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Safer ICUs: Cheap, simple, 'low-tech' steps work

December 28, 2006

Hospitals will quickly slash the rate of common, costly and potentially lethal catheter-related bloodstream infections in their intensive care units (ICUs) by using cheap, low-tech, common-sense measures like hand washing, timely removal of unneeded catheters, and use of sites other than the groin to place lines when possible, according to a report from safety experts at Johns Hopkins in the Dec. 28 issue of the New England Journal of Medicine.

"There's just no reason any more not to do these relatively simple things," says Peter Pronovost, M.D., professor of medicine and medical director of Hopkins' Center for Innovation in Quality Patient Care, who led researchers in their review of 103 Michigan ICUs, before, during and after implementing a variety of measures designed to reduce such infections.

"A common misperception among hospital-based clinicians is that it often costs much too much money and time to significantly improve patient safety," says Pronovost. "Our data destroys this myth by showing that profound improvements can be made with minimum cost and effort, as long as clinical teams are committed to improving safety and willing to diligently observe relatively simple safety measures."

Nationwide, an estimated 80,000 bloodstream infections occur each year as a result of central venous catheters, which are tubes inserted through a blood vessel that ends near or in the heart to deliver treatments and monitor care. Bloodstream infections are involved in up to 28,000 deaths in the United States alone among these ICU patients. Economically, the toll is enormous, Pronovost says, with an average cost to the health care system of $45,000 per patient for treatment and billions each year nationwide, "far more than it costs to implement steps to prevent the infections in the first place."

In the Michigan hospital system, which served as a pioneering pilot site for infection prevention measures, efforts included training physicians and nurses about infection control; using special, standardized central-line supply carts that are controlled for one-time use; requiring use of a cockpit-style "checklist" to ensure adherence to infection-control practices such as hand washing; avoiding catheter placement through the femoral artery in the groin, an area notoriously difficult to keep sterile; using and changing gloves, gowns and masks for each procedure; cleaning patients' skin with chlorhexidine; and removing catheters as soon as possible, even if there's a chance they might be needed again at some point.

The safety plan also requires immediate "stop now" orders by any member of the health care team when a checklist is not followed to the letter and feedback to each member of the care team about the number and rates of catheter-related bloodstream infections at weekly and quarterly meetings.

Pronovost said the study team gathered information in Michigan representing 375,757 ICU catheter-days, collected quarterly for up to 18 months after implementation of the safety measures.

The results were dramatic, he says, when the steps were implemented. The median rate of catheter-related bloodstream infections per 1,000 catheter-days decreased from 2.7 at baseline to 0 after implementation of the safety measures, and the mean rate decreased from 7.7 at baseline to 1.4 at 16 to 18 months of follow-up.

Johns Hopkins Medical Institutions