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 studied hospital mortality of patients admitted to ICUs before, during, and after implementation of the project and compared that with similar data from 11 surrounding states. The data demonstrated that patients treated in hospitals participating in the project were significantly more likely to survive a hospital stay during and after its implementation.

“Patient safety initiatives like the Keystone ICU Project are important to reducing the burden of catheter-related bloodstream infections.”

Although prior research has demonstrated that the Keystone ICU Project has been associated with a reduction in catheter-related bloodstream infections at participating hospitals, the BMJ study is the first to show that its use directly lowers mortality. We believed that when we applied the safety science principles to the delivery of healthcare that we would dramatically reduce infections in ICUs. This new data shows us that we’re also saving lives. Conservatively, thousands of people are believed to have survived because of the efforts of this project. Although our findings cannot definitively attribute the mortality reduction to the Keystone ICU Project, this is perhaps the only large-scale study to suggest a significant reduction in mortality from a quality-improvement initiative.

More to Come From the Keystone ICU Project

Patient safety initiatives like the Keystone ICU Project are important to reducing the burden of catheter-related bloodstream infections. The project was relatively low in cost and decreased the rate of catheter-related bloodstream infections, and our research did not show any negative effects for participating ICUs. These findings strongly support the investment in similar quality-improvement initiatives to maximize patient benefits. The Keystone ICU Project is now being rolled out throughout the U.S. and 40 states are now participating. Preliminary data from some of the early adopters has been encouraging, and there is optimism that more hospitals will benefit by implementing this intervention in the future. Local physician leadership is essential to success in this program.



Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ. 2011;342:d219. Available at:

Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732.

Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ. 2010;340:c309.

Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23:207-221.