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Eliminating CLABSI: A National Patient Safety Imperative

Results

Project Participation

State Participation. Recruitment to the project is an ongoing process that began in fall 2008 and is continuing. Lead organizations in States were encouraged to recruit as many teams of participants as they could. The ongoing success of this program, awareness of impending CMS public reporting of CLABSI rates, and the 2011 requirement that hospitals submit CLABSI data into NHSN are encouraging additional hospitals to enroll. 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. At present, five cohorts of States are participating in the project, and a sixth is scheduled to begin in January 2011. Many States are continuing to recruit additional hospital teams to participate. As a result, some lead organizations are supporting hospital participants in one or more of the project cohorts. Figure 1 illustrates the current status of State recruitment efforts.

Figure 1 is a map of the United States, depicting State participation in the On the CUSP: Stop BSI Project. Forty-four States plus the District of Columbia and Puerto Rico have committed to participating in one of the six cohorts. Each of the 50 States on the map is shaded to indicate the cohort to which it belongs. Some States are shaded to indicate they are participating in more than one cohort.

Forty-four States plus the District of Columbia and Puerto Rico have committed to participating in one of the six cohorts. Although Michigan is not listed as a formal project participant, Michigan hospitals continue to work with the MHA Keystone Center on sustaining the exceptionally low CLABSI rates they achieved in the initial Keystone Project.3,4  The State of Washington has participated in some project activities but has not submitted any CLABSI data.

Levels of participation within States vary substantially. Table 1 provides a breakdown of the number of participating hospitals and teams by State. This table is limited to the first four project cohorts; cohorts 5 and 6 are still actively recruiting hospital participants. Because some States have a higher percentage of very small hospitals that do not have an ICU or insert central lines, some variation in the percentage of hospitals in each State that could benefit from project participation is to be expected. Alabama, Delaware, Hawaii, and Maryland all have more than 50 percent of their hospitals participating in the project.

Information detailed reflective of data entered as of October 7, 2010.

State Participating Teams5 Participating Hospitals Community Hospitals in State6 Hospital Recruitment Percentage Hospitals in State with an ICU7
AL 91 77 115 67% 68
AR 54 28 95 29% 49
CO 8 6 84 7% 42
CT 18 15 35 43% 25
DE 14 8 7 114% 6
FL 73 35 215 16% 111
GA 36 23 154 15% 79
HI 38 16 25 64% 14
IA 17 9 118 8% 75
IL 71 35 189 19% 127
IN 20 15 134 11% 86
KS 12 9 146 6% 55
KY 59 33 109 30% 58
MA 18 12 80 15% 51
MD 58 37 49 76% 43
MN 28 10 133 8% 67
MO 10 10 134 7% 87
NC 47 29 117 25% 82
NE 17 8 90 9% 25
NH 10 9 28 32% 25
NJ 53 37 80 46% 56
NV 17 8 43 19% 16
NY 29 22 191 12% 123
OH 64 57 195 29% 132
OK 17 13 135 10% 46
OR 4 4 59 7% 52
PA 45 26 197 13% 125
SC 47 22 72 31% 54
TX 43 26 520 5% 268
VA 38 23 91 25% 56
WI 79 40 132 30% 84
WV 29 20 58 34% 37

5 Teams normally represent a single unit, but some teams include personnel from multiple units.
6 The term "Community Hospitals in State" reflects those hospitals defined as "Community Hospitals" in the American Hospital Association (AHA) Annual Survey and refers to all nonfederal, short-term and long-term general acute care hospitals. The recruitment percentage is calculated based on this number. There are instances where participating hospitals are not characterized as community hospitals, and these result in a recruitment percentage greater than 100.
7 This category denotes hospitals with some form of an intensive care unit (ICU). The project is reporting this because this hospital designation accounts for the majority of project participants, as well as the majority of hospitals likely to insert central lines and to experience Central-Line Associated Blood Stream Infections (CLABSIs).

Hospital Participation. Because CLABSIs can occur in all sizes and types of hospitals in which central lines are used, this project has encouraged each State lead organization to enlist the participation of all hospitals that use central lines when recruiting. Figure 2 summarizes the participation of hospitals in this project based on their size (defined by the number of hospital beds). Percentages were based on the number of hospitals with an adult ICU of each size participating in the project divided by the total number of hospitals of each size with an adult medical or surgical ICU (based on data in the 2008 AHA Annual Survey).

