On a snowy night in February 2001, Josie King, an adorable 18-month-old girl who looked hauntingly like my daughter, was taken off of life support and died in her mother’s arms at Johns Hopkins. Josie died from a cascade of errors that started with a central line-associated bloodstream infection, a type of infection that kills nearly as many people as breast cancer or prostate cancer.
Shortly after her death, her mother, Sorrel, asked if Josie would be less likely to die now. She wanted to know whether care was safer. We would not give her an answer; she deserves one. At the time, our rates of infections, like most of the country’s, were sky high. I was one of the doctors putting in these catheters and harming patients. No clinician wants to harm patients, but we were.
So we set out to change this. We developed a program that included a checklist of best practices, an intervention called CUSP [the Comprehensive Unit-based Safety Program] to help change culture and engage frontline clinicians, and performance measures so we could be accountable for results. It worked. We virtually eliminated these infections.
Then in 2003 through 2005, with funding from AHRQ, we partnered with the Michigan Health & Hospital Association. Within six months in over 100 ICUs, these infections were reduced by 66 percent. Over 65 percent of ICUs went one year without an infection; 25 percent went two years. The results were sustained, and the program saved lives and money, all from a $500,000 investment by AHRQ for two years.
With continued AHRQ and philanthropic support and in partnership with AHA and its research arm, HRET, SHA and many others, we have now spread this program state by state across the U.S., and these infections have been reduced by over 40 percent. Indeed over 1200 hospitals—large and small—have infection rates previously believed impossible.
Preventable patient harm and waste is a persistent and pervasive problem. This is the first national success story for broadly reducing a harm. So why did this work?
It worked because it was led by frontline doctors, nurses, and administrators, working as part of CUSP team, believing this was their problem, knowing they were capable of solving it. It worked because it was informed by science. It worked because it aligned many groups around a common measure, each doing their part to eliminate these infections. Like a fractal. The program aligned efforts at the national, state and local levels all around a common goal: to eliminate these infections.
No one group could have done this, yet together we can move a mountain. I want to thank all of the staff at Hopkins, AHRQ, HRET, MHA, SHA and individual hospitals who worked tirelessly to realize these results. People like Michael Tooke, the chief medical officer at Memorial Hospital in Easton, Maryland, and Theresa Hickman, a nurse educator at Peterson Regional Medical Center in Kerrville, Texas, both of whom you will hear from in a moment.
This could be health care’s man on the moon moment. In 1961 JFK challenged the world to safely put a man on the moon. Eight years later Neil Armstrong took those giant steps forward for all of us.
With these results, health care takes a giant step forward. So for the first time we can confidently look Sorrel King in the eye and say: Josie is less likely to die, at Hopkins, in Michigan, in Texas, in Maryland and across the U.S.
This program offers hope of what is possible when policymakers invest in the science of health care delivery.
The AHA, MHA and Johns Hopkins stood with many others to eliminate these infections. Let us continue stand together on this journey to address many other types of harms so we may say to Sorrel King that Josie would be less likely to die from any preventable harm.
Director of the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Peter Pronovost, MD, PhD is a practicing anesthesiologist and critical care physician who is dedicated to making hospitals and health care safer for patients. Pronovost has chronicled his work in his book, Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out. His posts will appear occasionally on THCB and on his own blog, Points from Pronovost .
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Having this check list in place is such a relief and as a nursing student I feel we are going in the right direction. This is a huge accomplishment for the health care system and the patients.
Congratulations! This initiative is a great example of using data to inspire and inform innovation, implement a comprehensive response, and measure the results. Health data innovation in action.
Congrats to Dr. Pronovost et al. We’ve come a long way from “these things just happen”, and the significance of this shouldn’t be underestimated.
I also recommend his book for an interesting tale of overcoming resistance both internally and externally to accomplish these things. Having spent 2 years of my residency at Hopkins in the early 80’s, I know whereof he speaks.
“This could be health care’s man on the moon moment. In 1961 JFK challenged the world to safely put a man on the moon. Eight years later Neil Armstrong took those giant steps forward for all of us.”
While I find the above described efforts highly commendable, I also take a moment to reflect on the virtue of modesty.