An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU
Peter Pronovost, M.D., Ph.D., Dale Needham, M.D., Ph.D., Sean Berenholtz, M.D., David Sinopoli, M.P.H., M.B.A., Haitao Chu, M.D., Ph.D., Sara Cosgrove, M.D., Bryan Sexton, Ph.D., Robert Hyzy, M.D., Robert Welsh, M.D., Gary Roth, M.D., Joseph Bander, M.D., John Kepros, M.D., and Christine Goeschel, R.N., M.P.A.
Background Catheter-related bloodstream infections occurringin the intensive care unit (ICU) are common, costly, and potentiallylethal.
Methods We conducted a collaborative cohort study predominantlyin ICUs in Michigan. An evidence-based intervention was usedto reduce the incidence of catheter-related bloodstream infections.Multilevel Poisson regression modeling was used to compare infectionrates before, during, and up to 18 months after implementationof the study intervention. Rates of infection per 1000 catheter-dayswere measured at 3-month intervals, according to the guidelinesof the National Nosocomial Infections Surveillance System.
Results A total of 108 ICUs agreed to participate in the study,and 103 reported data. The analysis included 1981 ICU-monthsof data and 375,757 catheter-days. The median rate of catheter-relatedbloodstream infection per 1000 catheter-days decreased from2.7 infections at baseline to 0 at 3 months after implementationof the study intervention (P0.002), and the mean rate per 1000catheter-days decreased from 7.7 at baseline to 1.4 at 16 to18 months of follow-up (P<0.002). The regression model showeda significant decrease in infection rates from baseline, withincidence-rate ratios continuously decreasing from 0.62 (95%confidence interval [CI], 0.47 to 0.81) at 0 to 3 months afterimplementation of the intervention to 0.34 (95% CI, 0.23 to0.50) at 16 to 18 months.
Conclusions An evidence-based intervention resulted in a largeand sustained reduction (up to 66%) in rates of catheter-relatedbloodstream infection that was maintained throughout the 18-monthstudy period.
Catheter-related bloodstream infections are common, costly,and potentially lethal.1,2 Each year in the United States, centralvenous catheters may cause an estimated 80,000 catheter-relatedbloodstream infections and, as a result, up to 28,000 deathsamong patients in intensive care units (ICUs). Given that theaverage cost of care for a patient with this infection is $45,000,3such infections could cost up to $2.3 billion annually. Accordingto the National Nosocomial Infections Surveillance (NNIS) systemof the Centers for Disease Control and Prevention (CDC), themedian rate of catheter-related bloodstream infection in ICUsof all types ranges from 1.8 to 5.2 per 1000 catheter-days.3,4Interventions aimed at decreasing the infection rate are neededto reduce the serious public health consequences of this hospital-acquiredinfection.
How many of these infections are preventable is unknown. Severalsingle-hospital studies and two multicenter studies have shownreductions in the rates of catheter-related bloodstream infection.5,6,7,8,9,10,11,12To build on this research, we studied the extent to which theseinfections could be reduced in Michigan, using an interventionas part of a statewide safety initiative regarding patientsin ICUs, known as the Michigan Health and Hospital Association(MHA) Keystone Center for Patient Safety and Quality KeystoneICU project, which was funded predominantly by the Agency forHealthcare Research and Quality (AHRQ). The objective of thestudy was to evaluate the effect of the intervention up to 18months after its implementation.
Methods
The Intervention
All Michigan hospitals with ICUs for adults were invited toparticipate in the Keystone ICU project, launched in October2003. Hospitals were not asked to provide reasons for not participating.Five out-of-state hospitals of a health system with its corporateheadquarters in Michigan participated at the request of thesenior executive of the health system. Between March 2004 andSeptember 2005, each ICU implemented several patient-safetyinterventions, according to a prospective cohort study design,and monitored the effect of these interventions on specificsafety measures.
In addition to the intervention to reduce the rate of catheter-relatedbloodstream infection, the ICUs implemented the use of a dailygoals sheet to improve clinician-to-clinician communicationwithin the ICU,13 an intervention to reduce the incidence ofventilator-associated pneumonia,14 and a comprehensive unit-basedsafety program to improve the safety culture.15,16 The periodnecessary for implementation of each intervention was estimatedto be 3 months. Hospitals started with implementation of theunit-based safety program and use of the daily goals sheet andthen, in any order, implemented the other two interventionsduring the subsequent 6 months.
Before implementing any of the components of the study intervention,the ICUs were asked to designate at least one physician andone nurse as team leaders.17 The team leaders were instructedin the science of safety and in the interventions and then disseminatedthis information among their colleagues. Training of the teamleaders was accomplished through conference calls every otherweek, coaching by research staff, and statewide meetings twicea year. The teams received supporting information on the efficacyof each component of the intervention, suggestions for implementingit, and instruction in methods of data collection (describedin detail in Appendix A of the Supplementary Appendix, availablewith the full text of this article at www.nejm.org). Team leaderswere partnered with their local hospital-based infection-controlpractitioners to assist in the implementation of the interventionand to obtain data on catheter-related bloodstream infectionsat the hospital.
The study intervention targeted clinicians' use of five evidence-basedprocedures recommended by the CDC and identified as having thegreatest effect on the rate of catheter-related bloodstreaminfection and the lowest barriers to implementation.1 The recommendedprocedures are hand washing, using full-barrier precautionsduring the insertion of central venous catheters, cleaning theskin with chlorhexidine, avoiding the femoral site if possible,and removing unnecessary catheters.
Strategies to increase the use of these procedures have beendescribed elsewhere.10 Briefly, clinicians were educated aboutpractices to control infection and harm resulting from catheter-relatedbloodstream infections, a central-line cart with necessary supplieswas created, a checklist was used to ensure adherence to infection-controlpractices, providers were stopped (in nonemergency situations)if these practices were not being followed, the removal of catheterswas discussed at daily rounds, and the teams received feedbackregarding the number and rates of catheter-related bloodstreaminfection at monthly and quarterly meetings, respectively. InApril 2004, a letter and a baseline survey were sent to thechief executive officers (CEOs) of the participating hospitals.The letter outlined the evidence supporting the use of chlorhexidine1and asked the CEOs to stock chlorhexidine in their hospitalsbefore implementing the study intervention.
