Dr. Robert Payne will never forget the premature baby who died years ago from what many now believe is preventable — a bloodstream infection caused by a central line, a catheter placed in a vessel that ends at or near the heart.
“The baby should never have died,” said Payne, the medical director of quality at Children’s Hospitals and Clinics of Minnesota. “That baby was destined to survive, was off the ventilator for a while, was doing quite well … and then developed this infection which over the course of a few months proved to be lethal.”
Every year, an estimated 250,000 central line-associated bloodstream infections, or CLABSI, occur in U.S. hospitals and 30,000 to 62,000 people die as a result, according to the Centers for Disease Control and Prevention. Although a successful prevention model exists, there has been no national improvement in reducing these infections, according to a report released this year by the Agency for Healthcare Research and Quality (AHRQ).
Meanwhile, experts struggle to explain why many hospitals, including most in Minnesota, are not participating in a national program known to reduce these infections and save lives.
Researchers from the Johns Hopkins University Quality and Safety Research Group, who have shown that CLABSI are largely preventable, have invited hospitals across the nation to participate in an initiative, “On the CUSP: STOP Blood Stream Infections (BSI).” This model nearly eliminated CLABSI in more than 70 Michigan hospitals and more than 103 intensive care units (ICUs) that participated in a study published in 2006 — and this success has been sustained for more than four years, saving thousands of lives and millions of dollars.
But “On the CUSP: STOP BSI,” funded by AHRQ and supported by the Secretary of Health and Human Services, has failed to engage many U.S hospitals since it was rolled out in Fall 2008. Although 94 percent of hospitals in Hawaii have committed to this initiative, fewer than 20 percent of hospitals in most states are participating, as of April 2010. In Minnesota, only seven hospitals are currently involved.
On the CUSP: STOP BSI
The goal of “On the CUSP: STOP BSI” is to eliminate CLABSI by improving patient safety culture and learning from mistakes. There are two components: a comprehensive unit-based safety program, or CUSP, coupled with a checklist of evidence-based steps known to reduce these infections.
In health care, when it comes to patient safety, often the same mistake happens time and time again, said Chris Goeschel, a nurse with critical-care nursing experience who has a doctorate in health systems management. “Different shift. Different unit. Different doctor or nurse. Different patient. Same set of unfortunate circumstances that resulted in error,” said Goeschel, who led the Michigan study and is a strategic leader for “On the CUSP: STOP BSI.”
CUSP sets the stage to address any patient safety issue by improving teamwork, communication, and accountability. It focuses on understanding the science of safety, identifying defects in care, partnering senior executives with clinical teams, learning from mistakes, and improving teamwork and safety culture. The “STOP BSI” checklist includes steps that everyone must take when a central line is placed — washing hands before the procedure, using full barrier precautions, cleaning the skin with chlorhexidine, and avoiding the femoral or groin site, which is more susceptible to infection. In addition, central lines are removed when they are no longer needed.
Essential to success is empowering staff to speak up if anyone, including the doctor, is not following the checklist. It’s everyone’s responsibility to keep patients safe.
“If the newest nurse practicing independently in your critical care unit was assisting with a central line insertion of the most senior physician and there was a breach in evidence-based insertion practices, would he or she feel comfortable speaking up, and would the physician inserting the line respect the voice?” Goeschel said. “Until we get there, we aren’t safe.”
Low participation in Minnesota
Since state hospital organizations have established relationships with member hospitals, they are the anchor for “On the CUSP: STOP BSI.” In May 2009, the Minnesota Hospital Association invited all Minnesota hospitals to participate; the low level of participation in Minnesota has been surprising, said Tania Daniels, the MHA vice president of patient safety.
Minnesota hospitals and other organizations have been very focused on patient safety efforts, said Daniels, who is the “On the CUSP: STOP BSI” local state coordinator. Several Minnesota hospitals participated in earlier projects designed to reduce central line infections, such as the Safest in America and the Institute for Healthcare Improvement 100,000 Lives Campaign. So, many of these organizations probably believe they’ve done this work and the problem is under control, Daniels said. “We have done a lot with culture, speaking up and engaging patients, root cause analysis, corrective action, and teamwork.”
In addition, other patient safety projects compete for limited resources. This includes the Minnesota adverse event law, established in 2003, which requires all Minnesota hospitals and ambulatory surgical centers to report “never events,” such as death associated with a fall or surgery done on the wrong patient or body part.
“It’s the same people in the facilities working on these [initiatives],” Daniels said. “And how much can you focus on at one time?”
