Sunday, December 17, 2006

What Works -- Part 4 -- Central Line Infections

Central line-related bloodstream infections are a serious problem in hospitals. A central line is a port installed directly into a major blood vessel to permit a catheter to be used for the quick delivery of medication for patients in ICUs and in other settings. Because of the direct connection to major blood flow, an infection associated with the installation will flow quickly into the blood stream and to major organs. This article from the Centers for Disease Control attributes a mortality rate of 12 to 25 percent (!) for each infection -- not to mention increasing costs by about $25,000.

The Institute for Healthcare Improvement likewise notes that "up to 4,000 catheterized ICU patients die each year in the US from avoidable infections and organ failure (sepsis) related to central venous catheters (CVCs). . . . Forty-eight percent of ICU patients in the US have central venous catheters, accounting for 15 million central-venous-catheter-days per year in ICUs. . . . Within this population, studies indicate an estimated 4% to 20% (500-4,000) of patients will die from catheter-related bloodstream infections."

Like others in the country, the medical leadership at BIDMC decided that our current rate of central-line infections was too high and set about to change it. When we started, our average rate of central line infections per thousand patient days in the ICUs was about 3. This was better than what we often see nationally, but our doctors were impatient to improve it. After all, each case has a high potential for serious patient injury or death. So the goal is to get to zero.

This turned out to be a multi-faceted problem. Central lines are often inserted by residents who have been trained how to do the insertion by other residents. (Dr. Atul Gawande provides a vivid description of this learning process in his book Complications: A Surgeon's Notes on an Imperfect Science.) Beyond the insertion process, decisions must be made about how long the line should stay in, and how often it should be maintained. Very often, there are only informal rules of thumb in a hospital for these determinations -- and there is often wide variation even within a single hospital.

Our folks set about to make this process more rigorous, analytical, and controlled. Sessions were held among surgeons, medical doctors, anaesthesiologists, nurses, and residents to reach a consensus on the proper method for inserting a central line. A specific kit was designed, so that anyone inserting a line had the full complement of supplies at hand. Detailed rules were established for the protocols surrounding maintenance of the line and its withdrawal. And, a system was set up so that every single infection that occurred would be analyzed to determine its cause -- so corrective measures would be taken going forward.

Here are the month-to-month results for the first year of the program:

Month ----- Infection Rate
Oct 05 ----- 1.67
Nov 05 ----- 1.28
Dec 05 ----- 2.43
Jan 06 ----- 3.07
Feb 06 ----- 1.40
Mar 06 ----- 1.07
Apr 06 ----- 0.00
May 06 ----- 0.59
Jun 06 ----- 1.15
Jul 06 ----- 0.57
Aug 06 ----- 3.03
Sep 06 ----- 2.50
Oct 06 ----- 0.00

As you can see, the figure goes up and down, although progress is good. The key thing is that every single case of infection is analyzed thoroughly, with the results shared across the broad range of hospital staff in the ICUs. What goes wrong? As many things as there are people. For example, one day, our chief of medicine happened to go by as another member of the staff was not following the protocol. When he pointed it out -- and none too gently! -- the person was embarrassed and really had no excuse for doing it wrong. So human nature often comes to play. Sometimes more technical factors arise. Regardless of the cause, each case is used to reinforce the program.

With about 1600 ICU patient days per month at BIDMC, the difference between an infection rate of 0.0 and one of, say, 2.5 is 4 actual people. Over the course of a year, that same difference amounts to 48 people who either get or do not get an infection. Applying the CDC's cited mortality rate of 12 to 25 percent, the difference amounts to saving the lives of 5 to 12 people -- just at our hospital.

When you look at numbers like those, you can see why our medical staff -- and people around the country -- are rabid about making this improvement real and permanent. Doctors and nurses devote their lives to alleviating human suffering caused by disease. They are heartbroken by the thought that their own well-intentioned actions might lead to death, and they are driven to get better and better at what they do.


