pqcnc grand rounds 6/14/2012
DESCRIPTION
PQCNC Grand Rounds: Wake Forest School of Medicine, Department of Pediatrics 6/14/2012TRANSCRIPT
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Transforming Perinatal Care Through Quality Improvement
Martin J McCaffrey, MD, CAPT USN (Ret) Clinical Professor of Pediatrics
Director of the PQCNC For the PQCNC
No disclosures to report.
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Aims
• Quality Improvement (QI) Collaborative Laboratories…and Why We Need Them
• The North Carolina Experience: PQCNC – CABSI, EHM Nursery/NICU
• The National Experience: NCABSI
• Lessons from collaboration
• Transforming the delivery of health care
• Revolutionizing the delivery of healthcare
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Collaborative Laboratories
• Vermont Oxford Network 1988
• CPQCC 1997 – Focus on NICUs
– Benchmarking key clinical outcomes
– “You wouldn’t care for a critically ill infant without monitors. How can you care for 30 infants without monitoring outcomes?”
– Leadership includes doctors, nurses, and payers
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Collaborative Laboratories
• Healthcare systems explore role of formal QI collaborative activities (2000s) – Intermountain Health – Ascension Healthcare – Others
• National organizations lead formal QI efforts – AHA: CLABSI, CAUTI, SSI
• CMS: “Hospital Compare” 2005 • State neonatal collaboratives conduct QI activities
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State Neonatal/Perinatal Collaboratives
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Why We Need State QI Collaboratives
Lee HC et al. Antenatal steroid administration for premature neonates in California From 2005-2007. Obstet Gynecol. 2011 Mar;117(3):603-9.
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Why We Need State QI Collaboratives
Lee HC et al. Antenatal steroid administration for premature neonates in California From 2005-2007. Obstet Gynecol. 2011 Mar;117(3):603-9.
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The North Carolina Experience: PQCNC
• The Perinatal Quality Collaborative of North Carolina (PQCNC)
• Stakeholders in perinatal care across the state – Doctors and Nurses (maternal and neonatal),
families and patients, administrators, DPH, payers (BCBS and DMA), legislators
• Conduct focused QI projects which target inpatient perinatal care
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The North Carolina Experience: PQCNC
• Mission: Make North Carolina the best place to be born
• Return maximal value on perinatal care in North Carolina – Spread best practice – Partner with families and patients – Optimize resources
• Nine statewide initiatives – 55 hospitals, 210 teams, impacting 60% North
Carolina births
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PQCNC CABSI
• 13 NC NICUs with 600 annual median admissions – 72% of NC VLBW infants
• Approved for ABP MOC Part IV Credit
• Expert team developed action plan – Led by Dr. David Fisher
– Review of existing literature
– Web based sessions including 45 participants • Doctors, Nurses, IC, Families, Senior Leaders
– Focus on insertion and maintenance activities
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PQCNC CABSI • Agreed on goal of 75% CABSI reduction
• NHSN CABSI data at baseline & throughout
• NICU teams execute the Action Plan
– Neo, Nurse, Family member and Senior Leader
• Three learning sessions, monthly webinars and weekly email updates
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PQCNC CABSI Data
• Observations for all line insertions
• Line maintenance all lines 7 shifts/week
• Infections based on NHSN criteria.
• Data entered in a secure web based PQCNC CABSI data system.
• Line insertions: 1308
• Maintenance reports: 17,801 shifts
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Insertion Bundle
• Hand hygiene standards
• Maximum sterile barrier precautions
• Sterile gown for operator & assistant
• Skin disinfected and dried
• All supplies at the bedside
• Time out pre-procedure
• Insertion checklist utilized
• Staff empowered to stop procedure
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Maintenance Bundle • Daily assessment of catheter need • “If no catheter today would one be
placed?” • DC catheters at >120 ml/kg/day • Review dressing integrity daily • Scrub connector friction for 15 sec • Gloves when accessing line • Allow surface to dry prior to entry
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PQCNC CABSI
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Oct '09 Nov '09 Dec '09 Jan '10 Feb '10 Mar '10 Apr '10 May '10 Jun '10
% L
ines
Inse
rted
Com
plia
nt w
ith In
sert
ion
Bun
dle
Months
PQCNC CABSI Insertion Compliance
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PQCNC CABSI Maintenance Compliance
Compliance excluding 120 cc/k/d and “If line not in today would one be placed?”
