Reducing Catheter Associated Blood Stream Infections in Thirteen California Regional/Surgical - PowerPoint Presentation

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Reducing Catheter Associated Blood Stream Infections in Thirteen California Regional/Surgical Neonatal Intensive Care Units

Paul Kurtin, MD

Chief Quality and Safety Officer

Rady Children’s Hospital San Diego

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Audience Participation

Question One

Do you think the rate of CABSIs in your NICU can be reduced to zero…and stay there?

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Audience Participation2

Question Two: Do you agree with this statement? “In my unit it is easy to speak up when something isn’t going right”

1=strongly disagree

2=disagree

3=neutral

4=agree

5=strongly agree

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California Children’s Services/California Children’s Hospitals Association NICU Improvement Initiative

13 sites aim California. 8 Children’s Hospitals,

4 UC Hospitals, Sutter Health

Aim:

to reduce/eliminate CABSIs in NICU patients

Metrics:

infections/1000 catheter days stratified

by weight, days between infections

Methods:

improvement collaboratives microsystem assessment, site visits

Partner with CPQCC

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CCS/CCHA NICU Improvement Initiative

CCS, the oldest managed care program for CSHCN in the country, wanted to evolve from a payer, standard setter, and regulator, to an active partner in improving care. This led to the historic collaboration between CCS and CCHA.

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Why This Project?

CASIs are a lose-lose-lose event

NICUs are very high cost units for the state program and commercial payers

Baseline data suggested room for improvement (compared to CDC national data) and wide in-state variation

Potential model for Rewarding Results (P-4-P) programs between the state and the hospitals

While not perfect, evidence to support potential interventions does exist

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The Goal

Reduce catheter associated blood stream infections in NICU patients by 25-50% over 6 months

In specific weight groups or overall

Zero is possible!

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SMART Aim: Example

To reduce CABSI’s by 25% in NICU infants born weighing 1000-1500 gms by June 30, 2007

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What We Know,and Don’t Know

CABSIs are an important cause of increased morbidity, mortality, and costs in hospitalized patients

CABSIs can be reduced/eliminated through the use of a ‘bundle’ of interventions

1. Hand hygiene

2. Maximum barrier precautions

3. Chlorhexidine skin antisepsis

4. Optimal site selection

5. Daily review of line necessity

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What We Don’t Know and Need to Find Out

Is the bundle transferable to NICU patients?

Chlorhexidine for infants < 2 months

Optimal site selection

What is the definition of a CABSI?

Clinical sepsis? Contaminants?

Number and volume of blood specimens?

CPQCC ‘tool kit’ (www.CPQCC.org)

No perfect closed system (especially umbilical lines)

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Key Interventions

Update and gain consensus on definitions and tool kit

Share experience with chlorhexidine

Hand hygiene for staff and parents

‘Stop the line’

Visual display of results (days since last infection)

Dedicated line insertion and maintenance teams/kits

Educate/collaborate outside of NICU

RCA for each infection

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Tips for Getting Started

Build the ‘burning platform’ (Build Will)

CABSIs are a lose-lose-lose event and are increasingly being publicly reported

(Provide ideas) from literature or best and promising practices

Focus on the what needs to be done and be flexible with the how to do it

Help sites identify interventions to try (content experts and networking)

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Key Measures

Creating your Baseline

Infections/1000 catheter days

Days between infections

Cost/infection (LOS, antibiotics, DX tests)

Morbidity

Mortality

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Results

Overall CABSIs were reduced by 29%. Varied by site and weight group

Approximately $3.4M was saved by avoiding these infections

Many sites set personal records for days without an infection, often exceeding 100 days

All sites improved as high functioning microsystems

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Results2

Improved hand hygiene

Widespread use of chlorhexidine

Improved configurations of lines especially umbilical lines

Creation of dedicated line teams

Collaboration with areas outside of NICU, especially radiology and anesthesia

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Improvement Process

Champions: physician, nurse, administrative

Respected content experts: D. Wirtschafter, MD; J. Pettit, MSN, NNP; T. Huber, MBA

Frequent phone with sites and project team

CPQCC bundles updated and refined

Agree on basic definitions

Frequent feedback of results

Site visits

PDSA cycles (what v. how)

Created a community of practice with active sharing

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Project Team

Virtual team

Data Analysis: M. Seid, PhD

Clinical expertise from known, respected MD and RN, NNP

Site visits

Experience in leading large, multisite collaboratives

Active State and Association participation

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Year Two: High Risk Requires

High Reliability

“When One is One Too Many”

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A High Risk Healthcare Environment

Potential for unexpected events due to the complexity of the patients, technologies and treatments (reduced physiologic reserve)

Risk, in part, results from a failure to detect early warning signals and respond aggressively to them

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High Reliability Organizations

Preoccupation with failure

Reluctance to simplify interpretations

Sensitivity to operations

Deference to expertise

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Preoccupation with Failure

Any lapse is a symptom of system vulnerability

All errors and near misses are reported and used as learning opportunities

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Reluctance to Simplify Interpretations

Our environment and patients are complex, we need more complete and nuanced understanding of the situation

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Sensitivity to Operations

“Latent failures”or loopholes in any system’s defenses will always occur because we are human

Discover latent failures in the course of normal operations before a failure occurs.

Attentive to the front line where the real work gets done

Culture: open, speak-up

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Sensitivity to Operations2

Maintaining explicit and communicated situational awareness (pre and post shift briefing sessions). What/who are we worried about; what went well; what could have gone better. Real time information permits early identification and action

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Deference to Expertise

Push decision making down to the front line

Decisions migrate to the person with most specific knowledge of the situation

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Default Position

No news is good news?

No news is bad news?

No news is no news?

For a HRO, no news is worrisome

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Things to Consider in Building a HRO

Create a climate where it is safe to report and question assumptions

Conduct incident reviews frequently and soon after the event

View close calls as sign of potential danger not success

Maintain situational awareness of current practices and changes in those practices

Make knowledge about the system transparent and widely known (process measures)

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Building a HRO: Prevent

Focus on uniform process guidelines and bundles and their adherence rates

Check lists

Feedback: real-time and aggregated

Hand hygiene: stop the line and

secret shopper

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Delivering High Reliability Care

Going Where No One Has Gone Before!