Similarly, Goeschel has been surprised by Minnesota’s low participation. But they’re seeing this in many states. “People think they have already done this,” Goeschel said. “A state like Minnesota, which really is on the leading edge of so many things related to patient safety and reporting … thinks central line infections are old news. And perhaps they are. Perhaps everyone in Minnesota has taken care of this issue. But without data, we don’t know that.”
And since Minnesota hospitals are not required to report CLABSI rates, access to that information is extremely limited.
Since last fall, Minnesota hospitals have been required to report compliance to a central line infection prevention bundle, a package of prevention steps identical to the “STOP BSI” checklist. Although compliance to the central line bundle is publically reported at the Minnesota Hospital Quality Report website, the ultimate outcome of interest — infection rates — are not publically reported.
Minnesota hospitals that have opted out, but report low infection rates
For Payne, the death of his young patient feels like yesterday, even though years have passed.
“I would go to the bedside every day and there was this mother, this wonderful, dedicated, devoted mother,” Payne said. “And she’s sitting there, making things for the baby, and obviously very loving — and she would ask, ‘How are we doing? Is the baby going to get better?’ [The death of that baby] was one of the worst experiences of my life.”
Children’s Hospitals and Clinics of Minnesota have been measuring their infection rates since 1994. To improve their outcomes, they joined the Vermont Oxford Network, a national collaborative focused on preventing infections in neonatal ICUs.
“The power of working with others and having deadlines and collaborative efforts and sharing data and going to sites visits — that was really a big difference for us,” Payne said. “And over time, we have become more successful.”
In fact, they’ve become so successful that bloodstream infections are now rare events.
Developing multidisciplinary teams, reporting and comparing infection rates, and recognizing that blood stream infections are preventable even in premature babies were critical turning points that contributed to their success, Payne said.
Although Payne supports programs focused on transparency and reporting actual infection rates, Children’s is not participating in “On the Cusp: STOP BSI.”
Children’s has a system that’s meeting their needs and is measuring and reporting their infection rates, Payne said. “We’re focusing our limited resources in an effort to reinforce and continue what we’re already doing so that we don’t lose the gains that we have already made.”
Mercy Community Hospital in Coon Rapids is leading the way among Allina hospitals to reduce CLABSI, said Michelle Farber, a nurse who is the lead infection preventionist at Mercy.
In 2003, Mercy enrolled in an Institute for Healthcare Improvement initiative designed to reduce CLABSI. Since that time, they’ve used a multidisciplinary team approach and the “STOP BSI” checklist. Like Children’s, Mercy is not participating in “On the Cusp: STOP BSI.”
“Because of our success learning from IHI, we didn’t enroll in the CUSP program,” Farber said. Mercy has demonstrated and reported the success in their ICU. One year prior to October 2007, the CLABSI rate was 3.15 infections per 1,000 catheter days. But since then, they have reached their goal of zero infections. The last CLABSI was in September 2008.
If hospitals are collecting their rates of infection and have sustained CLABSI rates that are 0 or less than 1 infections per 1,000 catheter days, then likely they have done their work, Goeschel said. But even if hospitals have met this goal, Goeschel encourages them to participate in “On the Cusp: STOP BSI.”
“Send your data, so we know you’ve addressed this problem, and share your stories and experiences,” Goeschel said. “Many institutions haven’t achieved [success] and we all have a lot to learn from each other.”
Mercy does share lessons learned when they can, Farber said. A key lesson has been the belief and senior leadership support that a central line infection is not acceptable. “This is a total culture change from the past, when we saw ICU patients as high risk and that infections are inevitable,” Farber said. “Well, we’ve learned that they’re not … just that attitude among all the leaders is imperative to success.”
But despite knowing the value of sharing their success, Mercy must focus on competing infection priorities that consume their time and energy, Farber said.
Other Minnesota hospitals that have opted out
Large hospitals are noticeably absent from the small group of Minnesota hospitals participating in “On the CUSP: STOP BSI.”
“We did think about participating,” said Lori Johnson, who is the patient safety officer and senior director of performance improvement services at Hennepin County Medical Center (HCMC). “We did decide not to participate because of other work we had going on related to central line bloodstream infections.”
Meanwhile, compliance to all steps in the central line infection prevention bundle at HCMC, from April 2009 to March 2010, was 44 percent, according to the Minnesota Hospital Quality Report. This is one of the lowest in the state.
