Regional and state initiatives
- Greater New York Hospital Association –United Hospital Fund Collaborative
- Johns Hopkins Center for Innovation in Quality Patient Care
- Maryland Patient Safety Center
- Michigan Keystone ICU project
- New Jersey Hospital Association ICU collaborative
- Pittsburgh Regional Health Initiative (PRHI)
The Greater New York Hospital Association - United Hospital Fund Collaborative
The Greater New York Hospital Association (GNYHA) and United Hospital Fund (UHF) embarked upon a Quality Improvement Collaborative in 2005 supporting the use of proven infection control practices in ICUs to improve the quality of care and patient safety. Thirty-eight hospitals throughout the Greater New York region participated in a CLABS Collaborative with the primary goal of reducing central line associated bloodstream CLABS) infections in intensive care units. In less than two years their CLABS rate dropped nearly 70 percent from 5 to 1.62 CLABS per 1,000 ICU patient days, with some hospitals reporting no infections for 9-12 months. A Web site called Joint Effort New York (Jeny), which is administered through IPRO, serves as the Collaborative's information-sharing resource center, with documents, sample tools, educational programs and best practices at http://jeny.ipro.org/clabs/
- Download a case study about the GNYHA-UHF CLABS Collaborative
Johns Hopkins Center for Innovation
in Quality Patient Care
The Johns Hopkins Center for Innovation in Quality Patient Care was created in 2002 to facilitate patient-centered revamping of healthcare delivery systems at Johns Hopkins Medicine. Supporting a grassroots model of improvement, the center helps coordinate the efforts of interdisciplinary teams of physicians, nurses and managers to gather data, evaluate changes, and recommend and implement best practices. The center is led by Dr. Peter Pronovost, medical director and a leading safety expert. Pronovost and his Hopkins colleagues are known for their groundbreaking research in ICUs to improve safety culture among staff and in particular, their research on the new technique of "bundling" of evidence-based practices. A set or "bundle" of specific evidence-based practices is being used to reduce catheter-related bloodstream infections, ventilator-associated pneumonia and sepsis. Their research began in 1998 in a surgical intensive care unit (ICU) and resulted in near elimination of catheter-associated bloodstream infections by 2002. It was estimated that these interventions prevented eight patient deaths and eliminated $1.8 million in additional costs per year in the study ICU teams.
Sample tools, resources, successes from their initiatives, case studies and processes used are available on the Johns Hopkins Web site. Resources include implementing a Daily Goals Sheet to improve communication in the ICU, as well as details on how they achieved reductions in bloodstream infections.
Maryland Patient Safety Center
The Maryland Health Care Commission (MHCC) on June 18, 2004, announced the selection of the Maryland Hospital Association (MHA) and the Delmarva Foundation (Delmarva) to jointly develop and run the new Maryland Patient Safety Center. The two organizations provide funding for the patient safety center through 2007.
In November 2004, the Maryland Patient Safety Center launched the first in a series of Safety Culture Collaboratives. More than 300 people from 50 Maryland hospital ICUs committed to a common goal of dramatically improving results for all intensive care unit patients. Throughout the next 12 months, these teams met regularly to share and learn from each other the best practices to improve patient outcomes. The aim was to achieve the following goals:
- Improve the culture of safety in ICUs by 50 percent.
- Eliminate deadly blood stream infections and ventilator associated pneumonia.
- Reduce ICU and hospital death rates by 30 percent.
- Reduce ICU and hospital length of stay by one day.
- Reduce ICU staff turnover and direct costs by 30 percent.
As reported in 2005, this collaborative effort showed evidence of success. The Maryland hospital ICU teams had reduced ventilator-associated pneumonia by 19 percent in just eight months. Teams working on reducing blood stream infections have seen a 36 percent reduction over this time period.
The Emergency Department (ED) Collaborative involved twenty-nine multi-disciplinary teams representing over half of the hospitals in the state working towards ensuring that the sickest ED patients get the care they need quickly, in a timely manner with the smallest possible exposure to preventable healthcare associated harm. Teams have begun to implement a series of change strategies that have been recommended in the scientific literature or reported as successful by other hospitals. These strategies are included in the Improvement Guide.
Michigan Keystone ICU project
The Michigan Health and Hospital Association's (MHA) Keystone Center for Patient Safety and Quality was created in March 2003 with some funding from the Agency for Healthcare Research and Quality (AHRQ). MHA Keystone brings together hospitals, national experts and best practice evidence to improve patient safety by addressing the quality of healthcare delivery at the bedside. One of Keystone's most ambitious collaboratives, the Keystone ICU (KICU), exists through an ongoing and innovative partnership with patient safety experts at Johns Hopkins University. As of June 2005:
- 127 ICU's representing more than 70 hospitals were involved.
- 68 of the participating ICU's had reported no bloodstream infections or ventilator associated pneumonia for six months or more.
