title: Interventions to decrease catheter-related bloodstream infections in the ICU: the Keystone Intensive Care Unit Project.
abstract: BACKGROUND
  A quality improvement initiative that included rigorous measurement, feasible interventions, and cultural change was shown to nearly eliminate catheter-related bloodstream infections (CR-BSIs) in patients in a surgical intensive care unit (ICU). To build on this research, a statewide collaborative cohort study was conducted using the same evidence-based interventions.
  
  
  METHODS
  Interventions included handwashing, using full barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters. Both technical and adaptive (cultural) aspects of implementing the intervention were addressed through engagement, education, execution, and rigorous evaluation. A "team checkup tool" was developed to help senior leaders assess their role in ensuring compliance.
  
  
  RESULTS
  Of 108 ICUs in the study, 103 reported data. Analysis included data from 1981 ICU-months and 375,757 catheter-days. The regression model showed a significant decrease in CR-BSI rates from baseline, with incidence-rate ratios decreasing from 0.62 at zero to 3 months after implementing the intervention to 0.34 at 16 to 18 months. Preliminary analysis suggested CR-BSI rates were sustained 4 years after implementation of the intervention.
  
  
  CONCLUSIONS
  Results suggest that this program model can be generalized and be implemented on a large scale in the United States or the world to significantly reduce the rate of CR-BSIs and their associated morbidities, mortalities, and costs of care.
authors.affiliation: Quality and Safety Research Group, Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA. ppronovo@jhmi.edu
authors.forename: Peter
authors.initials: P
authors.lastname: Pronovost
mesh_terms: D002408:Catheters, Indwelling / Q000009:adverse effects* / Q000382:microbiology*; D015331:Cohort Studies; D003428:Cross Infection / Q000453:epidemiology* / Q000517:prevention & control; D055317:Evidence-Based Practice; D019983:Guideline Adherence; D006801:Humans; D017053:Infection Control / Q000379:methods / Q000592:standards*; D007318:Inservice Training; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D016015:Logistic Models; D015397:Program Evaluation; D015203:Reproducibility of Results; D012306:Risk; D013503:Surgery Department, Hospital