Figure 2 is a bar graph indicating the percentage of participating hospitals by bed size. Percentages were based on the number of hospitals with an adult ICU of each size participating in the project divided by the total number of hospitals of each size with an adult medical or surgical ICU. As depicted by the figure, project recruitment has been strongest among hospitals with more than 400 beds and weakest among hospitals with fewer than 100 beds. Hospitals with fewer than 100 beds represented 9.8 percent of participants, hospitals with 101 to 175 beds comprised 15.8 percent of participants, hospitals with 176 to 250 beds were 19.6 percent of participants, hospitals with 251 to 325 beds were 20.6 percent of participants, hospitals with 326 to 400 beds comprised 23.5 percent of participants, and hospitals with more than 400 beds comprised 23.9 percent of participants.

Thus far, project recruitment has been strongest among hospitals with more than 400 beds, and weakest among hospitals with fewer than 100 beds. Although small hospitals insert central lines in their ICUs, the number of insertions is often very low, which perhaps has made CLABSI prevention a lower priority for these hospitals.

Figure 3 summarizes the recruitment levels for hospitals with a range of characteristics. More than 24 percent of teaching hospitals with ICUs are participating in the project. The involvement of rural referral hospitals, hospitals from the 100 largest cities, and hospitals that are part of hospital systems is slightly lower. Efforts to bolster recruitment in groups where involvement is lower are ongoing.

Figure 3 is a bar graph depicting the percentage of participating hospitals by type of hospital. Rural referral hospitals represented 15.5 percent of participants, hospitals in systems represented 16.1 percent of participants, hospitals in the country's 100 biggest cities were 16.7 percent of participants, critical-access hospitals comprised 22.4 percent of participants, and teaching hospitals comprised 24 percent of participants.

Appendix A provides a full list of all hospitals participating in the project as of January 2011. Ohio and Washington have not provided the names of participating hospitals, so those are not included. Because the number of participating hospitals continues to grow, the list of participating hospitals maintained on the project Web site at www.onthecuspstophai.org provides the best source of current information on which hospitals have chosen to participate. While the list in Appendix A and on the Web site includes every hospital that has been enrolled in the national project database, some hospitals on this list may not be continuing to submit CLABSI data or participate in scheduled project activities on a regular basis.

Unit Team Participation. Because the vast majority of central lines are placed in patients in an ICU, recruiting ICU teams has been the project's primary focus. However, some central lines are placed and maintained in non-ICU units. Thus, teams representing these units are also participating. At present, some pediatric or neonatal ICUs are participating in the project; HRET is working with other organizations that specialize in pediatric care to provide focused guidance to hospitals seeking to prevent CLABSIs in pediatric and neonatal ICUs. Figure 4 illustrates the range of units participating in the first four cohorts of the On the CUSP: Stop BSI initiative.

Figure 4 is a pie chart indicating the percentage of participants in the first four cohorts by unit type. ICUs represented 76.65 percent of participants, medical-surgical units represented 10.82 percent of participants, nonsurgical medicine units represented 2.49 percent of participants, surgery units represented 1.8 percent of participants, telemetry units represented 1.55 percent of participants, and other types of units represented 6.69 percent of participants.

More than 75 percent of units participating in the project thus far are ICUs, with a substantial majority of the ICUs consisting of adult medical/surgical ICUs.

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Project Impact

While participation of hospitals is critical, the ultimate measure of success is the reduction of CLABSI rates.8 Table 2 summarizes CLABSI rates at baseline and in each of the four measurement periods following the inception of the project.

Cohorts 1 & 2 with units reporting during any of the five time periods

Information detailed reflective of data entered as of October 7, 2010.

