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Eliminating Pediatric CA-BSIs
Marlene R. Miller, MD, MScVice Chair, Quality and Safety
Johns Hopkins Children’s CenterVice President, Quality Transformation, NACHRI
GOALS
Explain how and why this effort started
What have we achieved and learned in
first year?
Where are we now in NACHRI’s PICU CA-
BSI Collaborative efforts?
Why CA-BSI ?The Problem: Adults and Children
250,000 cases per year in US
80,000 cases per year in ICU’s
Attributable mortality: 9-25%
Attributable cost: $25,000-$45,000
National groups asking for solutions
Allows us to focus sharply on specific
problem
Mean and Median BSI Rate by PICUs
0
2
4
6
8
10
12
22 9 4 16 28 15 19 10 2 5 11 25 7 3 20 14 26 27 29 13 21 6 23 17 12
PICUs
BS
I R
ate
Mean BSI rate Median BSI rate
NNIS 50%
NNIS 10%
Baseline Variation Across PICUs – We HAVE MUCH to
learn from each otherNNIS 90%
NACHRI PICU CA-BSI Collaborative:
How Did We Form? Began as small expert meeting where several PICUs
presented their efforts on CA-BSI
PICUs realized that focusing on adult-based CA-BSI
efforts was NOT reducing pediatric CA-BSI rates
Larger planning meeting with ~20 PICU experts to help
develop actual bundles
Wrote up Charter and began recruiting PICUS
Sponsors and Contributors
Key Sponsors of Collaborative– NACHRI– American Board of Pediatrics– CHCQ: Center for Health Care Quality– Johns Hopkins Bloomberg School of Public Health– Johns Hopkins Quality and Safety Research Group
Involved Parties– CDC: Centers for Disease Control– NOC: National Outcomes Center– VPS: Virtual PICU Performance System
Co-Chairs and Faculty from Diverse Institutions– Content experts AND Process improvement experts
STEERING COMMITTEEChairs: Brilli MD, Miller MD
Members: Huskins MD; Rice MD; Campbell RN; Ridling RN; Moss MD; Niedner MD;
NACHRI Project Staff
Phase I29 units
Began 9/2006
Phase II33 units
Began 5/2008
Statistics and Data
Mitch
Clinical, Improvement
Scienceand
Operational
JayneGloriaMary K
JHU SOPHJHU-SAQ
CHCQ
PICU CA-BSI Collaborative Structure
PICU CA-BSI Collaborative:Long Term Goals and
Commitments Produce effective and sustained changes in your ICUs
via reliably doing best practice and building
colleagues
– Engage and educate providers in QI
– Develop and sustain ABP MOC effort
– Improve PICU safety culture and teamwork
Spread to all PICUs in USA
Generate new knowledge
Focus on minimizing costs while achieving and sustaining
gains
CHARTER: Specific Goals
Eliminate CA-BSI attributed to the PICU
First year goals:– Decrease CA-BSI by 50%– 90% of central venous line insertions completed using
collaborative insertion bundle – 70% of all central venous line catheter maintenance
care performed using collaborative maintenance care bundle
Improvement in PICU team function between physicians, nurses and other team members that results in a 10-point increase in Safety Culture score
Phase One: 29 PICU Teams in CA-BSI Collaborative
Arkansas Children’s Hospital
Children’s Hospital of Los Angeles
UC Davis Health System
Children’s National Medical Center
AI DuPont Hospital for Children
Children’s Hospital Illinois
Kosair Children’s Hospital
Johns Hopkins Children’s Center
Children’s Hospital Boston
Children’s Hospitals & Clinics of Minnesota (Minneapolis/ St. Paul)
U. of MN Children’s Hospital, Fairview
U. of Mich, CS Mott Children’s Hospital
DeVos Children’s Hospital
Mayo Eugenio Litta Children’s Hospital
Children’s Mercy Hospital
Duke Univ.
