Quantitative Results of a National Intervention to Prevent Central LineAssociated Bloodstream Infection
Widespread patient safety efforts in the United States have focused on health careassociated infection (HAI) (1, 2) Common HAIs include central lineassociated bloodstream infection (CLABSI) catheter associated urinary tract infection, Clostridioides difficile infection, and methicillin resistant Staphylococcus aureus bloodstream infection. For many reasons, CLABSI is the prototypical HAI: It is common (3) and fatal and was once thought to be inevitable (4) Even today, many people die of this preventable infection rather than the illness that brought them to the hospital (5) With the introduction of a checklist that systematically applied evidence to practice, rates of CLABSI in the United States declined 58% from 2001 to 2009 (3, 6) However, success has not been uniform. Many hospitals continue to experience higher than expected CLABSI rates. These so called low performing hospitals may suffer from key problems, including demoralizing hospital culture (7, 8) lack of auditing how CLABSI prevention bundles are implemented (9, 10) failure to address patient level risk factors (11, 12) and increased use of central venous catheters in the nonintensive care unit setting (13, 14) To date, no large scale intervention to improve CLABSI rates in low performing hospitals has been performed. To identify and support hospitals struggling with CLABSI and other HAIs, the Centers for Disease Control and Prevention (CDC) funded a national project, STRIVE (States Targeting Reduction in Infections via Engagement) (15) This article reports findings from interventions aimed at reducing CLABSI. Methods Data Sources, Measurement, and Outcomes For each cohort, analysis was structured into 2 time frames: 12 months of preintervention data followed by 12 months of postintervention data. The intervention began after sites completed a baseline assessment by using the Practice Change Assessment (PCA) or Infection Control Assessment and Response (ICAR) tool (16) The primary outcome was the number of CLABSIs per 1000 catheter days for all hospitals and by hospital type (acute care, long term acute care, and critical access) Cases of CLABSI were recorded through monthly data submitted to the National Healthcare Safety Network (NHSN) for participating hospitals. Secondary outcomes, also retrieved from NHSN, included central line utilization, which was calculated as the number of catheter days per 100 patient days. Hospital characteristics, such as bed size, teaching status, ownership, hospital type, and location (urban, rural, or critical access) were obtained from the 2015 American Hospital Association Annual Survey of Hospitals (17) Critical access hospital is a designation made by the Centers for Medicare Medicaid Services and includes hospitals that are small (25 inpatient beds) have short lengths of stay (average 96 hours) and are located more than 35 miles from another hospital or serve a community that is otherwise physically remote from another hospital (for example, owing to terrain or road conditions) Responses to the ICAR or PCA were collected at baseline and at the end of the intervention. Baseline ICAR/PCA responses related to CLABSI prevention, line insertion, and line maintenance were evaluated to characterize hospital HAI prevention efforts before implementation. Study Design and Cohort Recruitment To recruit hospitals for STRIVE, the CDC used NHSN data to identify hospitals with high rates of HAI. High HAI burden was defined by the cumulative attributable difference (CAD) (calculated by using the Department of Health and Human Services' HAI goals as the standardized infection ratio target) On the basis of CAD values, facilities with a high burden of C difficile infection (above the first tertile, or top one third of hospitals) and elevated rates of CLABSI, catheter associated urinary tract infection, or hospital onset methicillin resistant S aureus bloodstream infection were targeted for recruitment. This information was used to first identify states with the largest number of hospitals that had a high burden of HAI. Of the 30 states, including the District of Columbia, identified through this process, 24 agreed to participate. An additional 5 states that did not meet these criteria also volunteered to participate. All participating state hospital association leads were then given a list of potential target hospitals based on publicly reported NHSN infection rates to assist with hospital recruitment; however, any hospital within a participating state was allowed to join the STRIVE program regardless of HAI burden. A total of 462 hospitals (acute care, long term acute care, and critical access) participated in STRIVE over 4 separate cohorts. The STRIVE initiative included a multimodal evidence based intervention for CLABSI that was designed and implemented across participating hospitals. Rates of CLABSI and central line utilization were collected. Cohort 1, the initial