Intended for healthcare professionals

CCBYNC Open access

Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study

BMJ 2010; 340 doi: (Published 04 February 2010) Cite this as: BMJ 2010;340:c309
  1. Peter J Pronovost, professor1,
  2. Christine A Goeschel, director, patient safety and quality initiatives1,
  3. Elizabeth Colantuoni, assistant professor1,
  4. Sam Watson, senior vice president, patient safety and quality2,
  5. Lisa H Lubomski, assistant professor1,
  6. Sean M Berenholtz, associate professor1,
  7. David A Thompson, assistant professor1,
  8. David J Sinopoli, instructor3,
  9. Sara Cosgrove, assistant professor4,
  10. J Bryan Sexton, associate professor1,
  11. Jill A Marsteller, assistant professor5,
  12. Robert C Hyzy, associate professor6,
  13. Robert Welsh, chief7,
  14. Patricia Posa, special project coordinator8,
  15. Kathy Schumacher, director, quality, safety, standards and outcomes9,
  16. Dale Needham, assistant professor10
  1. 1Quality and Safety Research Group, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 1909 Thames Street, Baltimore, MD 21231, USA
  2. 2Michigan Health and Hospital Association Keystone Center, 6215 West St, Joseph, Lansing, MI 48917, USA
  3. 3Carey Business School, Johns Hopkins University, 10 North Charles Street, Baltimore, MD 21201-3707
  4. 4Division of Infectious Diseases, 615 N Wolfe Street, Osler 425, Baltimore, MD 21287
  5. 5Department of Health Policy and Management, 624 N Broadway, Hampton House 433, Baltimore, MD 21205
  6. 6Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, 3916 Taubman Center, Ann Arbor, MI 48109, USA
  7. 7Thoracic Surgery, William Beaumont Hospital, 3601 W 13 Mile Road, Royal Oak, MI, USA
  8. 8St Joseph Mercy Health System, 5301 East Huron River Drive, P O Box 995, Ann Arbor, MI, 48106-0995
  9. 9William Beaumont Hospital
  10. 10Division of Pulmonary and Critical Care Medicine, 615 N Wolfe Street, Baltimore
  1. Correspondence to: P J Pronovost ppronovo{at}
  • Accepted 22 November 2009


Objectives To evaluate the extent to which intensive care units participating in the initial Keystone ICU project sustained reductions in rates of catheter related bloodstream infections.

Design Collaborative cohort study to implement and evaluate interventions to improve patients’ safety.

Setting Intensive care units predominantly in Michigan, USA.

Intervention Conceptual model aimed at improving clinicians’ use of five evidence based recommendations to reduce rates of catheter related bloodstream infections rates, with measurement and feedback of infection rates. During the sustainability period, intensive care unit teams were instructed to integrate this intervention into staff orientation, collect monthly data from hospital infection control staff, and report infection rates to appropriate stakeholders.

Main outcome measures Quarterly rate of catheter related bloodstream infections per 1000 catheter days during the sustainability period (19-36 months after implementation of the intervention).

Results Ninety (87%) of the original 103 intensive care units participated, reporting 1532 intensive care unit months of data and 300 310 catheter days during the sustainability period. The mean and median rates of catheter related bloodstream infection decreased from 7.7 and 2.7 (interquartile range 0.6-4.8) at baseline to 1.3 and 0 (0-2.4) at 16-18 months and to 1.1 and 0 (0.0-1.2) at 34-36 months post-implementation. Multilevel regression analysis showed that incidence rate ratios decreased from 0.68 (95% confidence interval 0.53 to 0.88) at 0-3 months to 0.38 (0.26 to 0.56) at 16-18 months and 0.34 (0.24-0.48) at 34-36 months post-implementation. During the sustainability period, the mean bloodstream infection rate did not significantly change from the initial 18 month post-implementation period (−1%, 95% confidence interval −9% to 7%).

Conclusions The reduced rates of catheter related bloodstream infection achieved in the initial 18 month post-implementation period were sustained for an additional 18 months as participating intensive care units integrated the intervention into practice. Broad use of this intervention with achievement of similar results could substantially reduce the morbidity and costs associated with catheter related bloodstream infections.


  • We thank Christine G Holzmueller for her assistance in editing the manuscript. We also thank the Michigan Health & Hospital Association (MHA) Keystone Center and all the intensive care units teams in Michigan (list of participating hospitals in web appendix) for their tremendous efforts. Their leadership and courage in this innovative effort reflects an unrelenting passion and dedication to improve quality and safety for their patients.

  • Contributors: All the authors were involved in preparing this manuscript and had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. PJP was the principal investigator of the project, was responsible for the overall design and supervision of the study, and wrote the initial draft of the manuscript. All other authors contributed to study design, collecting or analysing data, and redrafting the manuscript. CG was the director of the Keystone Center during the initial evaluation period, and SW was its director during the sustainability period. SW and SB managed collection and quality control of data, and PJP, EC, DJS, and DM provided data cleaning and editing, statistical analysis, and interpretation of results. SB, LL, DT, and JM were part of the Johns Hopkins team that supported the collaborative, and RH, RW, PP, and KS were members of and represented intensive care unit teams in Michigan. SC provided expertise on definitions of catheter related bloodstream infection, measuring infection rates, and interventions to reduce infections. PJP is the guarantor.

  • Funding: Support for this project, for the period from October 2003 to September 2005, was provided by the Agency for Healthcare Research and Quality (1UC1HS14246) and the MHA. The Agency for Healthcare Research and Quality provided financial support, and the MHA provided support for the biannual statewide meetings. The researchers were independent of the sponsors, and neither sponsor had any influence over the study design; collection, analysis, or interpretation of the data; writing of the manuscript; or decision to submit it for publication.

  • Competing interests: PJP and CAG received grant support from the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, the National Patient Safety Agency, and the World Health Organization to study and improve quality of care, including catheter related bloodstream infections. They have received lecture fees from various healthcare organisations, and CAG has also received lecture fees from government agencies to speak on quality and patient safety. SC has grant support from Cubist and Astellas, has served as a consultant for Merck, and has been on the advisory boards for Astellas, Forrest, and Cadence. JBS and JAM have grant support from the Robert Wood Johnson Foundation. PP has received lecture fees from Lilly, Merck, Edward Life Sciences, and Sage for various speaking engagements. DMN has had grant and contract support from the National Institutes of Health/National Heart Lung and Blood Institute and a clinician-scientists award from the Canadian Institutes of Health Research.

  • Ethical approval: The Johns Hopkins University School of Medicine Institutional Review Board reviewed and approved this research.

  • Data sharing: The dataset and statistical codes are available from the corresponding author.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

View Full Text