Children’s Hospital of Austin
Cook Children’s Hospital
Children’s Hosp & Regional Medical Center, Seattle
Children’s Hosp of Wisconsin
Akron Children’s Hospital
Cincinnati Children’s Hospital
Univ of New Mexico Hospital
Joseph M. Sanzari Children’s
Beth Israel
Penn State Children’s Hospital
INOVA Fairfax Hosp for Children
All 29 PICUs are Fully Transparent to Each Other
Arkansas Children’s Hospital – PICU The Children’s Mercy Hospital
Children’s Hospital of New Jersey at Newark Beth Israel Medical Center
Children’s Hospital Los Angeles
University of California Davis Children’s HospitalThe Joseph M. Sanzari Children's Hospital Hackensack University Medical Center
University of New Mexico Children's Hospital Children’s National Medical Center
Alfred I duPont Hospital for Children Duke Children's Hospital and Health Center
Cincinnati Children’s Hospital Medical Center – PICU Children’s Hospital of Illinois at OSF Saint Francis Medical Center
Kosair Children’s Hospital Norton Healthcare Children’s Hospital Medical Center of Akron
Penn State Children’s Hospital at The Milton S Hershey Medical Center
Johns Hopkins Children’s Center
Children’s Hospital Boston Cook Children’s Medical Center
Dell Children’s Medical Center of Central Texas CS Mott Children’s Hospital University of Michigan Health System
Helen DeVos Children’s Hospital Inova Fairfax Hospital for Children
Children’s Hospital & Regional Medical Center Mayo Eugenio Litta Children’s Hospital Mayo
Children’s Hospitals and Clinics of Minnesota Children’s Hospital of Wisconsin
Arkansas Children’s Hospital – CICUCincinnati Children’s Hospital Medical Center – CICU
University of Minnesota Children's Hospital, Fairview
PICU CA-BSI Phase I MembersPICU CA-BSI Phase I Members
Levine Children’s Hospital (NC) Texas Children’s Hospital – PICU (TX)
Methodist Children’s Hospital of South Texas (TX) Texas Children’s Hospital – CVICU (TX)
Children’s Hospital of Philadelphia – PICU/PCU (PA) CHRISTUS Santa Rosa Children's Hospital (TX)
Children’s Hospital of Philadelphia – CICU (PA) Children’s Medical Center Presbyterian Hospital (NM)
Medical City Children’s Hospital (TX) Children’s Hospital (Denver) – PICU and CICU (CO)
Children’s Hospital of Michigan (MI) Cabell Huntington Hospital (WV)
Maria Fareri Children’s Hospital (NY) Arnold Palmer Hospital for Children – CICU (FL)
Yale-New Haven Children’s Hospital (CT) Arnold Palmer Hospital for Children – PICU (FL)
Children’s Hospital, Cleveland Clinic (OH) CS Mott Children’s Hospital University of Michigan – CICU (MI)
Children’s Hospital of Central California (CA) Children’s Hospital of Alabama (AL)
Schneider Children’s Hospital (NY) SSM Cardinal Glennon Children’s Medical Center (MO)
Riley Hospital for Children (IN)
Univ of Virginia Children’s Medical Ctr (VA)
Deaconess Hospital (IN)
Mary Bridge Children’s Hospital (WA)
Children’s Medical Center Dallas - PICUs (TX)
Children’s Medical Center Dallas – CICU (TX)
Nationwide Children’s Hospital – PICU (OH)
Nationwide Children’s Hospital – CICU (OH)
PICU CA-BSI Phase II MembersPICU CA-BSI Phase II Members
Insertion Bundle (Mainly MD practice)
Insertion Checklist Empowerment of staff to interrupt unsafe practices
Hand washing immediately prior CHG scrub (no iodine) at insertion site Full sterile barriers for all operators Maximal drapes for patient & bed Acceptable to use Femoral site
Procedure cart / tray Polyurethane or Teflon catheters only Standardized training for all providers
Maintenance Bundle (mainly RN practice)
Daily assessment whether catheter is needed
Catheter Site Care
– Adhere to CDC-rec’d dressing change intervals/indications
– CHG scrub (not iodine) with dressing changes
– Prepackaged dressing change kit
Catheter Hub / Cap / Tubing Care
Adhere to CDC-rec’d tubing/cap change intervals/indications
Prepackaged Cap Change Kit/Cart/Central Location
What have we achieved &
learned in the first year?
Where are we now in NACHRI’s
PICU Ca-BSI Collaborative
efforts?
Where are we going?
What Have We Achieved and What Have We Learned?
Have our efforts on Insertion and Maintenance had
an effect on pediatric CA-BSI rates?
Which components -- Ideal Insertion versus Ideal
Maintenance – have greater effect on pediatric CA-
BSI rate reduction?
