At each center we used

several interventions: 1) Catheters could only be placed by those who were trained, certified, and had performed enough procedures to maintain competence. Often, simulation was used in initial training. 2) All catheters were placed using five barrier precautions, using standardized line kits. 3) Time outs and documentation were standardized. 4) Inhibitors,research,lifescience,medical Vigorous efforts by the leadership and clinical thought-leaders assured that these measures were performed every time, with every line. 5) Because we believed that catheters placed outside of our hospitals were not up to our standards, all such catheters were removed within hours of the patient’s arrival. As figure 2 shows, at BIDMC these measures reduced central line infection 9-fold, and the improvements have been maintained for years since the interventions began. UPMC and other hospitals in Pittsburgh participated in a joint effort to eliminate these infections; the results were reported in Morbidity and Mortality Weekly Reports under the title “Elimination of central line infections: Pittsburgh”. Inhibitors,research,lifescience,medical More recently, a collaborative Inhibitors,research,lifescience,medical effort across the state of Michigan has resulted in sharp reductions in central line infections state-wide.9,10 Figure 2 Central line

infection rate in ICUs (CLABSI) by quarter, plotted on the ordinate as infections per thousand ICU patient days. FY refers to fiscal year. VENTILATOR-ASSOCIATED PNEUMONIA Endotracheal tubes provide ready access for mouth flora to enter the lung, often resulting in pneumonia. A large body of evidence has shown that adoption of several measures, including elevation of the head of the bed to 30 degrees, Inhibitors,research,lifescience,medical daily awakening of sedated ventilator patients, and frequent assessment of ability to remove the endotracheal tube, reduces the rate of ventilator-associated pneumonia (VAP).11 At both UPMC and BIDMC Inhibitors,research,lifescience,medical the ventilator bundle was adopted and performed on every patient, every day. The rate of VAP fell 10-fold with adoption of the bundle and

has remained at this new lower level for the past 2 years. With the adoption of these and other quality Epigenetic animal study improvement measures, length Thalidomide of stay in the ICUs fell 20%, permitting the same number of ICU beds to care for 20% more patients. This obviated the need to build an additional ICU to care for increasing ICU volume. Moreover, mortality in the ICU population fell 12%, so that for every 40 patients cared for in the ICUs, one less patient died. Since we care for 6,000 ICU patients per year, this means we now avoid deaths in some 150 patients per year. REDUCING IN-HOSPITAL CARDIOPULMONARY ARRESTS Retrospective forensic chart studies of patients who have undergone cardiopulmonary arrests reveal that up to 80% of cardiopulmonary arrests are preceded by some indication of physiologic instability, ranging from high fever to high or low pulse, to high or low respiratory rate, to loss of mental status, to marked nursing concern (reviewed in 12,13).