Factors determining success in
reduction of Central Line
Associated Blood Stream
Infection (CLABSI) on
statewide levels
HeeWon Lee, Doris Duke Clinical Research Fellow
PI Peter Pronovost, M.D. PhD.,
Bradford Winters, M.D. PhD.
Background
CLABSI
• A common, costly, and fatal cause of
hospital-related deaths, with
approximately 31,000 annual deaths in
the US
• $3 billion spent worldwide.1
• However, CLABSIs are preventable.2,3
1. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care-associated infections and
deaths in US hospitals, 2002. Public Health Rep. 2007; 122(2):160-166.
2. Edwards JR, Peterson KD, Mu Y, et al. National Healthcare Safety Network (NHSN) report: data
summary for 2006 through 2008, issued December 2009. Am J Infect Control. 2009;37(10):783-805.
3. Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related blood stream infections in
the intensive care unit. Crit Care Med. 2004;32(10):2014-2020.
Background
On the CUSP: Stop BSI
• Project led by the Johns Hopkins Quality
Safety Research Group
• Implementing a two-component,
multifaceted hospital safety program has
– Saved lives, health care $
– Reduced CLABSIs by 66%
– Sustained a median infection rate of 0, and
mean of 1 infection per 1000 catheter-days
for more than 3 years in Michigan.4
4. Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reductions in catheter relate bloodstrea infections in
Michigan intensive care units: observational study BMJ. 2010;240:c309.
Background
On the CUSP: Stop BSI
Timeline
Hospital recruitment,
registration,
orientation with
QSRG on CUSP
Month 0
Month 3
Implementation of
program:
1.
Evidence-based
Behaviors to
Prevent CLABSI
2.
Multifaceted
Safety Program
1.
Continued contact with QSRG
2.
Data collection--submission of monthly
CLABSI and monthly team checkup tool
data
Month 28
Background
On the CUSP: Stop BSI
I. Evidence-based Behaviors to Prevent CLABSI5
1. Remove Unnecessary Lines
2.
Wash Hands Prior to Procedure
3.
Use Maximal Barrier Precautions
4.
Clean Skin with Chlorhexidine
5.
Avoid Femoral Lines
5. Marschall et al. Infect Control Hosp Epidemiol 2008. CDC.gov
Background
On the CUSP: Stop BSI
II. Multifaceted Safety Program (Team Checkup
Toolkit)5
1. Learning from Defects
2. Daily Goals Checklist
3. Morning Briefing
4. Observing Rounds
5. Shadowing Another Profession
6. Culture Debriefing
7. Physician Call List
“When we all work together, we all win together”
Background
Expansion of Stop BSI Project
Overall goal: 75% national reduction in CLABSI over 3 years
But wait! Problems exist…
• Despite the expansion of the program
to numerous states…
– Median rates of CLABSI remain high or
unchanged
– Some hospitals claim to use the checklist,
despite having high or unknown infection
rates
– Some hospitals say that the ICU patients are
too sick and that infection is inevitable
– Hospital enrollment in the program has
been slow.6
6. Department of Health and Human Services. Department of Health and Human Services initiative http://www/jjs/gpv/
Accessed July 1, 2010.
What factors are
associated with success of
reducing CLABSIs?
Hypothesis
States with higher rates of meeting
the CLABSI reduction goals are
associated with greater hospital
participation and adherence to the
two-component, multifaceted safety
program.
CLABSI definition7
• For determining CLABSI rate
– Numerator: # of CLABSIs
– Denominator: # of central line-days
– Expressed as a rate of X CLABSI/1,000
central line days
• #CLABSI/# central line days X 1000
7. National Healthcare Safety Network (NHSN): Device-Associated (DA) Module www.cdc.gov/nhsn/psc_da.html.
Accessed July 1, 2010.
Study Design
Prospective observational
cohort study
Hospital recruitment,
registration,
orientation with
QSRG on CUSP
1.
Continued contact with QSRG: hospital
participation and dropout rates
2.
Data collection--submission of monthly
CLABSI and monthly team checkup tool
data
Month 0
Month 3
Month 28
Baseline CLABSI
rate
1o outcome:
2o outcome:
Reduction of CLABSI
from baseline rate in
the first 3 months of
participation
Sustained reduction of
CLABSI from baseline
rate after 28 months of
initiation of project
Stratification
Hospitals by…
• Teaching status
• Bed size
• Presence in a state with mandatory
participation in the National Healthcare
Safety Network (NHSN)
States by…
• Number of teaching/academic
institutions present
• Presence of mandate to report
Statistical methods
1. Two sample Wilcoxon rank-sum test
for comparison of medians with
baseline CLABSI rates
2. Poisson regression modeling for
comparison of CLABSI rates before,
during, and up to 3 and 28 months
after implementation of program
Limitations of study
• Observational study
• Confounders?
• Inconsistent data from individual
hospitals regarding use of
multifaceted toolkit
Implications of study
• CLABSI are preventable!
– On the CUSP: Stop BSI project has demonstrated
effective elimination of CLABSI on a statewide level
in Michigan
• Many states are participating, but CLABSIs still
exist
• Study is the first of its kind in examining all
participating states and CLABSI rates
• By identifying factors associated with success in
reducing CLABSI, we may be better able to
reach the goal of reducing and eventually
eliminating CLABSI, further helping save lives and
healthcare $
Acknowledgements
• Small group leaders:
– Dr. Vered Stearns, Dr. Pete Miller
• Small group members:
– James Chen, Hormuz Dasenbrock,
Andrew Ibrahim, Kevin Jeng, Yong Suh
• Research mentors:
– Dr. Bradford Winters, Dr. Peter Pronovost
• QSRG team members