Measurement and Categorization of Data
Throughout the study, data on the number of catheter-relatedbloodstream infections and catheter-days were collected monthlyfrom a trained, hospital-based infection-control practitioner.Hospitals were given the NNIS definition of catheter-relatedbloodstream infection (Figure 1). Study investigators askedmembers of the teams to adhere to the NNIS definition of catheter-relatedbloodstream infection during the study period. Three ICUs changedthe definition used from their own to that of the NNIS. Infection-controlstaff at the hospitals adjudicated contaminated cultures beforesubmitting data for the study. We defined a central catheteras a catheter that ends at or near the heart or in a great vesselclose to the heart, which included peripherally inserted centralcatheters, and the teams were explicitly instructed to countthe use of multiple lines in one patient as 1 catheter-day,in accordance with the NNIS guidelines. To simplify data collection,the average duration of catheter use in individual patientswas not monitored.
Figure 1. Catheter-Related Bloodstream Infections in Adults, as Defined by the National Nosocomial Infections Surveillance System.
To coincide with the implementation periods for the study intervention,monthly data were aggregated into 3-month periods (quarters).The quarterly rate of infection was calculated as the numberof infections per 1000 catheter-days for each 3-month period.Quarterly rates were assigned to one of eight categories onthe basis of when the study intervention was implemented: atbaseline, during the implementation period, or during one ofsix 3-month intervals occurring up to 18 months after implementation.We did not collect data on who inserted the central catheters.To our knowledge, no other infection-reducing practices wereimplemented during our study.
Exposure, Outcomes, and Study Hypotheses
We modeled exposure to the study intervention, after full implemention,according to six categorical temporal variables, comparing valuesfor those variables with baseline values. The outcome was thequarterly rate of catheter-related bloodstream infection. Theanalysis included three characteristics of the hospitals, obtainedfrom the American Hospital Association database: teaching status(a binary variable), bed size (a continuous variable), and geographicregion (eight categories). Teaching hospitals were requiredto be members of the Council of Teaching Hospitals Health Systemsand to have been approved for residency training by the AccreditationCouncil for Graduate Medical Education or the American OsteopathicAssociation. The primary study hypothesis was that the rateof catheter-related bloodstream infection would be reduced duringthe first 3 months after implementation of the study interventionas compared with baseline. A secondary hypothesis was that theobserved decrease in the rate of infection between 0 and 3 monthsafter implementation of the study intervention would be sustainedduring the subsequent observation period. We did not evaluatethe relative effectiveness of the separate components of theintervention.
Statistical Analysis
Because of the nonnormal distribution of the data on catheter-relatedbloodstream infections, medians and interquartile ranges wereused to summarize the data. Medians were compared with baselinevalues with the use of a two-sample Wilcoxon rank-sum test.To explore the exposure–outcome relationship, we useda generalized linear latent and mixed model18,19 with a Poissondistribution for the quarterly number of catheter-related bloodstreaminfections. In the model, we used robust variance estimationand included two-level random effects to account for nestedclustering within the data, catheter-related bloodstream infectionswithin hospitals, and hospitals within the geographic regionsincluded in the study.18,20 The addition of a third level ofclustering for a potential ICU effect (catheter-related bloodstreaminfections within ICUs, ICUs within hospitals, and hospitalswithin the geographic regions) did not change the results. Weadjusted for the hospital's teaching status and bed size inthe model and explored interactions between the effect of thestudy intervention (modeled as a continuous variable) and teachingstatus and bed size. We conducted a sensitivity analysis ofthese results in which only ICUs with continuous data, includingbaseline (preimplementation) data, were included. All reportedP values are two-sided; a P value of 0.05 or less was consideredto indicate statistical significance. We used Stata software(version 9.1) for the analysis. The study was approved by theinstitutional review board of Johns Hopkins University Schoolof Medicine. Informed consent was waived because the study wasconsidered exempt from review.
The AHRQ provided financial support for the Keystone ICU projectbut had no role in the design or conduct of the study; the collection,management, analysis, or interpretation of the data; the preparation,review, or approval of the manuscript; or the decision to submitthe manuscript for publication. The MHA provided support forthe biannual statewide meetings but had no influence on thedesign, implementation, analysis, or results of the study. Theauthors had full access to the data and vouch for the accuracyand completeness of the data and the analysis.
Results
Five of 108 participating ICUs were excluded: 4 because theydid not track or report catheter-related bloodstream infections,catheter-days, or both, and 1 because it merged with anotherparticipating ICU, so that the combined data were used in theanalysis. The data were obtained from 67 hospitals, of which52% were teaching facilities. The types of ICU included medical,surgical, cardiac medical or surgical, neurologic, and surgicaltrauma units and one pediatric unit. The ICUs represented 1625(85%) of all ICU beds in Michigan. Of 34 hospitals in Michiganthat did not participate in the study, 27 (79%) had fewer than100 beds; the total number of beds in the ICUs not includedin the study was 268.
Thus, 103 ICUs reporting data for 1981 ICU-months and 375,757catheter-days were included in the final analysis. The characteristicsof the ICUs according to the study period are summarized inTable 1. Baseline data on catheter-related bloodstream infectionsat the participating ICUs are summarized in Table 2, accordingto the teaching status and bed size of the hospitals. When theKeystone ICU project was launched, 13 of the 67 hospitals (19%)included chlorhexidine in the central-line kits used in theICUs. Six weeks after the study letter was sent to CEOs at the67 participating hospitals, 56 (84%) stocked chlorhexidine,46 (69%) stocked the agent in the ICU, and 43 (64%) stockedit in central-line carts.