  Baseline

12 months prior to intervention
Period 1

Months 1-3 post intervention
Period 2

Months 4-6 post intervention
Period 3

Months 7-9 post intervention
Period 4

Months 10-15 post intervention
Number of States 20 20 20 20 20
Number of units reporting 384 436 435 434 402
Average CLABSIs/unit 3.12 0.93 0.72 0.65 0.64
Average CL days/unit 1680 510 508 507 556
Average BSI rate 1.80 1.64 1.31 1.14 1.17
95% confidence interval (1.53, 2.08) (1.39, 1.89) (1.09, 1.53) (0.94, 1.35) (0.89, 1.44)
Change from baseline* NA -0.19 -0.53 -0.61 -0.59
95% confidence interval   (-0.58, 0.20) (-0.89,-0.17) (-0.97,-0.25) (-1.01,-0.17)

* Based on unpaired comparison of unit rates between time periods.

For all adult ICUs participating in the first two project cohorts, rates have dropped from an average of 1.8 infections per 1,000 central line days to 1.17 infections per 1,000 central line days, an overall relative reduction of 35 percent. Because mean CLABSI rates can be distorted by one or more units with very high rates, it is useful to examine both mean and median CLABSI rates. Figure 5 illustrates the changes in mean and median CLABSI rates across the data reporting periods. More than half of all participating units reported zero CLABSIs in each reporting period since they began participating in the project. Working to assist units that have not achieved this rate remains a top project priority.

Figure 5 illustrates the changes in mean and median CLABSI rates across the four reporting periods. The mean rate at baseline was 1.8 CLABSIs, and it steadily declined through the four reporting periods to slightly less than 1.2 CLABSIs. The median CLABSI rate was 1.2 at baseline and declined to zero during the four reporting periods.

Table 2 and Figure 5 include data from all units that reported data in each of the measurement periods. It is possible that the worst performing units at baseline simply failed to report data during later time periods, leading to an artificial drop in the rates. To rule out this possibility, the same analysis was performed using only units that reported data at baseline and in each subsequent reporting period. Table 3 presents these results, which are very similar.

Cohorts 1 & 2 with units reporting during all of the five time periods

Information detailed reflective of data entered as of October 7, 2010.

  Baseline

12 months prior to intervention
Period 1

Months 1-3 post intervention
Period 2

Months 4-6 post intervention
Period 3

Months 7-9 post intervention
Period 4

Months 10-15 post intervention
Number of States 20 20 20 20 20
Number of units reporting 349 349 349 349 349
Average CLABSIs/unit 3.20 0.83 0.69 0.67 0.66
Average CL days/unit 1736 499 502 518 598
Average BSI rate 1.76 1.65 1.31 1.22 1.21
95% confidence interval (1.51, 2.01) (1.36, 1.93) (1.07, 1.55) (0.98, 1.45) (0.90, 1.52)
Change from baseline* NA -0.11 -0.45 -0.54 -0.55
95% confidence interval   (-0.44, 0.22) (-0.77,-0.13) (-0.83,-0.26) (-0.93,-0.17)

* Based on paired comparison of unit rates between time periods.

Overall, rates decreased in the units with complete data by 31 percent, from 1.76 to 1.21 CLABSIs per 1,000 central line days, indicating that the CLABSI rate reductions observed in project participants cannot be attributed to missing data. One of the more surprising findings in this data is the relatively low baseline CLABSI rates. Alternative explanations for these low rates are being examined. However, we do not believe that only hospitals with good rates are participating in the project.

The other data concern is the accuracy of self-reported CLABSI rates. Data validation is not included in the scope of the project at this point. However, data submitted directly into our national project database is subject to more screens for accuracy than is currently the case for data submitted into NHSN. The national project team is continuing to work with AHRQ and CDC to explore the issue of validation.


3 Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006 Dec 28;355(26):2725-2732.

4 Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reductions in catheter-related bloodstream infections in Michigan intensive care units: an observational study. BMJ 2010 Feb 4;340:c309.

8 A second stated project goal is the improvement in safety culture in participating units.�Significant and sustained improvement in a clinical outcome such as CLABSI requires a culture where all staff understand and can be held accountable for ensuring the safety of patients.�To assess progress in culture change, participating units are asked to complete the AHRQ Safety Culture survey at the start and end of the project. Results of these administrations of the survey will be reported when they become available.


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Page last reviewed October 2014
Page originally created September 2012
Internet Citation: Results. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/professionals/quality-patient-safety/cusp/onthecusprpt/onthecusp4.html

 

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