A public health project aimed at reducing rates of health care–associated infections in Michigan intensive care units is associated with reduced mortality among patients aged 65 years and older, according to a retrospective study comparing Michigan ICU patients to ICU patients in other Midwest hospitals.
The study examined the impact of a quality improvement initiative, known as the Michigan Keystone ICU project, which used a series of evidence-based practices to reduce rates of catheter-related bloodstream infections and ventilator-associated pneumonia. While previous studies have shown that the Keystone project substantially reduced infection rates for up to 36 months after implementation, this is the first study to show a significant reduction in hospital mortality following implementation of the project. The study was published on Jan. 31 in the British Medical Journal (doi: 10.1136/bmj.d219).
Using Medicare claims data for patients aged 65 years and older who were admitted to ICUs, the researchers compared mortality and length of stay among patients in 95 Michigan ICUs and patients in 364 ICUs in surrounding Midwest states. The researchers compared mortality and length of stay before implementation of the Keystone project, during the project’s initiation and implementation, and post implementation.
They found that reductions in mortality were significantly greater during the postimplementation months for the study group. The adjust odds ratios for mortality at postimplementation months 1-12 were 0.83 vs. 0.88 for the study vs. the comparison group, respectively. During months 13-22, those odds ratios were 0.76 vs. 0.84.
There was no significant difference in length of stay between the two hospital groups. Although the length of stay was shorter among the Michigan ICUs after implementation of the Keystone project, there was not a statistically significant difference compared to baseline.
Although study involved data from more than 1 million ICU admissions, the researchers acknowledged that it was underpowered to detect the 0.1 day length of stay reduction they had originally projected.
"We knew that when we applied safety science principles to the delivery of health care, we would dramatically reduce infections in intensive care units, and now we know we are also saving lives," Dr. Peter J. Pronovost, one of the study authors and a professor of anesthesiology and critical care medicine at the Johns Hopkins University, Baltimore, said in a statement.
The Keystone Project, which was launched in 2003, has been touted as a national model by the Obama administration. The initiative promotes a culture of patient safety, encourages better communication among ICU staff, and uses checklists to remind providers to perform certain tasks. To prevent catheter-related bloodstream infections, the project promotes hand washing, full barrier precautions, skin antisepsis with chlorhexidine, avoiding the femoral site during catheter insertion, and removing unnecessary catheters. The interventions promoted for preventing ventilator-associated pneumonia included semirecumbent positioning, daily interruption of sedation infusions, and prophylaxis for peptic ulcer disease and deep venous thrombosis.
The researchers received no financial support for the study. However, they received funding from the Agency for Healthcare Research and Quality, the National Patient Safety Agency, and private philanthropic groups to expand the Keystone project to all 50 states.