Table 1. Characteristics of 103 Participating ICUs, According to the Period of Implementation of the Intervention to Reduce the Rate of Catheter-Related Bloodstream Infections.
The total number of catheter-days changed little during thestudy. In ICUs that implemented the study intervention duringthe 3 months (June to August 2004) after baseline data werecollected (Table 1), the mean number of catheter-days per monthwas 4779. During the follow-up period, the mean number of catheter-daysper month ranged from 4757 at 4 to 6 months after implementationof the intervention to 5469 at 10 to 12 months after implementation.
The overall median rate of catheter-related bloodstream infectiondecreased from 2.7 (mean, 7.7) infections per 1000 catheter-daysat baseline to 0 (mean, 2.3) at 0 to 3 months after implementationof the study intervention (P0.002) and was sustained at 0 (mean,1.4) during 18 months of follow-up (Table 3). A significantdecrease was observed in both teaching and nonteaching hospitalsand in small hospitals (<200 beds) and large hospitals (200beds) (Table 3).
Table 3. Rates of Catheter-Related Bloodstream Infection from Baseline (before Implementation of the Study Intervention) to 18 Months of Follow-up.
The multilevel Poisson regression model showed a significantdecrease in rates of catheter-related bloodstream infectionduring all study periods as compared with baseline rates, withincidence-rate ratios continuously decreasing from 0.62 (95%confidence interval [CI], 0.47 to 0.81) at 0 to 3 months to0.34 (95% CI, 0.23 to 0.50) at 16 to 18 months after implementationof the study intervention (Table 4). There was a significantinteraction between the intervention and bed size: the interventionwas modestly more effective in small hospitals, with an incidence-rateratio of 0.97 (95% CI, 0.96 to 0.99; P<0.001) for each 100-beddecrease in the size of the hospital. The results of a sensitivityanalysis of data from the 53 ICUs reporting data continuouslyfrom baseline onward were similar to those of the primary analysis,with incidence-rate ratios decreasing from 0.62 (95% CI, 0.46to 0.85) at 0 to 3 months to 0.15 (95% CI, 0.07 to 0.32) at16 to 18 months of follow-up.
Table 4. Incidence-Rate Ratios for Catheter-Related Bloodstream Infections.
Discussion
The goal of the MHA Keystone ICU project was to improve patientsafety in ICUs in Michigan. The analysis was focused on an interventionto reduce the rate of catheter-related bloodstream infectionthat was implemented in 103 ICUs in Michigan in 2004. Within3 months after implementation, the median rate of infectionwas 0, a rate sustained throughout the remaining 15 months offollow-up. All types of participating hospitals realized a similarimprovement.
This study showed that a large-scale project focused on reducingthe incidence of catheter-related bloodstream infection is feasibleand can have important public health consequences. Current effortsto improve patient safety in the United States are fragmented,with few large-scale improvements documented.21,22,23 The abilityto measure and evaluate the effect of interventions to increasepatient safety is still underdeveloped.21,24 In this project,monitoring catheter-related bloodstream infection rates waspossible because of the existence of an infrastructure —specifically, congressional funding to develop and maintainthe NNIS and a staff of hospital-based infection-control practitioners.Similar infrastructure does not exist for most other issuesrelated to patient safety.
Important reductions in morbidity and health care costs couldbe achieved if the intervention to reduce catheter-related bloodstreaminfections could be introduced successfully nationwide or worldwide.Given the results of the study, many of the estimated 80,000infections, up to 28,000 deaths, and $2.3 billion in costs attributedto these infections annually in the United States could be reduced.The intervention was implemented without the use of expensivetechnology or additional ICU staffing. However, the MHA andAHRQ funded this intervention, and the participating hospitalsprovided staff to implement it. The estimated costs associatedwith catheter-related bloodstream infections vary, ranging from$11,971 to $54,000 per infection.3,25 Given that the participatingICUs had reported 695 catheter-related bloodstream infectionsannually before the study, implementing the study interventionoffers a strategy to improve clinical outcomes and reduce costs.
The study has several limitations. First, the design reducesthe ability to make a causal connection between the interventionand reduced rates of catheter-related bloodstream infection.Randomized assignment of the intervention and of the time ofimplementation was not feasible, because all the ICU teams wantedto implement the intervention and to decide for themselves whento do so. However, several factors support a true and strongassociation between the intervention and a reduction in ratesof catheter-related bloodstream infection: variability in thetiming of implementation reduced any effect of seasonal trendon the baseline rates of infection, reduced infection rateswere sustained and fell further with continued exposure to theintervention, and similar large decreases in infection rateswere not observed outside Michigan during the study period.
Second, potential underreporting of catheter-related bloodstreaminfections and the lack of baseline data from ICUs that immediatelyimplemented the intervention when the project was launched couldhave created a measurement bias that exaggerated the results.However, the infection rates were collected and reported accordingto the guidelines of the NNIS by hospital infection-controlpractitioners who were independent of the ICU staff implementingthe intervention. Furthermore, a sensitivity analysis showedlittle change in the association between the intervention andoutcomes when only ICUs for which complete data (including baselinedata) were available were included.
Third, data on the organisms causing catheter-related bloodstreaminfections were not collected, limiting insight into the mechanismof the observed benefit. Fourth, we did not evaluate compliancewith the study intervention, because limited resources preventedobservation of central-line placements. Fifth, we could notevaluate the relative importance of individual components ofthe multifaceted intervention or of the safety-culture intervention.However, our goal was maximal improvement of patient safety,and the study program offered the greatest probability of reducingcatheter-related bloodstream infections. Sixth, we did not obtaindata on catheter-related bloodstream infection rates from nonparticipatingICUs. Nevertheless, the ICUs that participated in the studyaccounted for 85% of ICU beds in Michigan. Last, we studiedICUs in only one state, which may limit the ability to generalizeour findings. Nevertheless, a wide variety of types of hospitaland ICU were studied.
