Ground zero: Keystone produces stunning results

Ground zero: Keystone produces stunning results

ICU infection rates vanishing in group effort

A collaborative effort between the Michigan Health & Hospital Association and 77 state hospitals has dramatically lowered infection rates in intensive care units. Indeed, catheter-related bloodstream infections (CA-BSIs) have dropped to zero.

"Infections from central IV catheters plummeted," said Chris Goeschel, RN, MPA, MPS, executive director of MHA Keystone Center for Patient Safety and Quality in Lansing, MI. "The median CR-BSI rate in participating ICUs has now been at zero for almost a year. Ventilator-associated pneumonia rates in the ICUs have been cut by 40%. Forty-six ICUs have gone for over six months with no ventilator-associated pneumonias. Fifty-seven ICUs have gone for over six months with no bloodstream infections from IV catheters."

Goeschel described the staggering results of the program recently in Washington, DC, at a hearing held by the Committee on Energy and Commerce's subcommittee on Oversight and Investigations.

Using a predictive model based on empiric evidence and actual data collected from project participants, she estimated that the first 15 months of the project resulted in savings of 1,558 lives, more than 80,000 ICU patient days, and in excess of $165 million dollars.

Changing the clinical culture has been a key, she noted. "Hospitals are complex networks of information, interests and competing priorities and changing culture is incredibly challenging work," she told the committee. "Since our explicit goal was to improve ICU care for the patients in every participating hospital, teams were encouraged to share their experiences and provide social support to each other. They were amazingly candid in doing so. We discovered early in our MHA Keystone ICU project that the brightest and most motivated clinicians, even when presented with evidence for changing practice, encountered obstacles that required new understanding and new skills."

The program uses a model that includes principles of:

• engagement: creating the imperative for change;
• education: providing the evidence supporting the system redesign being asked for;
• execution: providing the materials and resources required to redesign work and ensure patients receive evidence-based interventions;
• evaluation: perform rigorous data collection and analysis to determine if patient safety and clinical outcomes are improved.

The success came without regulation, she noted, reminding the panel that current push to require infection rate disclosure laws is not the only way to ensure quality.

"Freedom from concern about imminent public reporting creates an environment where clinicians can share openly, learn rapidly, and quickly improve care," Goeschel said. "Because the focus of the project was and is to improve care for patients, everything else became a secondary issue. Teams did not waste time explaining away less than stellar performance; rather, time was spent determining how to improve care by tapping the learning community. That is, the 126 other ICUs working on the same initiatives, using the same standardized definitions, same data collection methodologies and same tools for improvement."

Michigan has a long history of voluntary public reporting of hospital specific parameters of care, always structured in a way to support consumer use, she emphasized. Yet, the Keystone ICU project leaders agreed that public reporting could have changed the focus from "doing good" to "looking good," she warned.

"Measuring and improving infection rates is clinically complicated," she testified. "It would be difficult to present infection information to consumers in a way that reflects appropriate consideration in individual decision making. Instead, the focus continues to be to make the best evidence-based care possible for every individual receiving ICU services in a participating hospital."

In any case, the program underscores that support of infection control efforts could reap huge fiscal rewards. "We believe MHA Keystone ICU is a powerful example of what federal pennies can do," she said. "National estimates are that there are nearly 75,000 central line infections in ICUs each year, resulting in some 14,000 to 28,000 deaths. If additional investments were made to take what we have learned and support similar expert led, evidence-based projects throughout the country, the impact could be profound."