Hospitals Slow to Adopt Infection Prevention Program

A simple checklist could help prevent errors, even deaths, in the ICU

November 3, 2010, 3:18 PM

Nov. 5, 2010— -- It's a common procedure in any intensive care unit.

Doctors insert into patients what is called a central line, which can be used to administer vital medications while monitoring various critical elements within the heart and blood.

But a Centers for Disease Control and Prevention estimate shows that 250,000 patients with central lines contract blood stream infections every year, and more than 10 percent die as a result. The study, conducted in 2002, is the CDC's most current figure.

A doctor at Johns Hopkins University says these deaths can be eliminated — at virtually no extra cost and with little additional training. Moreover, a program exists that promises to do just that, but almost two years after its inception, only a fraction of hospitals choose to participate.

"In what other industry, would there be a known safety standard — and nobody's debating the evidence — that a failure to comply with kills people," Dr. Peter Pronovost, medical director for the Center for Innovation in Quality Patient Care at Johns Hopkins, told

Pronovost, a practicing anesthesiologist and critical care physician, believes these infections can be eliminated with a program he developed. But, he said, progress is too slow.

Central line catheters are nonsurgical yet invasive procedures that involve snaking a small tube into a large vein, usually in the neck, of critically ill patients.

"You don't just willy-nilly put a central line in everybody in the ICU," said Nancy Exstrom, a registered nurse and clinical educator in critical care services at St. Elizabeth Regional Medical Center in Lincoln, Neb. "But the sick ones need it and it saves their lives."

Yet the use of central lines carries the tangible risk of infection — which usually leads to extra days in the hospital and increased costs, and sometimes death.

Early last year, Pronovost set out to eliminate those infections. He created a program called On the CUSP: Stop BSI (Comprehensive Unit-Based Safety Program to reduce Central-Line Blood Stream Infections in the ICU) in concert with Johns Hopkins, the Health Research and Educational Trust (an affiliate of the American Hospital Association), and the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality.

At its core, the CUSP program is a three-pronged approach to central lines. First, it establishes a simple, five-point checklist. Second — and perhaps most importantly — it also transforms the top-down hierarchal structure that often prevails in hospitals and clinics. The third and final element involves keeping meticulous records and data on infection rates.

The checklist itself is quite simple:

• Wash your hands with soap.

• Wear a cap, gown and gloves.

• Drape the entire patient in sterile sheets.

• Sterilize the patient's skin with chlorhexadine, an antimicrobial and antiseptic soap, and avoid inserting into the groin when possible.

• Finally, remove the catheter when it is no longer necessary.

Currently, 18 percent of the 5,815 nationally registered hospitals participate in the program. While many of the hospitals that don't participate are likely to be in small communities where central line procedures are uncommon, that still leaves a large number of hospitals that have elected not to join the program — a fact that troubles Pronovost.

"In some states only 20 percent are joining up for our effort," he said. "Twenty percent. And it's free."

Hospitals that forego the program often cite three common reasons. They claim to have already low or unverifiable infection rates, or they already follow the most basic component of the system — the checklist.

The third explanation for low participation is that there are other programs that aim to eliminate blood stream infections.

In May, the CDC issued a report that showed an 18 percent drop in blood stream infections among the 17 states that require hospitals to report their rates of infection.

"I would say if there is a reluctance to sign up it's not because people are reluctant in improving care," said John Combes, vice president at the American Hospital Association. "It's because people are engaged or busy in using other methods to improve care."

Combes also served as the president of the Health Research and Educational Trust when it launched the CUSP program.

But Pronovost believes similar methods don't yield the same results. Where the CUSP program differs from the others, is that it goes beyond the simple checklist. It attempts to address what Pronovost believes to be a core problem within healthcare — a hierarchal structure that places the physician at the top.

"Thinking [lowered rates are] just due to a checklist — as if a checklist is Harry Potter's wand — is naïve," Pronovost said. "What we found is that without measuring results and without culture change for the teamwork piece, it doesn't work."

His program alters that culture structure. It places the responsibility of patient care in everyone's hands, enabling nurses and others to speak up when a physician is tempted to take a shortcut. In essence, a physician would be compelled to put on a cap, gown or mask when a nurse demands it.

"Because if you don't have a culture that supports that nurse, that checklist is not going to get used properly, it's going to get violated," said Dr. Bradford Winters, assistant professor at Johns Hopkins and faculty lead for the CUSP project.

Empowering the nursing staff and others with the ability to stop a procedure was one of the critical elements that led to stunning results for a 2003 Michigan study conducted by Pronovost. Commonly known as the Keystone Project, the Michigan study revealed that ICUs could eliminate central line infections, and served as blueprint for the larger CUSP program.

The study was groundbreaking in that it completely changed how many in the medical field viewed infections caused by central lines, said Dr. David Gannon, critical care medical director at the Nebraska Medical Center in Omaha.

"What the Pronovost study showed us is that getting an infection after a central line is a medical error," he said. "And that's a term that makes doctors shudder, and it should."

And an error, Gannon added, "means it was preventable."

"I Almost Caused World War III"

But Pronovost discovered that he could not achieve total success with his checklist until he added a critical component. As compliance to the checklist lingered around 70 percent, he realized that he needed to empower the nursing staff in Michigan ICUs with almost supervisory abilities over the physicians. When doctors attempted to skip a step in the checklist, nurses were not inclined to tell them to stop. Either nurses feared the potential fallout from telling doctors how to do their jobs or didn't believe they would even listen in the first place.

Even if nurses did speak up, they often didn't have the needed support and encouragement from administration to act as a check on the doctors.

So Pronovost gave that power to the nurses.

"That was heretical," Pronovost said. "I mean, I almost caused World War III getting the nurses to do that."

Earlier this year, six hospitals in Nebraska began participating in CUSP.

Nancy Exstrom, who's been a registered nurse for 28 years, said the change in culture is dramatic compared with her early days in the field. But even today she sometimes encounters resistance.

"What was difficult was somebody like me being an educator, talking to all these doctors, and telling them, really, kind of how they need to start practicing differently," she said. "They don't like hearing that from a nurse."

Even Pronovost, listed as one of Time Magazine's 100 most influential people of 2008, admitted his own early reluctance to take guidance from nurses.

"We as physicians need to recalibrate our view of teamwork," he said. "I graduated from medical school here believing good teamwork was, I give an order and the nurse follows it."

Until that culture changes, it will be difficult to stop the kind of preventable infections the CUSP initiative proposes to eliminate, said Dr. Marcel Devetten, chief quality officer at the Nebraska Medical Center in Omaha which has also enlisted in the program.

"Most studies have shown that the crucial factor in almost every serious adverse patient outcome is a lack of communication," Devetten said. "It's frustrating because this has been known for a long time, and we haven't been able to fix it." contributor Charlie Litton is a member of the ABC News on Campus bureau in Lincoln, Neb.

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