In summary, catheter-related bloodstream infections are expensive,prevalent, and often fatal. As part of the Michigan statewidepatient-safety initiative, we implemented a simple and inexpensiveintervention to reduce these infections in 103 ICUs. Coincidentwith the intervention, the median rate of infection decreasedfrom 2.7 per 1000 catheter-days at baseline to 0 within thefirst 3 months after the implementation of the intervention.The benefit from the intervention was sustained, and there wasa reduction in the rate of catheter-related bloodstream infectionof 66% at 16 to 18 months after implementation. Broad use ofthis intervention could significantly reduce morbidity and thecosts of care associated with catheter-related bloodstream infections.
Supported by a grant from the AHRQ (1UC1HS14246) for the KeystoneICU project.
Dr. Pronovost reports receiving consulting fees from CriticalMedand DocuSys and holding equity ownership in DocuSys and Visicu;Dr. Berenholtz, receiving consulting fees from VHA; Dr. Cosgrove,receiving grant support from Merck, receiving consulting feesfrom Cubist Pharmaceuticals, and being a member of an advisoryboard for Ortho-McNeil; Dr. Hyzy, receiving lecture fees fromEli Lilly and Wyeth; and Dr. Bander, receiving consulting feesand lecture fees from Eli Lilly, Elan Pharmaceuticals, and theSurviving Sepsis Campaign. No other potential conflict of interestrelevant to this article was reported.
We thank C.G. Holzmueller for assistance in editing; P. Lipsettand T. Perl for thoughtful review of a draft of the manuscript;and the MHA Keystone Center and all the ICU teams in Michiganfor their tremendous efforts, leadership, and courage and theirdedication to improving the quality of the care and safety oftheir patients. (For a list of the participating hospitals,see Appendix B in the Supplementary Appendix.)
Source Information
From the School of Medicine (P.P., D.N., S.B., S.C., B.S.), the School of Professional Studies in Business and Education (D.S.), and the Bloomberg School of Public Health (H.C.), Johns Hopkins University, Baltimore; and the University of Michigan, Ann Arbor (R.H.); William Beaumont Hospital, Royal Oak (R.W.); Ingham Regional Medical Center, Lansing (G.R.); Harper University Hospital, Detroit (J.B.); Sparrow Health System, Lansing (J.K.); and the Michigan Health and Hospital Association Keystone Center for Patient Safety and Quality, Lansing (C.G.) — all in Michigan.
References
Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med 2000;132:391-402. [Erratum, Ann Intern Med 2000;133:5.] [Free Full Text]
Burke JP. Infection control -- a problem for patient safety. N Engl J Med 2003;348:651-656. [Free Full Text]
O'Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. MMWR Recomm Rep 2002;51:1-29. [Medline]
National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) System report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 2004;32:470-485. [CrossRef][Web of Science][Medline]
Warren DK, Zack JE, Mayfield JL, et al. The effect of an education program on the incidence of central venous catheter-associated bloodstream infection in a medical ICU. Chest 2004;126:1612-1618. [CrossRef][Web of Science][Medline]
Sherertz RJ, Ely EW, Westbrook DM, et al. Education of physicians-in-training can decrease the risk for vascular catheter infection. Ann Intern Med 2000;132:641-648. [Free Full Text]
Eggimann P, Harbarth S, Constantin MN, Touveneau S, Chevrolet JC, Pittet D. Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care. Lancet 2000;355:1864-1868. [CrossRef][Web of Science][Medline]
Cohran J, Larson E, Roach H, Blane C, Pierce P. Effect of intravascular surveillance and education program on rates of nosocomial bloodstream infections. Heart Lung 1996;25:161-164. [CrossRef][Web of Science][Medline]
Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32:2014-2020. [CrossRef][Web of Science][Medline]
Reduction in central line-associated bloodstream infections among patients in intensive care units -- Pennsylvania, April 2001-March 2005. MMWR Morb Mortal Wkly Rep 2005;54:1013-1016. [Medline]
Warren DK, Cosgrove SE, Deikema DJ, et al. A multicenter intervention to prevent catheter-associated bloodstream infections. Infect Control Hosp Epidemiol 2006;27:662-669. [CrossRef][Medline]
Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care 2003;18:71-75. [CrossRef][Web of Science][Medline]
Berenholtz SM, Milanovich S, Faircloth A, et al. Improving care for the ventilated patient. Jt Comm J Qual Saf 2004;30:195-204. [Medline]
Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a comprehensive unit-based safety program. J Patient Saf 2005;1:33-40.
Pronovost PJ, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: a model for safety improvement. Jt Comm J Qual Saf 2004;30:59-68. [Medline]
Pronovost P, Goeschel C. Improving ICU care: it takes a team. Healthc Exec 2005;20:14-6, 18, 20 passim. [Medline]
Rabe-Hesketh S, Skrondal A. Multilevel and longitudinal modeling using Stata. College Station, TX: Stata Press, 2005.
Skrondal A, Rabe-Hesketh S. Generalized latent variable modeling: multilevel, longitudinal, and structural equation models. Boca Raton, FL: Chapman & Hall/CRC, 2004.
Panageas KS, Schrag D, Riedel E, Bach PB, Begg CB. The effect of clustering of outcomes on the association of procedure volume and surgical outcomes. Ann Intern Med 2003;139:658-665. [Free Full Text]
Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA 2005;293:2384-2390. [Free Full Text]
Altman DE, Clancy C, Blendon RJ. Improving patient safety -- five years after the IOM report. N Engl J Med 2004;351:2041-2043. [Free Full Text]
Wachter R. The end of the beginning: patient safety five years after `To Err Is Human.' Health Aff (Millwood) 2004;23:Suppl 2 Web Exclusives:W4-534.