Infection Rate, Insertion & Maintenance Compliance
Pre-Collaborative
Collaborative
Data reflects first 12 months of effort with first 29 PICUS
Table 2. Results of negative binomial model assuming constant baseline infection rate and adding compliance variables
Covariate
Unadjusted Relative Rate (RR) Adjusted Relative Rate (RR)
Estimated RR 95% CI for RR
Estimated RR 95% CI for RR
Stable Effect vs. Q12 0.703 (0.541,0.913) 0.981 (0.73,1.319)
Northeast Region 0.880 (0.434,1.785) 0.746 (0.456,1.219)
Midwest Region 0.919 (0.458,1.844) 0.752 (0.508,1.114)
South Region 1.184 (0.575,2.438) 1.015 (0.629,1.638)
West Region 1.000 (1,1) 1.000 (1,1)
Bed capacity (per 100 beds) 6.376
(0.209,194.981) 8.219 (0.274,246.559)
Average length of stay (per day) 1.009 (0.867,1.174) 1.008 (0.854,1.189)
Insertion Compliance 0.640 (0.208,1.971) 0.885 (0.221,3.547)
Maintenance Compliance 0.382 (0.188,0.774) 0.409 (0.197,0.851)
NOTE: model is adjusted for stable vs. ramp-up effect, geographic region, bed capacity, and average length of stay.
Main driver for pediatric CA-BSI reduction is Maintenance Bundle not insertion practices
Where are we now in NACHRI’s PICU CA-BSI Collaborative efforts?
Phase I Efforts as of May 2009
We can sustain
Phase II Efforts as of May 2009
We can spread!
New focus after achieving reliable insertion &
maintenance
Supplemental Maintenance-Related Factors (SMRFs)
• Biopatch• CHG scrub for all line entries• Both Biopatch and CHG• Neither Biopatch and CHG
We need to improve the collaborative bundles…..PICUs are in a factorial trial
evaluating these 4 additional practice groups
• SMRF graphs
To date, no clear significant differences in pediatric CA-BSI rates between these 4 groups evaluating comparative
effectiveness of biopatch and CHG; trial ended in June 2009 and formal statistical analysis pending
PICU CA-BSI ‘Take Home’ Messages
• PICU CA-BSI Collaborative impact:• > 775 CA-BSIs prevented• > $27 million dollars saved• > 93 deaths prevented
• Reliable use of ideal Maintenance practices seems to have greatest impact
• New knowledge for children’s healthcare
• Model is sustainable and can uniquely support needed comparative effectiveness trials to create pediatric evidence
TAKE HOME MESSAGE
KEY for Pediatric CA-BSI effortsReliable Performance of
Insertion and Maintenance Bundles
Top 10 Money-Smart Reasons to Join National Pediatric QI
Collaboratives1. Improve patient care and outcomes 2. Achieve Improvement faster by sharing pediatric specific and relevant ideas3. Implement what works for children4. Save Design and Development $$5. Reduce Costs – Share Infrastructure and Tools6. Solves small sample, rare event problems7. Multi-disciplinary and multi-institutional
pediatric Faculty8. Expand QI Knowledge and Capacity9. Create effective Multidisciplinary Teams10. American Board of Pedaitrics MOC Credit for
Physicians
Who Do I Contact to Join?
Jayne Stuart, MPHDirector of Quality TransformationNACHRIEmail [email protected] 919.241.4312www.childrenshospitals.net
29
Marlene R. Miller, MD, MSc Title: Vice Chair Quality and Safety Hospital: Johns Hopkins Children’s Center Title: Vice President, Quality Transformation Organization: NACHRI Email: [email protected] Phone: 410-955-5089 (Assistant: Lorraine Kelly)
Dr. Marlene R. Miller is Vice Chair, Quality and Safety at Johns Hopkins Children’s Center and serves as Vice President, Quality Transformation at NACHRI. In these roles she oversees, coordinates, and expands ongoing quality and safety initiatives within the Children’s Center and serves to develop and expand the quality programmatic areas within NACHRI, especially the quality improvement and patient safety collaboratives. Dr. Miller is an associate professor of pediatrics at the Johns Hopkins University School of Medicine and an associate professor at the Johns Hopkins Bloomberg School of Public Health Department of Health Policy and Management.
Speaker Information