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 jstuart@nachri.orgPhone 919.241.4312www.childrenshospitals.net

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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: mmille21@jhmi.edu 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