduction of infection
rates. Thirdly, we did not evaluate the use of new tech-
nologies, such as impregnated dressings or catheters
and chlorhexidine baths, on rates of infection.
25-28
Implications and future research
These findings have important public health conse-
quences. If the multifaceted quality improvement
intervention and collaborative model were implemen-
ted in all intensive care units across the United States,
and the results were similar to those achieved in Michi-
gan, substantial and persistent reductions could be
made in the 82 000 infections, 28 000 deaths, and
$2.3 billion costs attributed to these infections
annually.
3
Moreover, the use of this quality improve-
ment model to reduce other complications may further
improve quality and reduce costs of care.
A prominent item on the research agenda for quality
improvement initiatives is identifying methods that
sustain a successful project. Sustainability is often
vague and may not be formally separated from the
initial implementation and evaluation of the project.
22
Although we do not have empirical data to support this
statement, both our experience and theoretical reasons
support the idea that sustainability should be examined
separately from implementation. Weick and Quinn
noted that organisations and teams vary in whether
they are best suited for episodic or continuous
change.
29
Moreover, early, mid, and late implementers
have differing characteristics and motivations for
implementing quality improvement interventions.
30
Some implementers focus efforts on short term results,
whereas sustainers generally focus on long term
results. Teams that are good “implementers”may not
be the same as those that are good “sustainers.”More
research is needed to better understand when imple-
mentation ends and sustaining begins, as well as the
attributes of teams that are good implementers and
good sustainers.
We thank Christine G Holzmueller for her assistance in editing the
manuscript. We also thank the Michigan Health & Hospital Association
(MHA) Keystone Center and all the intensive care units teams in Michigan
(list of participating hospitals in web appendix) for their tremendous
efforts. Their leadership and courage in this innovative effort reflects an
unrelenting passion and dedication to improve quality and safety for their
patients.
Contributors: All the authors were involved in preparing this manuscript
and had full access to all of the data (including statistical reports and
tables) in the study and can take responsibility for the integrity of the data
and the accuracy of the data analysis. PJP was the principal i nvestigator of
the project, was responsible for the overall design and supervision of the
study, and wrote the initial draft of the manuscript. All other authors
contributed to study design, collecting or analysing data, and redrafting
the manuscript. CG was the director of the Keystone Center during the
initial evaluation period, and SW was its director during the sustainability
period. SW and SB managed collection and quality control of data, and
PJP, EC, DJS, and DM provided data cleaning and editing, statistical
analysis, and interpretation of results. SB, LL, DT, and JM were part of the
Johns Hopkins team that supported the collaborative, and RH, RW, PP,
and KS were members of and represented intensive care unit teams in
Michigan. SC provided expertise on definitions of catheter related
bloodstream infection, measuring infection rates, and interventions to
reduce infections. PJP is the guarantor.
Funding: Support for this project, for the period from October 2003 to
September 2005, was provided by the Agency for Healthcare Research
and Quality (1UC1HS14246) and the MHA. The Agency for Healthcare
Research and Quality provided financial support, and the MHA provided
support for the biannual statewide meetings. The researchers were
independent of the sponsors, and neither sponsor had any infl uence over
the study design; collection, analysis, or interpretation of the data; writing
of the manuscript; or decision to submit it for publication.
Competing interests: PJP and CAG received grant support from the
Agency for Healthcare Research and Quality, the Robert Wood Johnson
Foundation, the National Patient Safety Agency, and the World Health
Organization to study and improve quality of care, including catheter
related bloodstream infections. They have received lecture fees from
various healthcare organisations, and CAG has also received lecture fees
from government agencies to speak on quality and patient safety. SC has
grant support from Cubist and Astellas, has served as a consultant for
Merck, and has been on the advisory boards for Astellas, Forrest, and
Cadence. JBS and JAM have grant support from the Robert Wood Johnson
Foundation. PP has received lecture fees from Lilly, Merck, Edward Life
Sciences, and Sage for various speaking engagements. DMN has had
grant and contract support from the NationalInstitutes of Health/National
Heart Lung and Blood Institute and a clinician-scientists award from the
Canadian Institutes of Health Research.
Ethical approval: The Johns Hopkins University School of Medicine
Institutional Review Board reviewed and approved this research.
Data sharing: The dataset and statistical codes are available from the
corresponding author.
1 Burke JP. Infection control
—
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Bloodstream infections from central venous catheters are preventable to some extent
Sustainability of quality improvement initiatives is a major challenge
WHAT THIS STUDY ADDS
A multifaceted quality improvement project can sustain reductions in bloodstream infection
rates to 36 months post-implementation
RESEARCH
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Accepted: 22 November 2009
RESEARCH
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