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Medical News & Perspectives
October 24 2012

Hospitals Slash Central Line Infections With Program That Empowers Nurses

JAMA. 2012;308(16):1617-1618. doi:10.1001/jama.2012.13364

It's been 31 months since a patient in the intensive care unit has developed a central line–associated bloodstream infection (CLABSI) at the Peterson Regional Medical Center in Kerrville, Tex, said nurse educator Theresa Hickman, RN, during a press briefing in September.

Comprehensive Unit-based Safety Program (CUSP) has helped hospital units drastically reduce or eliminate central line infections.
(Photo credit: AHRQ)

Comprehensive Unit-based Safety Program (CUSP) has helped hospital units drastically reduce or eliminate central line infections.

Hickman credits this achievement—eliminating infections that were once considered inevitable—to the staff of the 125-bed rural hospital, which implemented the Comprehensive Unit-based Safety Program (CUSP), an initiative being rolled out at hospitals nationwide to curb hospital-acquired infections. Hickman described it as the most powerful quality improvement effort she's encountered in her 32-year career. What makes it different from many other efforts is that it empowers nurses and other frontline caregivers to identify and fix problems that may compromise patient safety.

“We listen to the wisdom of our frontline caregivers,” she said.

And she's not alone in singing the praises of the program. Over the past 4 years, CUSP has been rolled out at 1100 intensive care units across the country, and preliminary data suggest that the effort has cut the rate of CLABSIs nationally by 40%, reducing the rate of infections per 1000 central-line days from 1.9 to 1.1. According to Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), which sponsored the project, the program has prevented 2000 infections, saved 500 lives, and saved $34 million in health costs.

“This could be health care's man-on-the-moon moment,” said Peter Pronovost, MD, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore, who created the program with colleagues at Hopkins and has been testing its effectiveness.

Pronovost explained that the program was inspired by the death of an 18-month-old girl at Hopkins as a result of a CLABSI. Infection rates were high at the hospital when the girl died. The hospital implemented a series of improvements, including nurse-administered checklists to ensure infection prevention practices were followed, hospital-wide culture about infection prevention underwent a change, and performance measures to gauge implementation were put in place.

“It worked,” he said. “Infections were virtually eliminated.”

The toolkit derived from this effort became CUSP, and with funding from the AHRQ, Pronovost has systematically tested its implementation on an increasingly larger scale. First, a 2-year, $500 000 project to implement the program at Michigan hospitals, led by the Michigan Health and Hospital Association, reduced CLABSIs by 66% at 100 intensive care units across the state within 6 months, eliminating such infections in 65% of the units. The latest results come from a 4-year effort to roll out the program in 44 states.

Pronovost credited the success of CUSP to cooperation at multiple levels within the health care system. The program, he said, is led by frontline health care workers, and it aligns the efforts of hospital-level leadership with state and federal leaders. Other key players have been the American Hospital Association (AHA) and its research arm, the Health Research & Educational Trust, which helped enlist hospitals to participate in the nationwide project.

“It's a model of the power of partnership in solving health care's thorniest problems,” said AHA chief executive officer Rich Umbdenstock. He said that the AHA would like to get all hospitals in all states to participate.

To help more hospitals implement the program, the AHRQ has released a CUSP toolkit, including videos, presentation slides, and other training tools (http://www.ahrq.gov/cusptoolkit/). Michael Tooke, MD, chief medical officer at Memorial Hospital in Easton, Md, summarized the program's 5 components as follows:

  • Engagement—assembling a team with the goal of prevention

  • Educating the team about what has worked for others

  • Executing the hospital's plan by making it mandatory

  • Evaluating execution by measuring outcomes

  • Building enthusiasm by acknowledging every milestone

Tooke, who helped implement CUSP at both Memorial Hospital and its sister facility, said acknowledging the milestones has been particularly important because it reinforces a sense of ownership of the program for clinicians working at the bedside. At the briefing, he noted that it has been 810 days since the last CLABSI at Memorial Hospital and that neither hospital has had a case of ventilator-associated pneumonia since February 2010.

Hickman agreed that celebrating such milestones is the key to maintaining the program over the long-term. “Once they get those zeros, staff is very protective of those zeros,” she said.