Eliminating CLABSI: Progress on a National Patient Safety Imperative
AHRQ
Eliminating CLABSI: Progress on a National Patient Safety Imperative
At any given time, about 1 in every 20 patients has an infection related to his or her hospital care. These infections cost the U.S. healthcare system billions of dollars each year and lead to the loss of tens of thousands of lives.
For too long, healthcare-associated infections (HAIs) were considered an inevitable consequence of a hospital stay. Today, health researchers have provided proof that these deadly and costly infections can be sharply reduced—and even eliminated—by adhering to a defined set of evidence-based practices. Preliminary findings from a national program to replicate these results in U.S. hospitals are encouraging, yet more work remains to achieve results we now know are possible.
The Agency for Healthcare Research and Quality (AHRQ), a leading partner in federal efforts to fight HAIs, has long supported research on evidence-based protocols that reduce the rate of central line-associated bloodstream infections, or CLABSIs. One of the most deadly types of HAIs, CLABSIs are typically present in hospital intensive care units (ICUs), inpatient units, and outpatient hemodialysis clinics. CLABSIs are linked to mortality rates that range between 12% and 25% (Centers for Disease Control and Prevention [CDC], 2011).
In 2009, the U.S. Department of Health and Human Services (HHS) announced an Action Plan to reduce the incidence of HAIs, including CLABSIs, by 2013. One year earlier, AHRQ expanded its support for the implementation of the Comprehensive Unit-based Safety Program, or CUSP, by hospitals in 10 states. Beginning in 2003, the Keystone Project used CUSP to substantially cut the incidence of CLABSIs in more than 100 Michigan ICUs within 18 months and was credited with saving 1,500 lives and $200 million (Pronovost et al., 2006).
Nationwide expansion of CUSP, with its $7 million in new funding, allowed AHRQ to spread the CUSP program to hospitals in all 50 states, extend it to other settings beyond ICUs, and focus on reducing other types of HAIs. It is taking place through an alliance that consists of AHRQ; the Health Research and Educational Trust, an affiliate of the American Hospital Association; the Johns Hopkins University Quality and Safety Research Group, which developed the CUSP protocol; and the Michigan Health and Hospital Association’s Keystone Center for Patient Safety and Quality, which successfully used the protocol (HHS, 2009).
HHS has strengthened its support for the prevention of HAIs in its new Partnership for Patients initiative, a national partnership with hospitals, medical groups, consumer groups, and employers. The Partnership’s goal is to decrease preventable hospital-acquired conditions, a term that includes HAIs and other causes of harm to patients such as falls, by 40% (compared with 2010 rates) by the end of 2013. Achieving this goal should result in approximately 1.8 million fewer injuries and illnesses to patients, saving more than 60,000 lives. In total, the Partnership’s initiatives seek to save up to $35 billion across the healthcare system, including up to $10 billion in Medicare savings.
Evidence of Progress
AHRQ’s alliance, called On the CUSP: Stop BSI, requires states to identify a lead organization to work with hospitals on implementing the protocol’s clinical and cultural changes. CUSP protocol includes using a checklist of evidence-based safety practices; improving teamwork among doctors, nurses, and hospital leaders; and measuring infection rates in a consistent and standard manner.
As of June 2011, 46 state hospital associations and one other umbrella group had recruited more than 1,055 hospitals and 1,775 hospital teams to the program, according to findings from a new 2-year progress report (AHRQ, 2011). Participation in the initiative is on a rolling basis: in 2009, 22 states began the project; 14 states and the District of Columbia began their work in 2010; and 8 states and Puerto Rico began their efforts in 2011. Once states agreed to participate, they were placed into a project group, or cohort, along with other states beginning the project at the same time.
Project recruitment has been strongest among teaching hospitals and hospitals with more than 400 beds and lower among hospitals with fewer than 100 beds. More than 75% of units participating in the project are ICUs, with the majority consisting of adult ICUs.
To determine impact, project evaluators focused on quarterly data from the hospital units that began participating in 2009 and 2010. Compared to a baseline CLABSI rate of 1.87 infections per 1,000 central line days in these units, hospital units have lowered their CLABSI rates to 1.25 infections per 1,000 days, a reduction of 33%. The improvement occurred in the 10 to 12 months following the introduction of the CUSP protocol.
Hospital units that reported quarterly CLABSI rates of zero increased from 27.3% at baseline to 69.5% at one year following the intervention.
Areas for Improvement
The progress by hospital ICUs in lowering the rate of CLABSIs by one-third is welcome news. Nonetheless, key opportunities for improvement remain; three were identified by the national program team as most important:
- Targeted interventions for high-rate units: Average CLABSI rates are above 1.0 because of a relatively small percentage of units with rates that exceed 5 per 1,000 central line days. The project team has identified these facilities and is working with state hospital associations to discuss and address their needs. The success of their efforts will have a significant impact on the ability of the national project to meet its overall goals.
- Data submission: Not all of the units have submitted CLABSI rate data in each of the reporting periods. While submitting data does not directly lower CLABSI rates, continuous monitoring is necessary for clinicians to identify which processes may require improvement.
- Sustainability: CLABSI rates among participating hospital units have dropped substantially during the project’s first year. However, sustaining these lowered rates and driving them down even further requires a sustained commitment on the part of hospitals and states. Project leaders are focusing their efforts on the important work of sustaining improvement among participating hospitals as well as those that have not taken part in the project.
Conclusion
Efforts to reduce CLABSI rates have generated a significant amount of encouraging news. A recent report by CDC found that hospital ICUs lowered their rates by 58%, from 3.6 per 1,000 central line days in 2001 to 1.6 per 1,000 central line days in 2009 (CDC, 2009).
The ongoing evaluation of the On the CUSP: Stop BSI project confirms our sense of optimism. This national initiative provides further evidence that, by aggressively monitoring and intervening, CLABSIs can be dramatically lowered and eventually eliminated, and their deadly and costly consequences averted.
Carolyn Clancy is director of the Agency for Healthcare Research and Quality, Rockville, Maryland. She is a general internist and holds an academic appointment at George Washington School of Medicine in Washington, DC. She may be contacted at carolyn.clancy@ahrq.hhs.gov.
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