Evidence Classic · Patient safety · Issue 00
Five steps and a line
How more than a hundred intensive care units brought a deadly infection close to zero, and kept counting.
Michigan, United States · published 2006
A central line is a thin tube threaded into a large vein. In intensive care it is routine, and for a long time so were the bloodstream infections it could carry. Many clinicians treated them as the price of doing serious medicine.
The Keystone ICU project, led by Peter Pronovost and colleagues at Johns Hopkins with Michigan hospitals, treated them as a system failure instead. The team chose five practices already recommended by the US Centers for Disease Control and Prevention: wash hands, use full barrier precautions when inserting the line, clean the skin with chlorhexidine, avoid the groin where possible, and remove lines that are no longer needed.
None of the five was new. What was new was making them reliable: a checklist, supplies gathered in one place, nurses supported to stop the procedure if a step was missed, and infection rates fed back to every unit.
Across 103 units and 375,757 catheter-days, the median infection rate fell from 2.7 per 1,000 catheter-days to zero within three months, and rates stayed down through eighteen months of follow-up.
None of the five steps was new. Making them reliable was.
Evidence Passport
- What changed
- A five-practice bundle for inserting and managing central lines, with a checklist, a supply cart, authority to stop the procedure, and regular feedback of infection rates.
- What was measured
- Catheter-related bloodstream infections per 1,000 catheter-days, recorded in each participating unit.
- Result
- Median rate 2.7 → 0 within three months; a sustained reduction of up to 66% over 18 months (as reported by the study).
- Limits
- A before-and-after study with no concurrent control group. The bundle came with a wider safety-culture programme, so the effect of each part cannot be separated.
Sources
- Pronovost P, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006
- Pronovost P, et al. Sustaining reductions in catheter related bloodstream infections in Michigan ICUs. BMJ 2010
An editorial feature about published work. The people named did not apply to Evinca, were not reviewed by us, and are not Evinca honorees.