COMMENTARY

John Bartlett's Game Changers in Infectious Disease: 2011

John G. Bartlett, MD

Disclosures

October 26, 2011

In This Article

Central Line-Associated Bloodstream Infections

A sentinel hospital study, conducted by the Centers for Disease Control and Prevention (CDC), analyzed systematic data from 19 hospitals that were thought to be representative of hospitals in the United States. Central line-associated bloodstream infections (CLABSI) for 2009 (18,000 cases) were compared with those for 2001 (43,000 cases) (Table1).

Table 1. Estimated Number of CLABSI in the United States, 2001 and 2009

Setting Year No. (95% CI)
Intensive care units 2001
2009
43,000 (27,000-67,000)
18,000 (12,000-28,000)

CI = confidence interval Data from CDC.[10]

A 58% reduction in CLABSI was demonstrated, an incredible achievement. CDC study authors estimated that if all hospitals reduced their CLABSI rates by this amount, 27,000 lives and $1.8 billion/year would be saved. The future of healthcare in the United States places great emphasis on saving lives and dollars. This CLABSI story is right in the center of healthcare reform and, to a large extent, predicts that "harm reduction" will receive even more attention in any new healthcare policies and plans. The question is: how did we reduce the frequency of CLABSI by this much? This result was not circumstantial but followed a crafted and logical series of events:

2001: A 5-step CLABSI "bundle" was defined to include: hand hygiene, full barrier precautions, skin cleansing with chlorhexidine, avoidance of the femoral site, and prompt removal of unnecessary catheters.

2003-2005: The Keystone Project implemented this bundle in 103 intensive care units (ICUs) in Michigan and showed a decline in rate of CLABSI from 7.7% to 1.4%.[11]

2008: The Department of Health and Human Services (HHS) rolled out 28 state programs to incorporate this bundle with the target of reducing CLABSI by 75%.

2009: A review of the Michigan ICU data showed that the previously demonstrated benefit had been sustained. Further reductions occurred, adding up to a 70% reduction compared with baseline rates of CLABSI.[12]

2010-2011: The Joint Commission incorporated the CLABSI bundle. Blue Cross and Blue Shield provided financial incentives for using the bundle and LeapFrog bestowed accolades for its use.[13]

Why Is This a Game Changer?

The totality of this sequence of events is now credited to a large extent with the substantial reduction in the rates of CLABSI along with the impressive accomplishment reported by the CDC. This not only signals an important advance that should be put into practice but it also reflects a change in methodology for healthcare reform. This would not have happened 10 years ago in terms of funding for the study (Blue Cross and Blue Shield) or the method of implementation with rapid engagement by the payers, HHS, The Joint Commission, LeapFrog, and others.

What Does This Mean to the Practitioner?

  • Expect more "bundles."

  • These interventions have the attention of the payers and hospital administrators. Incentives for compliance and/or penalties for noncompliance should be anticipated. Medicare performance indicators ("marching orders") will follow.

  • The next bundle will be prevention of ventilator-associated pneumonia, which is already far along in the process.[14]

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