cohort, was designated a 10 month pilot to refine the identification and recruitment strategy. Each subsequent cohort was enrolled for 12 months. Cohort 1 began in June 2016, and cohort 4 ended in May 2018. This analysis includes data from the 387 hospitals that completed participation in cohorts 2 through 4, spanning 1 November 2016 to 31 May 2018. The University of Michigan Medical School Institutional Review Board reviewed the study and determined that it did not meet the regulatory definition of research involving human subjects. Intervention To appeal to a broad range of health care facilities, STRIVE utilized a multimodal, multifaceted partnered facilitation program (Appendix Figure 1) The intervention consisted of 4 key components: a baseline assessment, a tiered approach to CLABSI prevention, online and on demand educational materials, and guided facilitation for HAI reduction (15) Appendix Figure 1. STRIVE project timeline. Outcome data were central lineassociated bloodstream infections as reported by participating hospitals to the CDC National Healthcare Safety Network. CDC Centers for Disease Control and Prevention; ICAR Infection Control Assessment and Response; PCA Practice Change Assessment; SHA state hospital association; STRIVE States Targeting Reduction in Infections via Engagement; TAP Targeted Assessment for Prevention. Baseline Assessment After an overview and introduction to the project, a state partner (such as a state hospital association) performed an in person assessment at each hospital by using either the ICAR (16) or the PCA. The PCA is a shorter version of the ICAR and was specifically developed for STRIVE. The PCA report generated from these tools included an executive summary that highlighted the hospital's 3 strongest practice areas and areas most in need of improvement. Project leads for the hospital used the summary generated from this report to communicate strategic goals with units and hospital leadership. Relevant STRIVE online resources were also identified to help sites in overcoming these barriers. Tiered Approach The STRIVE resources were organized into horizontal strategies for all HAIs and specific components for each HAI (for example, CLABSI, catheter associated urinary tract infection) (1821) The horizontal strategies included competency based training, hand hygiene, use of personal protective equipment, environmental hygiene, antimicrobial stewardship, adaptive strategies, patient and family engagement, and a business case for infection prevention. The CLABSI specific intervention included a tiered approach (18) Basic, fundamental CLABSI prevention interventions were emphasized in tier 1, whereas costlier and more labor intensive approaches were introduced in tier 2. Before moving to tier 2, hospitals were asked to complete the CLABSI guide to patient safety, a self check tool that helped identify key gaps in CLABSI prevention (22) Educational Content and Strategies The STRIVE team created 51 on demand educational modules and made them available to participating hospitals through a central Web site. To guide implementation, the STRIVE project team also provided coaching, in person meetings and site visits to hospitals, as needed. In addition, 31 monthly Learning Action Forum webinars were held to share best practices for infection prevention. The STRIVE team provided content expertise for these webinars and were available to answer questions from hospitals. Topics covered during the webinars were chosen to address challenges and barriers identified by the ICAR/PCA assessments, outcome data, state partner coaching activities, and specific topics requested by hospitals. To promote participant engagement, discussion, and peer to peer learning, webinars were conducted by using an interview or discussion format, rather than a didactic lecture (23) Finally, 29 in person meetings were also held, with every state involved with the project conducting at least one statewide meeting with their participating hospitals. Site Visits Site visits offered a way to provide on site technical assistance to hospitals. During site visits, state leads reviewed hospital PCA reports and discussed outcome data, providing one on one coaching to hospitals usually through the hospital's infection prevention team. State hospital associations were expected to conduct site visits with at least 50% of their registered hospitals. Clinical mentors and subject matter experts were also available if the state hospital associations requested assistance from the STRIVE project team. Statistical Analysis Hospital characteristics were reported by using descriptive statistics, including mean (SD) median (interquartile range) and number (percentage) Raw rates were calculated as the ratio of the total number of CLABSIs reported in each month (numerator) over the total number of catheter days for that same month (denominator) multiplied by 1000. Raw aggregate CLABSI and central line utilization rates were tabulated monthly
Annals of Internal Medicine