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PQCNC CABSI Individual Elements
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PQCNC CABSI Individual Elements
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PQCNC CABSI Infection Rate
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PQCNC CABSI Results
• 75% reduction in CABSIs
• Avoided 94 infections
• Saved 9 lives
• Hospital savings of $2.9M
• Assumptions: 10% mortality, 10 days extended hospital stay & $30K/infection
• Associated morbidities: CLD, IVH, NEC, ROP
http://www.hopkinsmedicine.org/quality_safety_research_group/our_projects/stop_bsi /toolkits_resources/clabsi_estimator.html
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NCABSI
• Partnership with AHA/HRET • Mission
– Reduce CABSI rates 75% across the collaborative – Support state perinatal collaboratives
• Proposed May 2011 • Action plan and data support system developed
June-August 2011 • State teams recruited July-October 2011 • Start Nov 2011
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NCABSI
• Nine States: MA, HI, WI, SC, NC, FL, NJ, MI, CO
• 95 NICUs entering data
• Partners include AHA/HRET, Pediatrix and State Hospital Associations
• Approved by ABP for MOC Part IV Credit
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NCABSI Action Plan and Methods
• Action plan based on PQCNC CABSI
• Physician state leaders partnered with State HA
• State leaders received $70K in funding
• CUSP training led by Missouri HA (coaching and content) embedded in the project
• Insertion data on all central lines
• Daily maintenance observations on every central line
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NCABSI Action Plan and Methods
• Insertion data reported by observer • Maintenance observations on every central
line daily by bedside nuirse • Web based reporting with real time updates
for hospital, state and national data metrics – Includes g-chart for days between infection for
hospitals, state, and nation
• Infections based on NHSN criteria • Centers report baseline & ongoing NHSN
data
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NCABSI to Date
• Line Insertions – 9051 central lines (umbilical, PICC, Broviac and
other)
• Line Days – 69,057 closed line days
• Maintenance Observations – 50,588 daily observations of central line
maintenance care – 72% completion rate
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NCABSI to Date Insertion Compliance
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NCABSI to Date
Maintenance Compliance
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NCABSI to Date
Line in place after 120 cc/k/d
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NCABSI to Date Infections per 1000 Line Days
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NCABSI Projections
• Reduction of CABSI rate from 3/1000 to 0.75/1000 line days
• 140,000 total line days in 95 NICUs
• Prevent 320 CABSIs
• Save 32 lives
• Avoid 3150 hospital days
• Save $9.5M in NICU costs
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EHM Nursery
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Phase I Skin to Skin
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Phase II Skin to Skin
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Phase I Breastfeeding Support
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Phase II Breastfeeding Support
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Phase I Separation
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Phase II Separation
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Phase I Hand Expression
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Phase II Hand Expression
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Phase I Exclusive Breastfeeding
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Phase II Exclusive Breastfeeding
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Key Drivers EHM Nursery
• Golden Hour – Skin to Skin after delivery
– Possible feed attempt with support
• Separation
• Breastfeeding Support
• Hand Expression
• Post Partum Skin to Skin
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EHM NICU Phase I
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Phase I Skin to Skin
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Phase I Pumping Conversation
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Discussion With Mom Re Milk Pumped
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500 cc/day Week 2
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Shift Knowledge of Hand Electric Pump Use
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Only Human Milk First 3 DOL
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Only Human Milk First 28 Days
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Key Drivers
• Golden Hour (Golden Six Hours?) – Early Pumping
• Provider Conversation with Moms
• Nursing Oversight of Pumping Progress – Skin to Skin
– Volume
– Pump availability
– Use of pump
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Transforming Perinatal Healthcare
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Transforming Perinatal Healthcare
• Partnership with DMA (Medicaid)
• Partnership with BCBSNC
• Partnership with Office of Rural Health and Community Care
• Partnership with NC Legislature and DPH
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Revolutionizing Perinatal Healthcare
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Revolutionizing Perinatal Healthcare
• Leadership from the field
• Clear aim, measureable goal
• Data supports the work • Lean, flexible and necessary
• Sustainable change changes culture • CUSP
• Leadership
• Partnership with patients and families
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Why We Do This? Gabby
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Leadership and Teamwork
If you tell people where to go, but not how to get there, you’ll be amazed at the results. Gen George S Patton
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Martin J McCaffrey, MD, CAPT USN (Ret) Director of the PQCNC
Clinical Professor of Pediatrics UNC Chapel Hill School of Medicine
Division of Neonatal Perinatal Medicine Department of Pediatrics
www.pqcnc.org
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PQCNC VON Infection Rates
0
5
10
15
20
25
30
2005 2006 2007 2008 2009 2010
% V
LBW
With
Infe
ctio
n (F
unga
l and
/or
Nos
ocom
ial)
VON Years
PQCNC Combined Nosocomial and Fungal Infections
27% Reduction in Combined Infections