Brennan TA, Gawande A, Thomas E, Studdert D. Accidental deaths, saved lives, and improved quality. N Engl J Med 2005;353:1405-1409. [Free Full Text]
Warren DK, Quadir WW, Hollenbeak CS, Elward AM, Cox MJ, Fraser VJ. Attributable cost of catheter-associated bloodstream infections among intensive care patients in a nonteaching hospital. Crit Care Med 2006;34:2084-2089. [CrossRef][Web of Science][Medline]
Pronovost, P. J, Goeschel, C. A, Colantuoni, E., Watson, S., Lubomski, L. H, Berenholtz, S. M, Thompson, D. A, Sinopoli, D. J, Cosgrove, S., Sexton, J B., Marsteller, J. A, Hyzy, R. C, Welsh, R., Posa, P., Schumacher, K., Needham, D.
(2010). Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ
340: c309-c309
[Abstract][Full Text]
Goldman, B., Dixon, L. B., Adler, D. A., Berlant, J., Dulit, R. A., Hackman, A., Oslin, D. W., Siris, S. G., Valenstein, M.
(2010). Rational Protection of Subjects in Research and Quality Improvement Activities. Psychiatr. Serv.
61: 180-183
[Abstract][Full Text]
Miller, M. R., Griswold, M., Harris, J. M. II, Yenokyan, G., Huskins, W. C., Moss, M., Rice, T. B., Ridling, D., Campbell, D., Margolis, P., Muething, S., Brilli, R. J.
(2010). Decreasing PICU Catheter-Associated Bloodstream Infections: NACHRI's Quality Transformation Efforts. Pediatrics
125: 206-213
[Abstract][Full Text]
Loewy, J. V.
(2010). Influential Commentary: Outbreak, Pandemic and Medical Response. Music and Medicine
2: 5-9
[Full Text]
Clarke, J.
(2010). Patient Safety First: supporting improvements in infection prevention. British Journal of Infection Control
11: 2-5
Hota, B., Lin, M., Doherty, J. A, Borlawsky, T., Woeltje, K., Stevenson, K., Khan, Y., Young, J., Weinstein, R. A, Trick, W., for the CDC Prevention Epicenter Program,
(2010). Formulation of a model for automating infection surveillance: algorithmic detection of central-line associated bloodstream infection. J Am Med Inform Assoc
17: 42-48
[Abstract][Full Text]
Thomas, E. J., Lucke, J. F., Wueste, L., Weavind, L., Patel, B.
(2009). Association of Telemedicine for Remote Monitoring of Intensive Care Patients With Mortality, Complications, and Length of Stay. JAMA
302: 2671-2678
[Abstract][Full Text]
Davidoff, F.
(2009). Heterogeneity Is Not Always Noise: Lessons From Improvement. JAMA
302: 2580-2586
[Abstract][Full Text]
Lyles, A., Fanikos, J., Jewell, K.
(2009). Aligning pharmacy and health-system objectives to eliminate central-line-associated bacteremias. Am J Health Syst Pharm
66: 2189-2197
[Full Text]
Saint, S, Conti, A, Bartoloni, A, Virgili, G, Mannelli, F, Fumagalli, S, di Martino, P, Conti, A A, Kaufman, S R, Rogers, M A M, Gensini, G F
(2009). Improving healthcare worker hand hygiene adherence before patient contact: a before-and-after five-unit multimodal intervention in Tuscany. Qual Saf Health Care
18: 429-433
[Abstract][Full Text]
Jacobson, J. O., Polovich, M., McNiff, K. K., LeFebvre, K. B., Cummings, C., Galioto, M., Bonelli, K. R., McCorkle, M. R.
(2009). American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards. JCO
27: 5469-5475
[Abstract][Full Text]
Schneider, E. C.
(2009). Improving the Quality of Cancer Care: Crossroads or Convergence?. J Oncol Pract
5: 284-286
[Full Text]
Clancy, C. M.
(2009). The Canary's Warning: Why Infections Matter. American Journal of Medical Quality
24: 462-464
Clancy, C. M.
(2009). Ten Years After To Err Is Human. American Journal of Medical Quality
24: 525-528
Wachter, R. M., Pronovost, P. J.
(2009). Balancing "No Blame" with Accountability in Patient Safety. NEJM
361: 1401-1406
[Full Text]
Eisen, L. A., Savel, R. H.
(2009). What Went Right: Lessons for the Intensivist From the Crew of US Airways Flight 1549. Chest
136: 910-917
[Abstract][Full Text]
Jha, A. K., Chan, D. C., Ridgway, A. B., Franz, C., Bates, D. W.
(2009). Improving Safety And Eliminating Redundant Tests: Cutting Costs In U.S. Hospitals. Health Aff (Millwood)
28: 1475-1484
[Abstract][Full Text]
Gallagher, T. H.
(2009). A 62-Year-Old Woman With Skin Cancer Who Experienced Wrong-Site Surgery: Review of Medical Error. JAMA
302: 669-677
[Abstract][Full Text]
Barsuk, J. H., Cohen, E. R., Feinglass, J., McGaghie, W. C., Wayne, D. B.
(2009). Use of Simulation-Based Education to Reduce Catheter-Related Bloodstream Infections. Arch Intern Med
169: 1420-1423
[Abstract][Full Text]
Botelho-Nevers, E., Thuny, F., Casalta, J. P., Richet, H., Gouriet, F., Collart, F., Riberi, A., Habib, G., Raoult, D.
(2009). Dramatic Reduction in Infective Endocarditis-Related Mortality With a Management-Based Approach. Arch Intern Med
169: 1290-1298
[Abstract][Full Text]
Binnekade, J. M
(2009). Review: central venous catheters treated with anti-infective agents prevent catheter-related bloodstream infections. Evid. Based Nurs.
12: 80-80
[Full Text]
Bahl, V., Campbell, D. A. Jr
(2009). Medicare's New Hospital Payment Rule: Limitations and Unintended Consequences. American Journal of Medical Quality
24: 347-351
Saint, S., Meddings, J. A., Calfee, D., Kowalski, C. P., Krein, S. L.
