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Background

The Centers for Disease Control and Prevention (CDC) estimate that roughly two million health care-associated infections occur each year in U.S. hospitals. These infections result in approximately $40 billion in excess health care costs and as many as 99,000 deaths. More people die as the result of health care-associated infections (HAIs) than from breast cancer, AIDS, and auto accidents combined. However there is good news: most HAIs are preventable.

In 2009, the Department of Health and Human Services (HHS) launched the HHS Action Plan to Prevent Healthcare-Associated Infections. As part of this action plan, the Agency for Healthcare Research and Quality (AHRQ) increased support and scope of a project funded in 2008 to reduce central line-associated bloodstream infections (CLABSI) and funded a second initiative to reduce catheter-associated urinary tract infections (CAUTI). Both of these projects, On the CUSP: Stop BSI and On the CUSP: Stop CAUTI, apply the Comprehensive Unit-based Safety Program (CUSP) to improve the culture of patient safety and implement evidence-based best practices to reduce the risk of infections.

On the CUSP: Stop BSI

In 2003, the Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality (MHA Keystone Center), together with patient safety innovators from the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality (formerly the Johns Hopkins University Quality and Safety Research Group) implemented a project in 127 intensive care units in the state of Michigan to apply the CUSP culture change model and evidence-based interventions to reduce CLABSI. The Michigan ICU project was an astounding success, achieving within 18 months a median CLABSI rate of zero and sustaining these reductions to the present time.

In 2008, AHRQ awarded a contract to the Health Research & Educational Trust (HRET), the research and education affiliate of the American Hospital Association, to work with project partners at Johns Hopkins and the MHA Keystone Center to replicate the 2003 Michigan ICU project to reduce CLABSI in ten states across the country. Like the earlier Michigan project, this new initiative, On the CUSP: Stop BSI, implemented the CUSP culture change model and evidence-based interventions to reduce CLABSI. AHRQ expanded the project nationwide in 2009 and in 2010 began providing limited financial support to states.

Forty-four states, the District of Columbia, and Puerto Rico all enrolled hospitals in On the CUSP: Stop BSI, and collectively, more than 1,055 hospitals and 1,775 hospital unit teams have participated in the program. By September 2012, there had been an overall relative reduction of 40 percent in CLABSI rates in participating intensive care units, and more than 2,000 CLABSIs had been prevented. More than 500 CLABSI-related deaths were prevented, and more than $34 million in health care costs were avoided.

Case studies from the On the CUSP: Stop BSI initiative are available on the AHRQ website. The action guide, Stories of Success: Using CUSP to Improve Safety, tells the stories of four hospitals that participated in the initiative and applied the Comprehensive Unit-based Safety Program, or CUSP, to dramatically reduce central line-associated bloodstream infections (CLABSI) and other health care-associated infections.

On the CUSP: Stop CAUTI

In 2007, the MHA Keystone Center implemented a project to reduce CAUTI, the most common of all HAIs, in 163 inpatient units in 71 Michigan hospitals. The project implemented two separate bundles, one of which emphasized the timely removal of nonessential catheters and the proper care of necessary catheters, while the second bundle addressed the insertion of catheters, both appropriate indications and proper insertion technique. Participating hospitals achieved a reduction in indwelling catheters from 19 percent to 14 percent between January 2007 and December 2010, resulting in an estimated 26 percent reduction of patients with urinary catheters and a 30 percent improvement in appropriate catheter use.

The national On the CUSP: Stop CAUTI effort began in 2009 with AHRQ support and with the goal of reducing mean rates of CAUTI in participating clinical units by 25 percent. Like the Stop BSI initiative, Stop CAUTI looks to the work of the MHA Keystone Center as a model and uses the CUSP framework developed at Johns Hopkins to address culture change. On the CUSP: Stop CAUTI was expanded nationwide, and since the launch of the first cohort of participating states in late 2010, more than 1,300 units in approximately 850 hospitals in more than 36 states have joined the initiative. AHRQ released an interim report of data from the project in September 2013. Overall, preliminary outcome data show a 16 percent average decrease in CAUTI rates among hospital units that have participated in the program at least 14 months. Visit the report online to learn more.

The Future of HAI Prevention

The results of On the CUSP: Stop BSI and On the CUSP: Stop CAUTI have been promising to date. Several factors are creating a favorable environment for the effort moving forward, including public reporting mandates and the 10th Scope of Work of state-level Quality Improvement Organizations (QIOs). The Partnership for Patients, a public-private partnership led by HHS, has identified CLABSI and CAUTI as two of ten hospital-acquired conditions to be reduced by 40 percent. The 26 Hospital Engagement Networks (HENs) established by the Partnership for Patients and supported by the Centers for Medicare & Medicaid Services are leading learning collaboratives, providing technical assistance for hospitals, and monitoring hospitals’ progress toward providing safer care for their patients.