THE persistence and virulence of healthcare-associated infections can only be a source of great frustration to nurses. The healthcare-associated infection, or HAI, is the most common complication of hospital care in the United States. HAIs, infections that patients get while receiving treatment for another condition in a healthcare facility, account for 1.7 million infections leading to 99 000 deaths annually.1,2

These are too many infections and too many deaths. Even one is too many. No patient should get sicker because of a preventable infection he or she contracts in a hospital or other healthcare facility. Thus, the "acceptable" number of infections stemming from a healthcare encounter should be zero. These infections persist despite the best efforts of millions of committed and compassionate professional nurses. Nobody ever intends to allow an infection. Yet systemic barriers impede our ability to combat HAIs to our fullest capability.

Establishing a goal to eliminate HAIs is not controversial, even if the task is daunting. HAIs are, by definition, preventable-and it is commonly acknowledged that if we take certain evidence-based steps, we can dramatically reduce their number.

We have national direction and incentive to reduce HAIs. Last spring, Kathleen Sebelius, Secretary of the US Department of Health and Human Services (HHS), challenged hospitals to reduce central line-associated bloodstream infections (CLABSIs) by 75% over 3 years.3 Secretary Sebelius understands the devastating effect that HAIs can have on patients and their families, on providers, and on the system at large. This followed the decision by the Centers for Medicare & Medicaid Services not to reimburse hospitals for added costs incurred when patients develop catheter-related urinary tract infections and other catheter-or surgery-related infections. That rule became final in 2008.

DIRECTION FORWARD

We know that eliminating HAIs is the right thing to do, but this knowledge alone is not enough. For years, we have measured infections, and we have become very good at measurement. But we must do more than simply measure; we must actually change our practice now, not at some distant point in the future. The good news is we now have proof of concept: examples of initiatives that are slicing the number of infections to a tiny fraction.

The Keystone project is a prominent such initiative. Readers of this journal may already be familiar with the Keystone project,4 which has helped hospital intensive care units (ICUs) in Michigan sharply reduce the rate of bloodstream infections from intravenous lines-and sustain these improvements for 3 years.5 This project, funded by a $454 000 grant from the Agency for Healthcare Research and Quality (AHRQ), reduced the rate of bloodstream infections from intravenous lines by two-thirds within 3 months in more than 100 ICUs. Over time, the Keystone project helped the average ICU decrease its infection rate from 4% to 0%.6

The initial investment paid off, saving more than 1500 lives and more than $18 million. This led to the project's expansion to 10 states, building capacity at the state level to replicate Keystone's success. Now, the project is going national. Late last year, AHRQ awarded nearly $7 million to the Health Research & Educational Trust (HRET) to support a national, voluntary expansion of the Keystone project. Hospitals from all 50 states, the District of Columbia, and Puerto Rico are now getting the opportunity to participate in a comprehensive unit-based safety program, or CUSP, to help prevent infections related to the use of central line catheters. The project is led by HRET, an affiliate of the American Hospital Association. Other partners are the Johns Hopkins University Quality & Safety Research Group (which pioneered the CUSP) and the Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality (which oversaw its implementation in Michigan).

The national expansion of Keystone demonstrates the success of the CUSP, which provides a structured strategic framework for safety improvement, yet is flexible enough to tap into staff wisdom and encourage clinicians to fix hazards that they perceive pose the greatest risks. CUSP is composed of five steps:

1. Staff are educated on the science of safety training.

2. Staff use a written survey to help identify defects based on unit reports, liability claims, and sentinel events.

3. A senior hospital executive partners with the unit to improve communications and educate leadership.

4. Staff learn from unit defects.

5. Staff use tools to improve teamwork, communication, and other systems of work.7

The Keystone expansion is part of a broader HHS-wide effort, which AHRQ is supporting, to prevent HAIs, including methicillin-resistant Staphylococcus aureus (commonly known as MRSA). This effort is spelled out in HHS' Action Plan to Prevent Healthcare-Associated Infections, which calls for significant reductions in HAIs nationwide within 5 years by establishing national goals, benchmarks, and an integrated information system strategy to monitor HAIs.8

LESSONS LEARNED SO FAR

Nurses can take justifiable pride in the success of Keystone. Nurses of every credential and every nursing position participated, and in some instances maintained leadership roles, in this broad-scale improvement effort. The engagement and involvement of nurses at every turn was a critical factor in its development and success.9 This should put to rest the notion that responsibility for stopping HAIs lies exclusively with infection control professionals; we now know that infections can be prevented only when nurses and other critical members of the care team "own" the responsibility.

One feature of the project is a patient-safety checklist10 developed by Johns Hopkins University researcher Peter Pronovost, MD, that is foundational to the CUSP and the success of Keystone. Checklists are very much in vogue in medicine today,11 and with good reason: by reminding physicians and nurses to remember mundane but important aspects of surgical care (eg, did you wash your hands?), clinicians are freed up to concentrate on the more complex aspects.

Also relevant to the improvement process is the transformation model that guided improvement teams during Keystone's implementation in Michigan. As Christine Goeschel, RN, MPA, MPS, of the Johns Hopkins University Quality & Safety Research Group has noted,12 the interaction among senior leaders, ICU physicians and nurse managers, and front-line staff influenced the project progress.

To facilitate these relationships, teams were encouraged to consider a construct that included 4 key processes, "the 4 E's":

* Engagement: Understanding how this project makes the world a better place.

* Education: Understanding what must happen for change to occur.

* Execution: Understanding exactly what they need to do to facilitate the change.

* Evaluation: Seeing the results of their efforts in a meaningful way.

Notice a fifth "E" that is missing: Easy. This is not simple stuff. The use of checklists and evidence-based protocols may make the entire process sound straightforward and trouble-free, but I can assure you it is not. Simply employing a checklist is not sufficient; the CUSP is a comprehensive, integrated approach that includes teamwork, improved communication, and culture change as well. To use a checklist while ignoring other elements of the CUSP would be to ignore some of the most fundamentally important lessons of Keystone. It requires a new way of thinking and often can be difficult.13 We should pursue this change, but we should not minimize the challenge.

The lessons learned by nurses engaged in the Keystone work can apply to other quality improvement initiatives, particularly those having to do with HAIs, in other clinical settings. We will have the opportunity to apply these lessons soon. In December 2009, AHRQ announced its intention to fund further research to combat HAIs both in hospitals and in ambulatory care centers, including ambulatory surgical centers, the fastest growing provider type in Medicare.14

Our challenge is clear: 99 000 deaths per year due to HAIs are far too many. Even 1 death per year due to HAIs is too many. The Keystone project and other such initiatives demonstrate that we have a proven roadmap to combat these infections. It will not be easy and sustaining improvement is never assured. Working together, we can eliminate HAIs if we embrace the goal that success can only be defined by getting to zero.

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