(2009). Catheter-Associated Urinary Tract Infection and the Medicare Rule Changes. ANN INTERN MED
150: 877-884
[Abstract][Full Text]
Kapczynski, A.
(2009). Commentary: Innovation Policy for a New Era. J Law Med Ethics
37: 264-268
Leape, L. L.
(2009). New World of Patient Safety: 23rd Annual Samuel Jason Mixter Lecture. Arch Surg
144: 394-398
[Full Text]
Hagtvedt, R., Griffin, P., Keskinocak, P., Roberts, R.
(2009). A Simulation Model to Compare Strategies for the Reduction of Health-Care-Associated Infections. Interfaces
39: 256-270
[Abstract]
Pronovost, P. J., Goeschel, C. A., Olsen, K. L., Pham, J. C., Miller, M. R., Berenholtz, S. M., Sexton, J. B., Marsteller, J. A., Morlock, L. L., Wu, A. W., Loeb, J. M., Clancy, C. M.
(2009). Reducing Health Care Hazards: Lessons From The Commercial Aviation Safety Team. Health Aff (Millwood)
28: w479-w489
[Abstract][Full Text]
Long, S., Neale, G., Vincent, C.
(2009). Practising safely in the foundation years. BMJ
338: b1046-b1046
[Full Text]
Gajic, O., Afessa, B.
(2009). Physician Staffing Models and Patient Safety in the ICU. Chest
135: 1038-1044
[Abstract][Full Text]
Needham, D. M., Sinopoli, D. J., Dinglas, V. D., Berenholtz, S. M., Korupolu, R., Watson, S. R., Lubomski, L., Goeschel, C., Pronovost, P. J.
(2009). Improving data quality control in quality improvement projects. Int J Qual Health Care
21: 145-150
[Abstract][Full Text]
Timsit, J.-F., Schwebel, C., Bouadma, L., Geffroy, A., Garrouste-Orgeas, M., Pease, S., Herault, M.-C., Haouache, H., Calvino-Gunther, S., Gestin, B., Armand-Lefevre, L., Leflon, V., Chaplain, C., Benali, A., Francais, A., Adrie, C., Zahar, J.-R., Thuong, M., Arrault, X., Croize, J., Lucet, J.-C., for the Dressing Study Group,
(2009). Chlorhexidine-Impregnated Sponges and Less Frequent Dressing Changes for Prevention of Catheter-Related Infections in Critically Ill Adults: A Randomized Controlled Trial. JAMA
301: 1231-1241
[Abstract][Full Text]
Perencevich, E. N., Pittet, D.
(2009). Preventing Catheter-Related Bloodstream Infections: Thinking Outside the Checklist. JAMA
301: 1285-1287
[Full Text]
Kuper, K. M., Septimus, E. J.
(2009). Health-care-associated infections: The legislative perspective and the pharmacist's role. Am J Health Syst Pharm
66: 488-494
[Full Text]
Janofsky, J. S.
(2009). Reducing Inpatient Suicide Risk: Using Human Factors Analysis to Improve Observation Practices. J Am Acad Psychiatry Law
37: 15-24
[Abstract][Full Text]
Iwashyna, T. J., Christie, J. D., Kahn, J. M., Asch, D. A.
(2009). Uncharted Paths: Hospital Networks in Critical Care. Chest
135: 827-833
[Abstract][Full Text]
Clancy, C. M.
(2009). CMS's Hospital-Acquired Condition Lists Link Hospital Payment, Patient Safety. American Journal of Medical Quality
24: 166-168
Corrigan, J., McNeill, D.
(2009). Building Organizational Capacity: A Cornerstone Of Health System Reform. Health Aff (Millwood)
28: w205-w215
[Abstract][Full Text]
Burton, D. C., Edwards, J. R., Horan, T. C., Jernigan, J. A., Fridkin, S. K.
(2009). Methicillin-Resistant Staphylococcus aureus Central Line-Associated Bloodstream Infections in US Intensive Care Units, 1997-2007. JAMA
301: 727-736
[Abstract][Full Text]
Conway, P. H., Clancy, C.
(2009). Transformation of Health Care at the Front Line. JAMA
301: 763-765
[Full Text]
Braithwaite, J, Runciman, W B, Merry, A F
(2009). Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. Qual Saf Health Care
18: 37-41
[Abstract][Full Text]
Krimsky, W S, Mroz, I B, McIlwaine, J K, Surgenor, S D, Christian, D, Corwin, H L, Houston, D, Robison, C, Malayaman, N
(2009). A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures. Qual Saf Health Care
18: 74-80
[Abstract][Full Text]
Mer, M., Duse, A. G., Galpin, J. S., Richards, G. A.
(2009). Central Venous Catheterization: A Prospective, Randomized, Double-Blind Study. CLIN APPL THROMB HEMOST
15: 19-26
[Abstract]
Pronovost, P. J., Goeschel, C. A., Marsteller, J. A., Sexton, J. B., Pham, J. C., Berenholtz, S. M.
(2009). Framework for Patient Safety Research and Improvement. Circulation
119: 330-337
[Full Text]
Kuschner, W. G., Gruenewald, D. A., Clum, N., Beal, A., Ezeji-Okoye, S. C.
(2009). Implementation of ICU Palliative Care Guidelines and Procedures: A Quality Improvement Initiative Following an Investigation of Alleged Euthanasia. Chest
135: 26-32
[Abstract][Full Text]
Rodriguez-Paz, J. M., Mark, L. J., Herzer, K. R., Michelson, J. D., Grogan, K. L., Herman, J., Hunt, D., Wardlow, L., Armour, E. P., Pronovost, P. J.
(2009). A Novel Process for Introducing a New Intraoperative Program: A Multidisciplinary Paradigm for Mitigating Hazards and Improving Patient Safety. Anesth. Analg.
