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A Quality Improvement Strategy to Reduce Infection Rates

An estimated 80,000 patients each year experience catheter-related bloodstream infections during treatment in hospitals, about 31,000 of whom die, and the cost of treating these infections may be as high as $3 billion nationally. In 2009, the United States Department of Health and Human Services called for a 50% reduction in catheter-related infections nationwide by 2012. Institutions throughout the U.S. have initiated different interventions to accomplish this feat, but with varying degrees of success. Reducing Bloodstream Infection Rates Several years ago, the Keystone ICU Project was launched. Developed by Johns Hopkins University in partnership with the Michigan Hospital Association, the project utilizes a checklist for healthcare providers to follow when placing catheters. The checklist highlights five basic steps to decrease catheter-related bloodstream infection rates: 1. Promoting hand washing. 2. Full barrier precautions. 3. Skin antisepsis with chlorhexidine. 4. Avoiding the femoral site during catheter insertion. 5. Removing unnecessary catheters. Along with the checklist, the Keystone ICU Project promotes a culture of safety consisting of safety science education, training in the identification of potential safety problems, development of evidence-based solutions, and measurement of improvements. A key aspect of the program was to empower all caregivers—regardless of their level of experience—to question each other and stop procedures if safety is compromised. Profound New Data on Eliminating Infections In the January 31, 2011 issue of BMJ, my colleagues and I had a study published. It found that the virtual elimination of catheter-related bloodstream infections in ICUs throughout Michigan through the Keystone Project correlated with a 10% reduction in mortality rates in the state when compared to surrounding states. Using Medicare claims data, we...

Measuring Preventable Harm

Although the healthcare community has expressed a strong desire to measure safety outcomes, accomplishing this feat has been challenging due to poor investment in the basic science of patient safety. There is a need for basic science because it can allow for better understanding of the causes of harm, help in designing and pilot testing interventions to reduce harm, and enable researchers to evaluate the effects of harm. To advance the science of measuring safety outcomes, it’s critical to separate and distinguish preventable harm from inevitable harm. In healthcare, the term preventable harm differs substantially from that in other industries. Despite receiving evidence-based medical therapies, some patients will inevitably die or sustain complications and problems that are preventable are likely to change over time. It’s important to consider strategies that tease apart preventable harm from inevitable harm, such as: Assuming all harm is preventable (high sensitivity, low specificity). Adjusting for preventability (low sensitivity, low specificity). Linking care received to outcomes (high specificity, low sensitivity). Assessing Potential Strategies Virtually all harm has been labeled as inevitable for decades by clinicians, but recent efforts by payers (eg, CMS) have aimed to label all harm as preventable. This strategy could be appropriate when evidence suggests that most harmful events are preventable. However, the problem is most measures of harm are missing one or several of the required validity components. Most harms are preventable to some degree, but we don’t have evidence to tell us how much. Another strategy could be to use risk-adjustment models to account for preventable and inevitable harm. Such models typically adjust for severity of illnesses, patient demographics, comorbid...
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