Quality Update

Dana Moore, the MICU’s clinical practice committee chair, helped guide a unit project that cut its catheter-related bloodstream infection rate.

But Brower wanted each change to have the weight of the best evidenced-based practices behind it. In 2002, for example, the Hospital changed its policy on central-line insertions to recommend that either betadine or chlorahexidine could be used as a skin prep before catheter insertions. Brower, however, thought the evidence clearly pointed to chlorahexidine as the wash that would best reduce the chances for infection and worked with the infection control group to make this the preferred prep.

Through the determination of Brower, Dana Moore, clinical nurse specialist and the MICU clinical practice committee chair, and other staff, the unit has seen a remarkable 75 percent reduction in its bloodstream infection rates. “It’s been our best success story,” asserts Trish Perl, the Hospital’s infection control officer.

In fact, Hospital catheter-related bloodstream infection rates have fallen significantly below the national average in a number of ICUs over the past 18 months, from an annual high of 235 per 1,000 catheter-use patient days to around 90. This was accomplished thanks to a convergence of efforts spearheaded by Perl and her team of physicians, the ICU medical teams and, most recently, the Johns Hopkins Medicine Center for Innovation in Quality Patient Care.

Hopkins isn’t alone in battling hospital-acquired infections. Hospitals around the United States are bedeviled by this problem, according to the Centers for Disease Control and Prevention. The CDC reports that about 2 million hospital patients a year—one of every 20 admissions—contract an infection unrelated to their condition, and more than 90,000 of them die.

Perl started looking at Hopkins’ catheter-related bloodstream infections more than six years ago. It was a slow process, beginning with marshaling evidence that showed central-line insertions harbored dangers to patient safety. “Next we needed a policy to put in front of caregivers,” Perl says. “It took us several years, but by 2001, we had one that reflected the CDC’s best evidenced-based guidelines.”

These recommendations for central-line insertions, in addition to using a certain kind of skin prep, include requiring doctors and nurses involved in the procedure to wear sterile gowns, masks and caps, and using large sterile drapes around the insertion site.

But having protocols in place, Perl found, didn’t automatically translate into success. “It became readily apparent that we couldn’t just legislate change.” 

Using a five-year CDC grant worth $400,000 a year to instill best practices for central-line insertions, Infection Control launched an aggressive intervention in August 2002 to reduce bloodstream infections in the MICU and the cardiac surgery intensive care unit. It also sought to buttress efforts already under way in the surgical intensive care unit led by surgeon Pam Lipsett and anesthesiologist Todd Dorman.

The Center for Innovation in Quality Patient Care stepped in to lend salary support for epidemiologist Sara Cosgrove so she could undertake an intensive education program on the units. Infection Control also created a Web-based, mandatory training module for all residents rotating through the units and made the exercise a prerequisite for physicians to get their credentialing renewed.

The innovations center, Perl points out, has been invaluable in knocking down bureaucratic barriers to getting products, harnessing support from the Hopkins Medicine leadership and plugging the central-line-infection reduction projects into the institution’s patient safety program.

Infection control experts Sara Cosgrove, left, and Trish Perl discovered that changing old practices requires education and evidence-based policies.

The units also took their own lead in making changes beyond the protocols. The MICU, for instance, purchased an ultrasound machine that displays the location of veins and guides the placement of the catheter needle. “Data shows that this helps reduce infections by limiting unnecessary needle sticks,” says Dana Moore.

Since this exhaustive push by so many to address bloodstream infections began, Perl says, Hopkins has achieved more success reducing infection rates than any other institutions involved in the CDC grant, including Washington University and the Medical College of Virginia. “Everyone likes to take credit for this accomplishment,” she muses, “and that’s OK. It shows that everyone is invested in the program.”