Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections Melinda Sawyer, MSN, RN, PCCN; Kristina Weeks, BA, BS, MHS; Christine A. Goeschel, MPA, MPS, ScD, RN; David A. Thompson, DNSc, MS, RN; Sean M. Berenholtz, MD, MHS; Jill A. Marsteller, PhD, MPP; Lisa H. Lubomski, PhD; Sara E. Cosgrove, MD, MS; Bradford D. Winters, PhD, MD; David J. Murphy, MD; Laura C. Bauer, MPH; Jordan Duval-Arnould, MPH; Julius C. Pham, MD, PhD; Elizabeth Colantuoni, PhD; Peter J. Pronovost, MD, PhD R ecent estimates suggested that the four most common healthcare-acquired infec- tions (bloodstream, urinary tract, and surgical site infections and ventilator-associated pneumonias) ac- count for up to 800,000 preventable in- fections, 60,000 preventable deaths, and $27 billion in excess costs annually in the Unites States. Preventable infections are a prominent target of pay-for-perfor- mance proposals and a concern for con- sumer groups, accrediting agencies, pro- fessional societies, hospitals, and healthcare systems (1–3). Although such infections are an ongoing concern, progress in reducing them has been slow and difficult to measure. A safety project developed at The Johns Hopkins University School of Medicine and implemented in 100 in- tensive care units (ICUs) in Michigan, called the Keystone ICU project, led to a 66% reduction in central line (cathe- ter)-associated bloodstream infections (CLABSIs) and a median CLABSI rate of zero, with improvements sustained for 4 yrs (4). This project encompassed both the technical (e.g., summarizing evidence, using robust measurement) and adaptive (e.g., culture change) work needed to successfully implement any quality and safety improvement initiative. Thus, it used an approach different from the plan-do-study act cycle (5, 6). We recognize that to reduce infections, clinicians need to implement best prac- tices, robustly measure and give feedback about performance, and perhaps the most difficult of all, improve culture and team- work. Although diverse disciplines (e.g., ICU clinicians, infection control practitio- ners, quality improvement leaders, and se- nior healthcare leaders) collaborate to real- ize improvements in CLABSI rates, ultimately the ICU clinicians (physicians, nurses, nurse practitioners, and physician assistants) who insert and manage the catheters must assume responsibility and be held accountable for reducing infections in the ICU. Such a decentralized leadership model is new for many healthcare organi- zations. The model used in Michigan is now being implemented state by state across the United States and throughout Spain and England, and is undergoing pilot testing in several hospitals in Peru. In this article, we describe the evolu- tion of the Michigan project into a na- tional program called On the CUSP: Stop BSI and the three key program compo- nents: measuring results, translating ev- From The Johns Hopkins University School of Med- icine and Bloomberg School of Public Health, Balti- more, MD. This study was supported, in part, by the Agency for Healthcare Research and Quality. Dr. Pronovost and Ms. Goeschel report receiving honoraria from hospital associations and health sys- tems to speak on quality and patient safety, along with support from the Agency for Healthcare Research and Quality (AHRQ; Rockville, MD) from 2003 to 2005 (iUC1HS14246) (PJP). Dr. Cosgrove has also received support from the AHRQ. Dr. Marsteller also received funding from the AHRQ. The remaining authors have not disclosed any potential conflicts of interest. For information regarding this article, E-mail: ppronovo@jhmi.edu Copyright © 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0b013e3181e6a165 Healthcare-associated infections are common, costly, and of- ten lethal. Although there is growing pressure to reduce these infections, one project thus far has unprecedented collaboration among many groups at every level of health care. After this project produced a 66% reduction in central catheter-associated bloodstream infections and a median central catheter-associated bloodstream infection rate of zero across >100 intensive care units in Michigan, the Agency for Healthcare Research and Quality awarded a grant to spread this project to ten additional states. A program, called On the CUSP: Stop BSI, was formulated from the Michigan project, and additional funding from the Agency for Healthcare Research and Quality and private philanthropy has positioned the program for implementation state by state across the United States. Furthermore, the program is being implemented throughout Spain and England and is undergoing pilot testing in several hospitals in Peru. The model in this program balances the tension between being scientifically rigorous and feasible. The three main components of the model include translating evidence into practice at the bedside to prevent central catheter-associated bloodstream infections, improving culture and teamwork, and having a data collection system to monitor central catheter- associated bloodstream infections and other variables. If suc- cessful, this program will be the first national quality improve- ment program in the United States with quantifiable and measurable goals. (Crit Care Med 2010; 38[Suppl.]:S292–S298) KEY WORDS: central catheter-associated bloodstream infection; Comprehensive Unit-Based Safety Program; translating evidence into practice; quality improvement; culture; multidisciplinary teamwork; measurement; healthcare-associated infections; pa- tient safety S292 Crit Care Med 2010 Vol. 38, No. 8 (Suppl.)