The low bundle compliance is more of a documentation problem than an actual practice issue, said Mary Ellen Bennett, who is the HCMC director of infection prevention. “We feel strongly that we’re complying with [the bundle], it’s just getting the documentation issues worked out,” Bennett said. “The last several months, it’s been much higher, like 100 percent.”
HCMC collects CLABSI rates and has seen tremendous decreases over time, Johnson said. “We won’t rest until we’re at zero on this — and that’s our goal.”
But despite reported success, Johnson was unable to release their infection rates. In the past, measurement wasn’t done consistently across organizations, Johnson said. “So, it’s not fair to put numbers out their when it’s not measuring the same measurement,” Johnson said. “And you’re asking people who don’t necessarily have clinical background to interpret things … it can lead people to believe things that aren’t accurate.”
MHA reintroduced “On the CUSP: STOP BSI” to Minnesota hospitals during an informational meeting this week. They hope to encourage more hospitals to participate in this program. And Johnson planned to attend this meeting. “We are certainly going in to hear if there is something new we should reconsider,” Johnson said.
Like HCMC, the University of Minnesota Medical Center, Fairview decided not to participate in “On the CUSP: STOP BSI.”
“When we looked at the particular program … which really has remarkable results, the content is really things that we have already been doing,” said Steven Meisel, who has a doctorate in pharmacology and is the director of patient safety for Fairview Health Services. “So, it wasn’t that we didn’t think the topic was important, or that we thought we were perfect with our performance or results, but that the approach that program is using … are topics and pieces that we were already working on.”
As one example, the University of Minnesota Medical Center has participated in numerous CLABSI initiatives for more than 14 years, said Dr. Susan Kline, the medical director for infection prevention at the University of Minnesota Medical Center, Fairview. And recent compliance to the central line infection prevention bundle was 100 percent.
Although all Fairview hospitals are measuring CLABSI rates, the organization is not comfortable sharing that information, Meisel said.
“We’re a transparent organization. But when we put rates and data out, we want to make sure that we control the message and the explanation and the interpretation of it,” Meisel said. “We know that comparing the University of Minnesota with a small community hospital or even a large secondary care facility may not be the right kind of comparison.”
Meisel said he is open to the “On the CUSP: STOP BSI” program. “We may look at this and decide, this is really the right [group] for us to be partnering with,” Meisel said. “I think that it’s timely to look at it again.”
Experience at participating hospitals
“I’m surprised that the none of the large Minnesota hospitals are participating in STOP BSI,” said Kathy Miller, who is the nurse director of the St. Joseph’s Medical Center ICU and telemetry unit. She’s glad that St. Joseph’s, located in Brainerd, decided to participate.
Roxanne Wilson, our chief nursing officer, thought it would be very helpful to be involved, said Miller, who used to work at a large hospital in the Twin Cities. “I’m thinking to myself…we haven’t had a central line infection … we were already reporting [the central line prevention bundle] to the state … so I felt, gosh, should our energies go somewhere else,” Miller said.
But Wilson had a bigger vision — the culture of safety. This was an opportunity to focus on communication and address ways that patients could be harmed.
“If [staff] sees anything that they think could be a safety issue, a communication issue, anything — they’re very good about bringing it forward,” Miller said.
Cuyuna Regional Medical Center, in Crosby, joined “On the CUSP: STOP BSI” even though it, like other Minnesota hospitals, had participated in earlier programs that addressed this problem. “We always try to be sure that we’re following guidelines and best practices … and although we didn’t really think we had any issues, we thought it would be a good idea to participate,” said Robert Pastor, who is the director of nursing at Cuyuna. “We try to participate as much as we can with everything, just so we can make sure that we’re doing everything that we can do.”
For Cuyuna, educating staff about the science of safety and training nurses to identify defects and look at processes has provided the greatest value, Pastor said. And this approach can be applied any new patient safety goals.
Also, sharing stories and experiences with other hospitals has been important. “If we have something that’s not working here, it’s nice to be able to ask other hospitals what they’re doing. … People are usually forthcoming with struggles that they’re having or things that work well.”
An open invitation
It’s not too late for Minnesota Hospitals to join the “On the CUSP: STOP BSI” initiative, Goeschel said.
“I’ve held the hand of people who have probably died unnecessarily. … I never forget that,” she said. “And the next time it could be your loved one or mine.”
“When we did this work in Michigan and saw the rates of infection plummet, it took our breath away,” she said. “And when we see the potential for this to happen across the country it gives me hope. It gives me hope that we really can do this.”
Kay Schwebke is a physician who recently completed a master’s degree in health journalism at the University of Minnesota School of Journalism and Mass Communication.