Quest for zero: Spreading the checklist gospel

'The polio campaign for the 21st century'

Infection control interventions appear to be making a difference against central line-associated bloodstream infections (CLABSIs), which have declined 18% nationally in a recent data reported by the Centers for Disease Control and Prevention.

Credit where considerable credit is due goes to Peter Pronovost, MD, PhD medical director of the Center for Innovations in Quality Patient Care at Johns Hopkins Hospital in Baltimore. Pronovost and colleagues dramatically reduced CLABSIs through an infection prevention intervention that included a checklist for proper insertion of central venous lines, which can seed subsequent infections if placed without proper precaution. (For a copy of the checklist go to the Hospital Infection Prevention & Control archives, Feb. 2008, p. 15 at The program emphasizes:

  • Hand hygiene
  • Full-barrier precautions during catheter insertion
  • Skin cleansing with chlorhexidine
  • Avoiding the femoral insertion site
  • Removal of unnecessary catheters.

Implemented at Hopkins and 108 intensive care units in the Michigan Keystone project, the program reduced CLABSIs so dramatically it has become the poster — make that the checklist – child of the zero tolerance movement in infection prevention. Indeed, the median participating ICU went from an infection rate of 4% to zero over an 18-month period.1

"The intervention was cheap, involving a checklist of evidence-based practices developed by the CDC, robust measuring of infections, and improving teamwork among doctors and nurses," Pronovost said at a press conference on the recent CDC report. "The results have now persisted for over four years.  And others have achieved similar results."

He urged infection preventionists to adopt the program. "Join your statewide efforts to reduce these infections, if you haven't done so," he said. "Create an interdisciplinary team in each area that uses catheters, monitor and report your infection rates, ensure that supplies to comply with the checklist are readily available, empower nurses to stop the placement of a catheter if the physicians don't comply with the checklist."

In addition, audit catheter maintenance and investigate every infection "as if it's a defect," he urged, noting that "central line-associated bloodstream infections are the polio campaign for the 21st century.  Working together, following this checklist, we can substantially reduce these infections.  We've seen what is possible.  We have prevented infections and we've saved lives."

Pronovost is working now with the American Hospital Association to get the program implemented in every state. "Thus far, 33 states have committed to participate and over 600 hospitals are actively engaged, and we are seeing amazing results," he said. "All of the hospitals in Rhode Island, 94% in Hawaii, and approximately half of New Jersey and Georgia have virtually replicated these Michigan results."


  1. 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.