Anonymous said...

Congratulations. It shows that significant improvement can happen when leadership and determination come together.

My questions are: as you analyze each infection to determine the cause and how the process can be improved going forward, how does the need to promulgate the results among your people (and perhaps share your experience with other hospitals) affect malpractice litigation -- number of suits, likelihood of an award and the size of an award? Would specialized healh courts as a replacement for the jury system largely take this issue off the table in trying to learn from mistakes, publicize your findings, and spread best practices?

Anonymous said...

This is a laudable effort, and as someone involved in marketing writing, I know it's gutsy of you to post the months that have less-flattering numbers, too - especially since you're in a business where some people are all to eager to (literally and figuratively) bury their mistakes. Good for you, and I invite everyone to be as open!

It sounds like your work used some of the methods of Six Sigma quality improvement. Do you use (or study) any formal discipline like that or is it all home-grown thinking?

Anonymous said...

This is a wonderful program, Paul, and a beautifully written explanation of the complexities involved in driving and measuring change. Thank you for making what goes on in the hospital real, accessible, and transparent in a way that is easy to understand for someone with a non-clinical background. It is very clear that you and the rest of your staff at BID really care about what you all do together, and that you have created an environment that allows people to interact in this way. I really enjoy reading your blog each day!

Anonymous said...

Dear bc,

Our hospital is a member of the Risk Management Foundation, a non-profit organization that shares claims and quality information throughout the Harvard hospital system (BIDMC, MGH, the Brigham, Children's, and others). When any of us learn something worthwhile that might improve patient safety and quality, or affect malpractice claims, we share that with one another. Under RMF's auspices, we also do research on promising area of quality improvement. Also, being an academic medical center, our faculty often public articles in medical journals about progress in this arena.

So, I guess I am not sure if a specialty health court system would result in greater promulgation of this kind of material. I would welcome other folks' thoughts on that question.

Anonymous said...

Dear patient dave,

We try to borrow and learn from other disciplines, but, truthfully, a lot of this is home grown. Medicine is not an industrial process, with repetitive and somewhat uniform inputs and outputs. While there can be general rules, the patient's particular situation requires physician and nurse judgment, and so you have to leave them the discretion to override the general rules.

Also, we do not have the same people doing the same functions all the time. Many of them are trainees: A resident who is assigned to the ICU today might be seeing it for the first time, having spent time on other floors and in other disciplines before.

Six Sigma is more likely to show up in more process-oriented situations like clinical laboratories. The improvement in central line infection rates in the ICU is certainly based on documented best practices from elsewhere in the health care field -- for example, those collected by IHI -- but the actual implementation process has to be cognizant of the culture of an academic medical center.

Anonymous said...

> Six Sigma is more likely to show up
> in more process-oriented situations
> like clinical laboratories.

Got that. Besides, I'm always looking to distill the "active ingredient" in any process - I don't care that much about the literal methods.

One approach I've seen in a non-industrial situation is

- let the customer, not your opinion, decide what's a failure.

- be data-driven (not subjective)

- analyze every single failure incident to understand how it arose, address those causes, and if necessary add more measurements to keep track of improvement there too.

And it sounds like that's basically what your team did.

Anyway, pass our admiration to the people whose commitment to improvement is trumping any concern about covering their own butts. This is a new world that's very much worth creating.

Anonymous said...

congratulations on your diligent work!

this is an area that will be in the headlines more once Patients First begins to publish these rates next year (altho they plan to use catheter days not icu patient days as their denominator).

Anonymous said...

Congratulations. The example of an academic medical center showing that "zero" is possible will add will and optimism to many others. Thanks for this terrific work, and for the transparency.

--Don Berwick

pdozier said...

Nice to see such openness. You might want to visit visit They are launching disposable products for infection control for IVs while showering, bathing, and so forth as a direct respone to the CDC Guidelines. I know they are looking for trial opportunities and feedback. Cheers, and keep up the good work.