Simple measures reduce infections

Hopkins study finds catheter rules, clean hands aid hospitals

December 28, 2006|By Chris Emery | Chris Emery,Sun reporter

A study by Johns Hopkins researchers offers strong evidence that careful adherence to a few simple and cheap procedures - as basic as hand-washing - can drastically reduce the spread of infection in hospitals.

The Hopkins researchers tracked infection rates in Michigan hospitals that had agreed to institute strict safety practices for catheters, which are small tubes inserted into patients' veins. Used to administer medication and nutrients to some patients, the tubes can also be the source of life-threatening infections.

A year and a half after the changes were made, the rates of catheter-related bloodstream infections dropped by 66 percent, according to the study, published today in The New England Journal of Medicine.

"The results are pretty breathtaking," said Dr. Peter Pronovost, the lead author and a professor of anesthesiology and critical care medicine at the Johns Hopkins University's School of Medicine. "The numbers of infections went down quickly and they stayed down."

He said the catheter protocols studied in Michigan hold broader lessons for curbing the spread of germs in hospitals nationwide.

The federal Centers for Disease Control and Prevention estimates that 90,000 Americans die every year from infections they contract while hospitalized.

Public outcry in Maryland and elsewhere led the General Assembly to pass a law last spring requiring certain health care facilities to track and report hospital-acquired infections.

Because many such infections are thought to result from antibiotic-resistant organisms, hospitals have been searching for ways to prevent the spread of the germs without relying on drugs.

Last summer, Franklin Square Hospital and Johns Hopkins began a two-year pilot project to test methods that include stricter hygiene protocols.

Pronovost said his study in Michigan proves the effectiveness of simple measures.

"We think this model really helps to advance the science of patient safety," he said. "It shows what's possible. We no longer have to accept the infections as inevitable."

To ensure that doctors and nurses adhered to the safety protocols, the researchers instituted a team approach comparable to that used by airplane pilots and in the business world. This included setting daily performance goals and following checklists.

Dr. Richard P. Wenzel, who co-wrote an editorial on the study, called the outcome dramatic.

"This is one of the most important papers in the last decade," said Wenzel, chairman of the department of internal medicine at Virginia Commonwealth University in Richmond.

The Hopkins team focused on improving the safety of central venous catheters, a type that is inserted into most patients treated in intensive-care units. About 80,000 ICU patients contract infections from bacteria that contaminate such catheters every year, and about 35 percent of those patients die from the infections, according to CDC estimates. Treating a patient for a catheter-related infection costs $45,000 on average.

"When you open up your vascular system to the outside world, which is what these catheters do, you now have a direct route for bacteria to get into the bloodstream," said Dr. Michael B. Edmond, a hospital epidemiologist at VCU. "Bacteria in the bloodstream is a very bad infection."

The Hopkins study was part of the Keystone initiative, an effort to improve overall ICU safety in Michigan. To reduce the numbers of catheter-related infections, the Hopkins researchers formed teams of doctors and nurses at more than 100 intensive-care units. The teams implemented several precautions known to be effective.

These included rigorous hand-washing, thorough cleaning of the skin around catheters, and wearing sterile masks, gowns and gloves. Doctors removed catheters from patients as soon as possible and avoided inserting catheters in the groin area.

Checklists were used as memory aids.

The guidelines were introduced in March 2004. Within three months, rates of infection in many of the hospitals dropped to zero. Within 18 months, all of the ICUs had cut catheter-related infections by two-thirds on average.

"It really had a big impact across many hospitals," Edmond said.

Edmond said cost is another benefit.

"They didn't do things that cost a lot of money," he said. "It was just about doing things the right way."

Edmond said he was skeptical when he first saw the results of an earlier, smaller study published by the Hopkins researchers. "It was such a small thing they did to have such a huge impact.

"I asked colleagues of mine and they said, `It's real.'"

Afterward, he introduced a similar approach at VCU, and the rates of catheter-related infections dropped there as well. Yet he cautioned that changing the culture in hospitals is more difficult than it sounds.

"It is simple on its face, but at a system level it is complicated," he said. "For example, if a doctor doesn't have a nurse there to help with the checklist, it often doesn't get done correctly."

Getting doctors and nurses to consistently adhere to safety guidelines was a difficulty also noted by Wenzel. Previous studies have shown that hospital workers wash their hands less than half as often as they should, he said.

"We've know for 150 years that hand-washing works, but they created a team-based approach. They took it away from the individual and made it zero tolerance," he said.

Pronovost also linked the method's success to collective vigilance.

"These interventions don't work unless there is a collaborative culture," he said. "You have people with hopes and dreams and egos working in these hospitals. The key lesson is how to work together with all of them."

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