CUSP highs and lows

A four-year federally financed program aimed at reducing rates of central line-associated bloodstream infections made big strides in prevention but not necessarily in state-by-state participation.

According to preliminary data released Sept. 10, just weeks before the project's scheduled end, rates of such infections declined by 40% among the more than 1,100 hospitals that participated in the program, known as On the CUSP: Stop BSI.

That's a marked improvement from an earlier progress report released by the Agency for Healthcare Research and Quality around this time last year, which showed a 33% drop in central line-associated bloodstream infections among participating hospitals.

States' participation in the program has been uneven, however, said Dr. Peter Pronovost, head of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins University, Baltimore. Of the 44 states that took part, only five—Hawaii, Maryland, Washington, Delaware and Alabama—and the District of Columbia were able to recruit more than 50% of the hospitals in their states.

Many fell far shorter. Texas, for instance, enlisted only 6.5% of its hospitals—34 out of 520—according to data published by AHRQ. Two of New Mexico's hospitals took part in the program, a participation rate of just under 5%.

Those that did take part have seen, on average, significant drops in their infection rates and related costs and complications. As a result of this latest 40% decrease in infections (about 2,000 fewer than would have been expected without the program), 500 lives were saved and $34 million in additional healthcare costs were avoided, said AHRQ, which funded the national rollout of On the Cusp: Stop BSI.

Many hospitals saw even better results, Dr. Carolyn Clancy, AHRQ's director, said during an event marking the release of the project's latest results.

Peterson Regional Medical Center, a 124-bed facility in Kerrville, Texas, hasn't had a single central line-associated bloodstream infection in 31 months, said Theresa Hickman, a nurse educator at the hospital. Easton, Md.-based Shore Health System also saw central-line infections fall to zero in its two hospitals' ICUs. It has been more than 1,000 days since 44-bed Dorchester General Hospital, Cambridge, Md., had a central line-associated bloodstream infection, and more than 800 days at 107-bed Memorial Hospital at Easton (Md.), said Dr. Michael Tooke, Shore Health System's chief medical officer.

Developed by Pronovost and his colleagues, the CUSP framework—CUSP stands for Comprehensive Unit-based Safety Protocol—uses a simple set of evidence-based practices, including a checklist. It also emphasizes teamwork, leadership by frontline clinicians and the use of common measurement.

“We've had guidelines for a long time, but this approach is different because it makes sure that the team takes ownership of the safety problems in their unit,” said Dr. James Cleeman, senior medical officer in AHRQ's Center for Quality Improvement and Patient Safety.

In February 2009, following a much-publicized initiative that used the CUSP model to virtually eliminate central line-associated bloodstream infection in more than 120 intensive-care units in Michigan, AHRQ, in partnership with the Health Research and Educational Trust, extended funding for the program to 10 additional states.

Soon after, in October 2009, AHRQ green-lighted a national expansion of CUSP for central line-associated bloodstream infections, which relied on state hospital associations to lead recruitment efforts.

State hospital associations, though, have varied in their enthusiasm for enlisting hospitals, Pronovost said. And some rural states have mostly smaller hospitals that place few central lines, he added.

But other states say they made a conscious choice to limit the number of hospitals in the program. Louisiana, for instance, enrolled 17 units across 13 of its 192 hospitals, a participation rate of 6.8%. “We hadn't participated in a project like this before, so for me, it was important to have the ability to manage the data and have the infrastructure,” said Kenneth Alexander, vice president of quality and regulatory activities at the Louisiana Hospital Association. Alexander says the LHA limited the number of participating units to 20. “We're just under the number of units I felt like we could work with at a given time,” he said.

After the AHRQ funding for On the Cusp: Stop BSI ends later this month, the Louisiana Hospital Association plans to continue its focus on infection prevention through HHS' Partnership for Patients, as part of its work with HRET's Hospital Engagement Network, Alexander added. HENs are networks of hospitals that are tasked with helping their members to reduce patient harm by 40% and readmissions by 20% by 2013.

The Oregon Hospital Association, also part of HRET's HEN, also plans to target central line-associated bloodstream infections through the Partnership for Patients, said Diane Waldo, the association's director of quality and clinical services. Oregon recruited only 10 of its 59 hospitals for the CUSP program, but Waldo said that's partly because the state has a large number of critical-access facilities.

The hospitals that did participate saw great results, she said, adding that average rates were roughly 0.66 infections per 1,000 central-line days.

“The Partnership for Patients will provide us with a new opportunity to engage hospitals that may not have participated previously,” Waldo said. “We're also planning to extend the program to NICUs.”

Pronovost said he hopes the program's results put added pressure on the hospitals whose rates of central-line infections are higher. “When we have 1,100 hospitals whose infection rate is one, on average, it shows it can be done.”