The Keystone Project: Part 2

By now nearly everyone is aware of the landmark study by Peter Pronovost and his colleagues that demonstrated significant reductions in the rate of catheter-related bloodstream infections (CLABSIs) in 103 Michigan hospitals (the Keystone Project) with the implementation of relatively simple interventions (handwashing, full barrier precautions, skin prep with chlorhexidine, avoidance of the femoral site, and removal of unnecessary catheters). He has just published a follow-up study in BMJ (free access to the paper here) in which 90 of the original 103 ICUs continued in the project and were able to sustain the reduction in CLABSIs.

It seems to me that without question, the checklist which contains the interventions, should be standard practice for all central line insertions. But what interests me is how the quality community and the infection prevention community approach problems differently. I plan to write more about this in a future posting, but will focus on one aspect of those differences here. The quality folks convert problems to projects and bring people together to implement solutions (collaboratives). The Keystone Project is a great example of how successful this can be. But a critical question is what happens when there's no longer a project? It would be interesting to know what happened to CLABSI rates in the hospitals that dropped out of the project. Can CLABSI reductions be sustained without a project to drive practices or could the checklist intervention become standard practice without any further need for a team, meetings, etc. To some degree, it seems that QI has more of a short-term view. As a hospital epidemiologist, I think we sometimes stumble because we want the ultimate, long-term solution and become overwhelmed at how daunting that can be. On the other hand, we're in this for the long haul, so the challenge is ultimately ours to develop sustainable solutions that are at least semi-autonomous. Does it take a village to continually reduce infections or does it take a village to just get it started? Or maybe the key question should be why should it ever take a village to implement safety practices? Could it be that we just can't or won't hold clinicians accountable and continue to defer to their autonomy?


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