108: 202-210
[Abstract][Full Text]
Mathews, S. C., Pronovost, P. J.
(2008). Physician Autonomy and Informed Decision Making: Finding the Balance for Patient Safety and Quality. JAMA
300: 2913-2915
[Full Text]
Jones, N. E., Heyland, D. K.
(2008). Implementing Nutrition Guidelines in the Critical Care Setting: A Worthwhile and Achievable Goal?. JAMA
300: 2798-2799
[Full Text]
Brown, C., Lilford, R.
(2008). Evaluating service delivery interventions to enhance patient safety. BMJ
337: a2764-a2764
[Full Text]
Edmond, M., Lyckholm, L., Diekema, D.
(2008). Ethical Implications of Active Surveillance Cultures and Contact Precautions for Controlling Multidrug Resistant Organisms in the Hospital Setting. Public Health Ethics
1: 235-245
[Abstract][Full Text]
Luce, J. M.
(2008). Medical Malpractice and the Chest Physician. Chest
134: 1044-1050
[Abstract][Full Text]
Lemaire, F.
(2008). Informed Consent and Studies of a Quality Improvement Program. JAMA
300: 1762-1762
[Full Text]
Pronovost, P. J, Berenholtz, S. M, Needham, D. M
(2008). Translating evidence into practice: a model for large scale knowledge translation. BMJ
337: a1714-a1714
[Full Text]
Ogrinc, G, Mooney, S E, Estrada, C, Foster, T, Goldmann, D, Hall, L W, Huizinga, M M, Liu, S K, Mills, P, Neily, J, Nelson, W, Pronovost, P J, Provost, L, Rubenstein, L V, Speroff, T, Splaine, M, Thomson, R, Tomolo, A M, Watts, B
(2008). The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration. Qual Saf Health Care
17: i13-i32
[Abstract][Full Text]
Kottke, T. E., Solberg, L. I., Nelson, A. F., Belcher, D. W., Caplan, W., Green, L. W., Lydick, E., Magid, D. J., Rolnick, S. J., Woolf, S. H.
(2008). Optimizing Practice Through Research: A New Perspective to Solve an Old Problem. Ann Fam Med
6: 459-462
[Abstract][Full Text]
Chastre, J.
(2008). Preventing Ventilator-Associated Pneumonia: Could Silver-Coated Endotracheal Tubes Be the Answer?. JAMA
300: 842-844
[Full Text]
Stevens, D. P
(2008). Healthcare system error: beyond apology. Qual Saf Health Care
17: 234-235
[Full Text]
Kollef, M.
(2008). SMART Approaches for Reducing Nosocomial Infections in the ICU. Chest
134: 447-456
[Abstract][Full Text]
Brown, C, Hofer, T, Johal, A, Thomson, R, Nicholl, J, Franklin, B D, Lilford, R J
(2008). An epistemology of patient safety research: a framework for study design and interpretation. Part 1. Conceptualising and developing interventions. Qual Saf Health Care
17: 158-162
[Abstract][Full Text]
Brown, C, Hofer, T, Johal, A, Thomson, R, Nicholl, J, Franklin, B D, Lilford, R J
(2008). An epistemology of patient safety research: a framework for study design and interpretation. Part 2. Study design. Qual Saf Health Care
17: 163-169
[Abstract][Full Text]
Pulcini, C., Defres, S., Aggarwal, I., Nathwani, D., Davey, P.
(2008). Design of a 'day 3 bundle' to improve the reassessment of inpatient empirical antibiotic prescriptions. J Antimicrob Chemother
61: 1384-1388
[Abstract][Full Text]
Parienti, J.-J., Thirion, M., Megarbane, B., Souweine, B., Ouchikhe, A., Polito, A., Forel, J.-M., Marque, S., Misset, B., Airapetian, N., Daurel, C., Mira, J.-P., Ramakers, M., du Cheyron, D., Le Coutour, X., Daubin, C., Charbonneau, P., for Members of the Cathedia Study Group,
(2008). Femoral vs Jugular Venous Catheterization and Risk of Nosocomial Events in Adults Requiring Acute Renal Replacement Therapy: A Randomized Controlled Trial. JAMA
299: 2413-2422
[Abstract][Full Text]
Kahn, J. M., Bates, D. W.
(2008). Improving Sepsis Care: The Road Ahead. JAMA
299: 2322-2323
[Full Text]
Pronovost, P. J., Goeschel, C. A., Wachter, R. M.
(2008). The Wisdom and Justice of Not Paying for "Preventable Complications". JAMA
299: 2197-2199
[Full Text]
Blot, F., Gachot, B., Nitenberg, G.
(2008). Are Urokinase Rinses Needed to Reduce Catheter-Related Bloodstream Infections When Standard Preventive Guidelines Are Observed?. JCO
26: 2415-2416
[Full Text]
Kahn, M. W.
(2008). Etiquette-Based Medicine. NEJM
358: 1988-1989
[Full Text]
Karanicolas, P. J., Kunz, R., Guyatt, G. H.
(2008). Point: Evidence-Based Medicine Has a Sound Scientific Base. Chest
133: 1067-1071
[Full Text]
Labriola, L., Crott, R., Jadoul, M.
(2008). Preventing haemodialysis catheter-related bacteraemia with an antimicrobial lock solution: a meta-analysis of prospective randomized trials. Nephrol Dial Transplant
23: 1666-1672
[Abstract][Full Text]
Costello, J. M., Morrow, D. F., Graham, D. A., Potter-Bynoe, G., Sandora, T. J., Laussen, P. C.
(2008). Systematic Intervention to Reduce Central Line-Associated Bloodstream Infection Rates in a Pediatric Cardiac Intensive Care Unit. Pediatrics
121: 915-923
[Abstract][Full Text]
Fowler, R. A., Adhikari, N. K. J., Scales, D. C., Lee, W. L., Rubenfeld, G. D.