The final results of the 18 month study involving 103 ICUs were published in the New England Journal of Medicine (NEJM) in December, 2006. The NEJM reported that 103 Michigan intensive care units (ICUs) reduced catheter-related bloodstream infection to zero at three months. Up to 66 percent sustained the zero rates during the 18-month study period.
A study at one Michigan hospital implemented a reminder system that was found to reduce, by seven percent, the amount of time an indwelling urinary catheter is in place, a step that could help stem infections among the 25 percent of hospital patients who have urinary catheters in place at any given time.
The Michigan Hospital Association's toolkit consists of a series of recommendations based on current research and best practices. It was developed by a nine-member volunteer workgroup of health professionals experienced in leading ICUs and improving patient safety and quality of care.
2010 Update: Ninety of the Michigan ICUs reported the reduced rates of catheter-related bloodstream infections (CLABSI) achieved in the initial 18-month study were sustained for an additional 18 months. The mean and median rates of CLABSI decreased from 7.7 and 2.7 percent at baseline to 1.3 and 0 percent at 16-18 months, and to 1.1 and 0 at the 34-36 month post-implementation period, representing a greater than 60 percent reduction in infection rates from baseline sustained at the end of the 36-month period. See the May 2010 Safety Share for complete details
- Press release (2005)
- Pronovost study abstract – Catheter-related bloodstream infections
- Abstract: Reminder Reduces Urinary Catheterization
- Michigan ICU Toolkit
- Michigan Keystone Center Web site
- Michigan Keystone Center CLABSI insertion checklist 2006
- May 2010 Safety Share
New Jersey Hospital Association ICU collaborative
The New Jersey Hospital Association (NJHA) ICU collaborative, an initiative of the NJHA Quality Institute, was initiated in June 2004. Twenty-four hospitals and health systems encompassing more than 30 facilities were involved in the initial phase of the project, which uses a collaborative model to report data, reinvent processes and share best practices in ICU care. Expert faculty members Dr. Peter Pronovost of Johns Hopkins University and Dr. Thomas Rainey, chairman of the Institute for Healthcare Improvement's ICU initiative, lead the effort. It is based on a successful model used in IHI's 100,000 Lives Campaign. As reported in June 2005, results based on data reports from all participating hospitals show that:
- The rate of ventilator-associated pneumonia decreased from 5.12 in June 2004 to 3.29 in January 2005.
- The rate of catheter-related bloodstream infections fell from 7.2 in June 2004 to 4.82 in January 2005.
- The average ICU length of stay declined from 4.28 days in June 2004 to 3.59 days in January 2005.
The New Jersey Hospital Association ICU Collaborative focuses on several dimensions of care, including culture of patient safety, ventilator-associated pneumonia and catheter-related blood stream infections. Collaborators analyze evidence-based practices to update ICU protocols and introduce patient safety improvements, utilize workshops, surveys, and conference calls to facilitate communication and determine best practices.
Additional resource
Pittsburgh Regional Health Initiative (PRHI)
The Pittsburgh Regional Health Initiative (PRHI) is different from other initiatives that routinely convene experts in various healthcare areas to generate discussion and the sharing of ideas. The unique elements include:
- Regional collaboration: This collaboration is a built on professionally safe, neutral clinical working groups so the best thinking can be rapidly shared throughout the region. Information is shared on best practices across competitive lines. Current working groups include cardiac surgery teams; critical care and emergency medicine physicians; chronic conditions; infection control; and long-term care.
- Perfecting Patient Care™: In a frontline approach to problem solving, care teams learn how to implement the best practices every time. Studies confirm that, even when clinicians know the best therapies, they may not always be able to apply them in the day-to-day chaos of practice. Practitioners schooled in Perfecting Patient Care learn a disciplined and detailed approach to solving problems quickly, one by one, in the course of work, always aiming toward perfection instead of an arbitrary benchmark.
According to a CDC report based on the Pittsburgh initiative, the participants have reduced bloodstream infections associated with the use of intravenous catheters by 63 percent during the past four years. The overall incidence of catheter-related bloodstream infections has dropped from 4.3 to 1.6 bloodstream infections per 1,000 catheter days. Participating hospitals began a strict enforcement of safety guidelines in 2001 and the strict implementation of a set of practices known to reduce the risk of infections during catheter insertion. The bundle included the use of large sterile barriers, gowns, gloves, masks, and head coverings; application of appropriate skin antiseptics; insertion of the catheter in the neck versus the groin area; and completion of a checklist verifying that all infection control procedures were followed. All were used correctly with empowerment of nurses to intervene when protocols were not followed to assure compliance.
2010 Update: A team from Allegheny General Hospital (tertiary, academic center in Pittsburgh) used Perfecting Patient Care to identify root causes of CLABSIs, and designed intensive staff training and standardized line insertion procedures to reach zero CLABSIs within 90 days. The hospital has since remained at or near zero CLABSI by adding regular refresher training, annual physician recertification for central line insertion, and intensive initial training for new staff.
