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Dr. Peter Pronovost
Dr. Peter Pronovost

The future of healthcare: Patient safety

Zero tolerance: Hospital executives play a key role in defeating deadly infections

By Dr. Peter Pronovost
Posted: July 25, 2011 - 12:01 am ET

When polio struck the U.S. in the early 1950s, scientists and commercial industry worked diligently together to develop a cure that led to the National Polio Vaccination Program, eliminating polio in most countries. Over the past several years, an ever-increasing number of hospitals have collaborated within their facilities to reach and sustain a rate of zero central line-associated bloodstream infections—which kill 31,000 annually in the U.S., nearly as many deaths as breast cancer.

Similar to the polio campaign, it took robust measurement, science and concerted efforts by many to establish a chain of accountability to eradicate these infections. Everyone in the hospital is an important link in the chain.

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Based on our experiences while working with more than 1,000 hospitals in 45 states, on-site visits, and on interactions with health professionals in hospitals, we see significant reductions when all of the following occurs:

A senior hospital leader commits to a goal of zero infections. It is not sufficient for the leader to say they want a low infection rate. They must commit to zero.

A senior hospital leader holds unit-level leaders (not the infection prevention professionals) accountable for central-line infection rates. This means, expecting unit leaders to routinely present data on infection rates and weeks without an infection to their senior executives and board of trustees, and expecting unit leaders (working with infection prevention professionals), to investigate every infection and report their findings (e.g., where the line was placed and whether the insertion or maintenance was the mode of the infection) to senior leaders within days of an infections occurrence.

Hospital managers make it easy for staff to comply with the central line insertion checklist. This means providing a line cart or a kit that meets the needs of staff in each unit where lines are inserted and consistently stocking all of the needed supplies.

Unit physicians and nurse leaders own the problem. These staff members should know their infection rates and should be accountable for improvement.

Clinical leaders standardize catheter insertion and maintenance practices across their hospital. They must ensure that staff are aware of these practices, then audit staff and report back their performance. Besides creating a policy for catheter maintenance, clinical leaders should also gather “ground truth,” observing work and ensuring clinicians perform the expected behaviors.

Clinical leaders create and enforce a policy that empowers nurses to stop a line insertion (or any potentially harmful act), and engages senior physicians in serving as role models by supporting this empowerment.

Clinical leaders and infection preventionists build central-line infection prevention training into physician and nurse orientations. If your hospital employs residents or other rotating doctors, clinical leaders should also ensure each new rotating doctor on a unit receives this training.

Infection preventionists work closely with unit-level teams to train, monitor and investigate infections and to improve performance. Infection preventionists are the in-house experts. Tap into their expertise to aid your efforts, rather than limiting their role merely to data collection. Yet, hold the clinicians who insert and use catheters accountable for infection rates.

Unit leaders and infection preventionists investigate all central-line infections as defects. Each investigation should examine whether the checklist was used appropriately, where the catheter was placed (if placed in the operating room, take the issue to the OR), and whether the infection most likely resulted from the insertion or maintenance practices (not a perfect distinction, but helpful).

The longer a catheter is in place when an infection occurs, the more likely it is due to maintenance. The investigators can develop a plan to prevent future infections based on their results.

Unit nurses review and audit catheter maintenance policy and practices.

Providers avoid placing catheters in the groin whenever possible. This may require that clinicians obtain additional training, including in the use of ultrasound.

Infection preventionists post the quarterly rate of infections, the number of patients infected, and the weeks without any infections in clinical units where infections are measured, and routinely report these data to senior leaders. All unit staff should know their infection rates.

Hospitals that reached zero infections were not fluke occurrences. They implemented this series of specific practices—practices that any hospital can implement. Far too many patients continue to suffer preventable harm from central line infections.

Yet, there is hope. Large, small, academic and community hospitals across the country have demonstrated that achieving and sustaining zero infections is possible. In these hospitals, individuals from every level of the organization worked together to achieve a common goal: eliminating these infections. You can then apply these tasks to reduce other types of preventable harm.

Dr. Peter Pronovost is medical director at the Center for Innovation in Quality Patient Care at Johns Hopkins Medicine.

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