Vox: To stop infections, hospitals must plan for a 'plane crash'—not a 'car crash'

When it comes to reducing central line infections, some hospitals are leading the way—while others are stuck in an old mindset that endangers patients, Sarah Kliff writes for Vox.

Physicians insert millions of central line catheters into patients a year to deliver medication. But thousands of U.S. patients per year are infected by germs that can enter the bloodstream when clinicians change the catheter lines' dressing or inject drugs. Nearly 10,000 patients died from central line infections in 2013.

Providers have made strides in preventing such infections in recent years. Between 1990 and 2010, about 500,000 patients contracted central line infections, Kliff notes. But between 2008 and 2013, the number of central line infections decreased by 46%.

Hospitals change their practices

What changed? Researchers determined that providers could eliminate nearly all central line infections by adhering to a short safety checklist.

For instance, Johns Hopkins Medicine safety expert Peter Pronovost and his colleagues pared down a 90-item CDC document to a list of five simple steps for providers to prevent infections:

• Wash hands;
• Cover the patient and yourself in sterile drapes and clothing;
• Use the antiseptic chlorhexidine on-site;
• Do not use groin-area catheters; and
• Remove unneeded catheters.

When Pronovost implemented the checklist in Johns Hopkins' ICU in the early 2000s—including by encouraging nurses to enforce doctors' adherence to the procedures—central line infections declined in the ICU by 70% within six months. And central line infections dropped 70% within three months at 103 ICUs that used the checklist method, according to a 2006 study published in the New England Journal of Medicine.

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'Plane crash hospitals vs. car crash hospitals'

Still, Kliff wonders why this seemingly preventable medical harm still exists. "Given everything we know about preventing central line infections, why do they happen at all?" she asks.

"If there were maybe a couple dozen of these each year, I'd shrug and say, given the size of this country, I think that's acceptable," says Harvard School of Public Health professor Ashish Jha. But "the fact that we have thousands," he argues, "points to a much bigger problem in health care."

The states where hospitals have higher-than-expected infection rates

In Kliff's view, the root of the problem is a divide among hospitals in how they view the infections. Some view them as tragic but inevitable—like automobile companies view car crashes, she says. But others view every central line infection as a major problem that needs to be investigated and learned from—similar to how airlines view plane crashes.

An 'airline hospital' in action

Kliff points to Roseville Medical Center—a 328-bed facility near Sacramento, California—as one example of a "plane crash hospital." 

Roseville had 11 central line infections in 2005. But after implementing a seven-item checklist and restricting the task of inserting central lines to an 18-nurse team in 2006, the hospital did not have another infection for seven years.

When that streak ended, and two patients contracted central line infections in 2014, Roseville did not brush them off as inevitable, but instead launched a (still-ongoing) root cause analysis, according to Deborah Dix, the hospital's oncology director.

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Dix found that the nurses who treated dialysis patients at the hospital were not all applying catheter lines in the same way. The nurses—employed by a subcontractor—had last been trained in applying central lines in 2007. Now, starting this month, Roseville will require contract nurses who manage central lines to undergo yearly competency checks.

Dix says her hospital's approach is vital to saving patient's lives. "When you have an outcome that isn't what you wanted," she argues, "if you don't say, 'Is there anything we could have done better? Is there any way we could have changed?'—people are going to get really sick, and they're going to die" (Kliff, Vox, 7/9).