• accreditation
• attitudes
• ambulatory care

In this issue of BMJ Quality & Safety, Meddings et al 1 report the evaluation of a national effort to reduce two well-known safety targets, central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). The paper’s introduction helpfully informs readers of the context. Prior projects funded by the US Agency for Healthcare Research and Quality (AHRQ) have reported well-known successes for both these targets.2 3 One national collaborative reported a greater than 40% reduction in CLABSI in intensive care units (ICUs).2 And, a comparably large project reported a 32% reduction in CAUTI in clinical units other than ICUs, but with no reduction occurring in ICUs.3

This lack of improvement for CAUTI in ICUs might perplex those familiar with the history of these interventions. The AHRQ On the CUSP: Stop CAUTI project3 included the Comprehensive Unit-based Safety Program (CUSP) to support behavioural and cultural changes seen as crucial to support uptake of the technical elements of the CLABSI bundle4 and other checklist-type interventions.5 Why would an intervention for CAUTI modelled after one which has apparently worked so well for CLABSI in ICUs2 6 work only outside ICUs? This unexpected result, along with the fact that, even in the seemingly more successful CLABSI project2 a substantial proportion of ICUs did not improve, led to the national collaborative now reported by Meddings et al.1

The programme recruited 366 ICUs from 220 US hospitals, with 274 ICUs providing complete data. Neither target showed significant improvements. For CLABSI, the incidence rate ratio (IRR) was 0.75, but the 95% CI extended up to an increase of 1.08 (p=0.13). CAUTI showed a similar result: IRR=0.79 but with a CI extending up to 1.06.1 Moreover utilisation for both catheters decreased only marginally and non-significantly.

The authors …