CR-BSI prevention program draws Congressional praise
CR-BSI prevention program draws Congressional praise
Gives support for nationalizing Keystone project
Even as health care epidemiologists fear that "getting to zero" infection prevention efforts may be unleashing some unintended consequences, one highly successful program associated with the movement recently drew the praises of Congress.
The program also was recently in the news because it was temporarily halted by the federal Office for Human Research Protections due to concerns that it's use of a checklist and other components violated informed consent protections. That decision was reversed after considerable national protest, and now the program is being hailed as a national model for infection prevention. Developed at Johns Hopkins Hospital in Baltimore and implemented by 108 intensive care units in the Michigan Keystone project, the effort dramatically reduced catheter-related bloodstream infections (CR-BSIs). Indeed, it was heralded as a prime example of the "zero" movement as the median participating ICU went from an infection rate of 4% to zero over an 18-month period.1
"Thanks to the work of one of our witnesses, Dr. Peter Pronovost, and the efforts of Michigan hospitals, we know that by taking simple steps, hospitals can significantly reduce the number of patients who become infected while they are receiving treatment," said Rep. Henry Waxman, chairman of the Committee on Government and Oversight Reform. "Entitled to Healthcare Associated Infections: A Preventable Epidemic," the April 16 hearing was primarily held to hear the results of a new government report on HAIs. The onus for much of the "needless suffering and death" caused by health care-acquired infections (HAIs) was ascribed to a failure of leadership by the Department of Health and Human Services (HHS) in a scathing report by the U.S. Government Accountability Office (GAO).
"Hospitals should not wait while HHS sorts out the evidence," said Waxman. "They should adopt the simple measures that are already proven and give their patients the benefit of the lowest achievable risk of infection. It's not too often that a prevention strategy comes along that is simple, inexpensive to implement, and proven to be effective in reducing the number of patient deaths. The experience of the Michigan hospitals demonstrates clearly that this prevention strategy works. Today we will try to understand why the Department of Health and Human Services is not doing more to lead in the dissemination and adoption of this strategy nationwide."
Indeed, Waxman was sufficiently impressed with Pronovost's program and testimony that after the hearing on May 6, 2008, he sent out a letter to all state hospital associations alerting them about the CR-BSI program. Pronovost, MD, PhD, FCCM, director of the center for innovations in quality patient care at Johns Hopkins University, testified that the "results of this project were breathtaking . . . . Within three months of implementing our program, which included simple interventions like using a checklist to ensure doctors followed recommended practices, these infections were nearly eliminated. More than 50% of participating ICUs reduced their rate of catheter-related bloodstream infections to zero and that rate has persisted for four years. The overall rate of these infections was reduced by two-thirds. If implemented nationally, this program could substantially reduce the 28,000 deaths and 3 billion dollars in excess costs attributed to these preventable hospital-acquired infections."
Individual states, including California and Ohio, are seeking funding to replicate the Michigan project, he told the committee. "In addition, clinicians in Michigan want to develop a program to eliminate two very serious health care-acquired infections that are becoming an increasingly common and expensive problem in the U.S. health care system and a growing concern with the public, methicillin resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococcus (VRE)," he revealed. "These bacteria are among the most common health care-acquired infections that affect one in 10 patients, kill approximately 90,000 individuals, and cost between 5 and 11 billion dollars annually in the United States. "Many, although not all, of these infections are preventable by the use of known interventions," Pronovost said. "Most of these infections could likely be prevented if we invested in ways to identify and implement effective preventative therapies. Yet, as a country, there is neither funding nor an infrastructure to create and implement such programs."
The Michigan project to eliminate blood stream infections is one such program, he noted. "We need leadership at the federal level to support widespread implementation of this program, develop future programs, and provide appropriate methods of ethical oversight for these efforts." Specifically, Pronovost asked the committee to consider four recommendations:
- Provide support to the Agency for Health Care Research and Quality (AHRQ) to replicate the Michigan project in every state, to build capacity to address patient safety problems, and to develop and implement new safety programs.
- Urge HHS to promptly clarify government oversight requirements for quality improvement projects and remove barriers to implementing and evaluating quality improvement efforts.
- Substantially increase funding for research aimed at identifying and delivering effective therapies.
- Support training for physicians, nurses, and other clinicians in quality improvement methods in order to improve the delivery of health care across the United States.
- Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Eng J Med 2006; 355:2,725-2,732.
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