(2008). Update in Critical Care 2007. Am. J. Respir. Crit. Care Med.
177: 808-819
[Full Text]
Fennell, J. P., O'Donohoe, M., Cormican, M., Lynch, M.
(2008). Linezolid lock prophylaxis of central venous catheter infection. J Med Microbiol
57: 534-535
[Abstract][Full Text]
Pronovost, P. J., Berenholtz, S. M., Goeschel, C. A.
(2008). Improving the Quality of Measurement and Evaluation in Quality Improvement Efforts. American Journal of Medical Quality
23: 143-146
Diekema, D. J., Climo, M.
(2008). Preventing MRSA Infections: Finding It Is Not Enough. JAMA
299: 1190-1192
[Full Text]
Miller, F. G., Emanuel, E. J.
(2008). Quality-Improvement Research and Informed Consent. NEJM
358: 765-767
[Full Text]
Baily, M. A.
(2008). Harming through Protection?. NEJM
358: 768-769
[Full Text]
Barlow, G., Nathwani, D., Myers, E., Sullivan, F., Stevens, N., Duffy, R., Davey, P.
(2008). Identifying barriers to the rapid administration of appropriate antibiotics in community-acquired pneumonia. J Antimicrob Chemother
61: 442-451
[Abstract][Full Text]
Hales, B., Terblanche, M., Fowler, R., Sibbald, W.
(2008). Development of medical checklists for improved quality of patient care. Int J Qual Health Care
20: 22-30
[Abstract][Full Text]
Committee on Pediatric Emergency Medicine,
(2007). Patient Safety in the Pediatric Emergency Care Setting. Pediatrics
120: 1367-1375
[Abstract][Full Text]
Amin, A. N., Pistoria, M. J.
(2007). Update in Hospital Medicine. ANN INTERN MED
147: 628-632
[Full Text]
Buerhaus, P. I.
(2007). Is Hospital Patient Care Becoming Safer? A Conversation With Lucian Leape. Health Aff (Millwood)
26: w687-w696
[Abstract][Full Text]
Mimoz, O., Villeminey, S., Ragot, S., Dahyot-Fizelier, C., Laksiri, L., Petitpas, F., Debaene, B.
(2007). Chlorhexidine-Based Antiseptic Solution vs Alcohol-Based Povidone-Iodine for Central Venous Catheter Care. Arch Intern Med
167: 2066-2072
[Abstract][Full Text]
Bleasdale, S. C., Trick, W. E., Gonzalez, I. M., Lyles, R. D., Hayden, M. K., Weinstein, R. A.
(2007). Effectiveness of Chlorhexidine Bathing to Reduce Catheter-Associated Bloodstream Infections in Medical Intensive Care Unit Patients. Arch Intern Med
167: 2073-2079
[Abstract][Full Text]
Pronovost, P. J., Miller, M., Wachter, R. M.
(2007). The GAAP in Quality Measurement and Reporting. JAMA
298: 1800-1802
[Full Text]
Tino, G., Ware, L. B., Moss, M.
(2007). Clinical Year in Review IV: Chronic Obstructive Pulmonary Disease, Nonpulmonary Critical Care, Diagnostic Imaging, and Mycobacterial Disease. Proc Am Thorac Soc
4: 494-498
[Full Text]
Baumann, M. H., Lewis, S. Z., Gutterman, D.
(2007). ACCP Evidence-Based Guideline Development: A Successful and Transparent Approach Addressing Conflict of Interest, Funding, and Patient-Centered Recommendations. Chest
132: 1015-1024
[Abstract][Full Text]
Angus, D. C.
(2007). Caring for the Critically Ill Patient: Challenges and Opportunities. JAMA
298: 456-458
[Full Text]
Lee, T. H., Torchiana, D. F., Lock, J. E.
(2007). Is Zero the Ideal Death Rate?. NEJM
357: 111-113
[Full Text]
Snydman, D. R.
(2007). Prevention of Catheter-Related Bloodstream Infections: Looking to the Department of Veterans Affairs Health Care System for Guidance. Mayo Clin Proc.
82: 665-665
[Full Text]
Graham, A. S., Ozment, C., Tegtmeyer, K., Lai, S., Braner, D. A.V.
(2007). Central Venous Catheterization. NEJM
356: e21-e21
Amarasingham, R., Pronovost, P. J, Diener-West, M., Goeschel, C., Dorman, T., Thiemann, D. R, Powe, N. R
(2007). Measuring Clinical Information Technology in the ICU Setting: Application in a Quality Improvement Collaborative. J Am Med Inform Assoc
14: 288-294
[Abstract][Full Text]
Milbrandt, E. B., Ishizaka, A., Angus, D. C.
(2007). Update in Critical Care 2006. Am. J. Respir. Crit. Care Med.
175: 638-648
[Full Text]
Jenny-Avital, E. R., Daley, M. R., Pronovost, P. J., Needham, D. M., Berenholtz, S.
(2007). Catheter-Related Bloodstream Infections. NEJM
356: 1267-1268
[Full Text]
Duffy, F. D., Holmboe, E. S.
(2007). What Procedures Should Internists Do?. ANN INTERN MED
146: 392-393
[Full Text]
(2007). Medical Errors: Focusing More on What and Why, Less on Who. J Oncol Pract
3: 66-70
[Full Text]
A correction has been published: N Engl J Med 2007;356(25):2660.
0.002), and the mean rate per 1000 catheter-days decreased from 7.7 at baseline to 1.4 at 16 to 18 months of follow-up (P<0.002). The regression model showed a significant decrease in infection rates from baseline, with incidence-rate ratios continuously decreasing from 0.62 (95% confidence interval [CI], 0.47 to 0.81) at 0 to 3 months after implementation of the intervention to 0.34 (95% CI, 0.23 to 0.50) at 16 to 18 months. 
200 beds) (Table 3). 
Previous
