Assessment of the Reported Effectiveness of Five Different Quality- Improvement Initiatives for the Prevention of Central Line-Associated Bloodstream Infections in Intensive Care Units

Lawrence F Muscarella

doi:10.2174/1874297101205010005

Abstract

Five studies that evaluated five different quality-improvement initiatives for the prevention of central line-associated bloodstream infections (CLABSIs) in adult, pediatric and/or neonatal intensive care units (ICUs) and that were published within the past two years in an infection-control and epidemiology journal were reviewed, assessed and compared. Each is a prospective cohort study that similarly concludes that the evaluated initiative was responsible for a significant and calculated reduction in the CLABSI rate, ranging from 30.3% to 85%. The soundness of these conclusions and calculations, however, like the legitimacy of several other common uses of CLABSI data, requires, in addition to satisfying a number of other criteria, that each study's CLABSI rates be accurate and complete. The primary goal of this analysis, therefore, was to confirm the hypothesis that each of these five studies had validated its CLABSI rates. The analysis found, however, that these five studies did not validate the accuracy and completeness of their CLABSI rates, which raises reasonable questions about each study’s assessment of and conclusions about the initiative's effectiveness for the prevention of CLABSIs. In addition to their aims, calculations, and conclusions, these five studies share in common a number of features, as well as circumscribing qualities, which are discussed. The distinction between a qualitative assessment and a quantitative determination of an initiative's performance is also discussed. Both the circumspective use of CLABSI data that have not been validated and the cautious interpretation of conclusions about central-line care that are based on these CLABSI data are recommended.

Highlights

The focus of many newspaper articles, medical studies, and governmental reports, state and federal agencies frequently study central line-associated bloodstream infections (CLABSIs) rates to identify trends or deficiencies in health care; to set qualityimprovement standards and goals, such as achieving a 50% reduction in CLABSIs, nationwide, by 2013; and as a metric to verify the effectiveness of targeted funding for the prevention of healthcare-associated infections (HAIs) [1,2,3,4,5]
Several studies that evaluated the effectiveness of an initiative for the prevention of CLABSIs in adult, pediatric or neonatal intensive care units (ICUs) were randomly selected from a number of medical journals
Each of the five reviewed studies evaluated the effectiveness of a different quality-improvement initiative for the prevention of CLABSIs in one or more adult, pediatric and/or neonatal ICUs

Summary

Introduction

Rates of central line-associated bloodstream infections (“CLABSIs”) have many applications, several of which are listed in Table 1. For example, the focus of many newspaper articles, medical studies, and governmental reports, state and federal agencies frequently study CLABSI rates to identify trends or deficiencies in health care; to set qualityimprovement standards and goals, such as achieving a 50% reduction in CLABSIs, nationwide, by 2013; and as a metric to verify the effectiveness of targeted funding for the prevention of healthcare-associated infections (HAIs) [1,2,3,4,5]. In one recently published federal study, the Centers for Disease Control and Prevention (CDC) calculated that CLABSI rates in intensive care units (ICUs) in the U.S had decreased dramatically from 2001 to 2009 [1]. The CDC concluded in this study that these calculated reductions were likely due primarily to state and federal efforts coordinated and supported by the CDC, the Agency for Healthcare Research and Quality, and the Centers for Medicare and Medicaid Services (CMS) [1]. Based on its calculations, the CDC further concluded that between 2001 and 2009 “the cumulative excess health-care costs of all CLABSIs prevented in ICUs could approach $1.8 billion, and the number of lives saved could be as high as 27,000” [1]. 1874-2971/12CLABSI data and rates may be used by:• Clinicians and researchers: o to manage the quality of central-line care; and o to evaluate and quantify the performance and costeffectiveness of specific initiatives, such as a checklist or a bundle of “best-practices,” for the prevention of CLABSIs in ICUs [6,7,8,9,10,11,12,13,14];• Hospitals to advertise to the public their quality and safety [26, 27];• State lawmakers to improve public health and enhance health care’s transparency and accountability [5, 8, 15, 16, 21, 26, 28];• Consumers to compare the relative safety of hospitals in different cities, states, and countries [1,2,3,4,5, 26, 28];• Consumer organizations to rate hospitals and to label some “poor” or “top” performers [28];• State and federal governmental agencies: o to evaluate trends in and to advance claims about the quality of health care and central-line care; o to set goals (e.g., a 50% reduction in CLABSIs, nationwide, by 2013 [1]); and o to evaluate the effectiveness of targeted efforts and funding, if not also, at times, to justify expenditures [1,2,3,4,5]; and• Private and public healthcare insurers, as well as federal and state rules, programs and policies, to incentivize improved health care and the prevention of healthcare-associated infections (HAIs) by conditioning reimbursements, financial rewards, and other forms of compensation on the reporting of CLABSI and other HAI rates (e.g., CMS’s pay-for-reporting programs) [1,2,3,4,5, 12, 14].2012 Bentham Open

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