Safety checklist for infection control reduces hospital deaths by
7 March 2011
A programme to introduce a safety checklist when placing a
central-line catheter has virtually eliminated bloodstream infections in
intensive care units in Michigan and also appears to have reduced deaths
Central lines are thin plastic tubes used regularly for patients in
ICUs to administer medication or fluids, obtain blood for tests, and
directly gauge cardiovascular measurements such as central venous
blood pressure. But the tubes are easily contaminated.
The Keystone ICU Project, developed at Johns Hopkins, includes a
much-heralded checklist for doctors and nurses to follow when
placing a central-line catheter, highlighting five cautionary and
basic steps from hand-washing to avoiding placement in the groin
area where infection rates are higher.
Along with the checklist, the program promotes a “culture of safety”
that comprises safety science education, training in ways to
identify potential safety problems, development of evidence-based
solutions, and measurement of improvements. The program also
empowers all caregivers, no matter how senior or junior, to question
each other and stop procedures if safety is compromised.
Although prior research showed a major reduction in central-line
related bloodstream infections at hospitals using the checklist, the
new study is the first to show its use directly lowered mortality.
“We knew that when we applied safety science principles to the
delivery of healthcare, we would dramatically reduce infections in
intensive care units, and now we know we are also saving lives,”
says Peter J Pronovost, MD, PhD, a professor of anesthesiology and
critical care medicine at the Johns Hopkins University School of
Medicine and leader of the study published in the British Medical
Journal. “Thousands of people are believed to have survived because
of this effort to reduce bloodstream infections.”
Pronovost’s previous research has shown that coupling a
cockpit-style, infection-control checklist he developed with a work
environment that encourages nurses to speak up if safety rules
aren’t followed reduced ICU central-line bloodstream infections to
nearly zero at The Johns Hopkins Hospital and at hospitals
throughout the states of Michigan and Rhode Island.
Experts say an estimated 80,000 patients a year with central
lines get infected, some 31,000 die — nearly as many as die from
breast cancer annually — and the cost of treating them may be as
high as $3 billion nationally.
For the new study, Pronovost and his team, using Medicare claims
data, studied hospital mortality of patients admitted to ICUs in
Michigan before, during and after what is known as the Keystone ICU
Project, which features the checklist.
They compared the Michigan information to similar data from 11
surrounding states. While data from both Michigan and the other
states showed a reduction in hospital deaths of elderly patients
admitted to ICUs over the five-year period from October 2001 to
December 2006, the patients in Michigan were significantly more
likely to survive a hospital stay during and after the Keystone
These findings cannot definitively attribute the mortality
reduction to the Keystone project, Pronovost says, but no other
known large-scale initiatives were uniquely introduced across
Michigan during the study period. “This is perhaps the only
large-scale study to suggest a significant reduction in mortality
from a quality-improvement initiative,” Pronovost says.
In 2009, US Health and Human Services Secretary Kathleen Sebelius
called for a 50% reduction in catheter-related infections nationwide
by 2012. To that end, in partnership with a branch of the American
Hospital Association and the Michigan Hospital Association, the
Johns Hopkins model is being rolled out state-by-state across the
country. Forty states have launched the program, and preliminary
data from some of the early adopters is very encouraging, Pronovost