Transcript NICHQKurtin
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
Audience Participation
Question One
Do you think the rate of CABSIs in your
NICU can be reduced to zero…and stay
there?
Audience Participation
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
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
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.
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
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!
SMART Aim: Example
To reduce CABSI’s by 25% in NICU
infants born weighing 1000-1500 gms
by June 30, 2007
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
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)
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
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)
Key Measures
Creating your Baseline
Infections/1000 catheter days
Days between infections
Cost/infection (LOS, antibiotics, DX tests)
Morbidity
Mortality
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
Results
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
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
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
Year Two: High Risk Requires
High Reliability
“When One is One Too Many”
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
High Reliability Organizations
Preoccupation with failure
Reluctance to simplify interpretations
Sensitivity to operations
Deference to expertise
Preoccupation with Failure
Any lapse is a symptom of system
vulnerability
All errors and near misses are reported
and used as learning opportunities
Reluctance to Simplify
Interpretations
Our environment and patients are
complex, we need more complete and
nuanced understanding of the situation
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
Sensitivity to Operations
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
Deference to Expertise
Push decision making down to the front
line
Decisions migrate to the person with
most specific knowledge of the situation
Default Position
No news is good news?
No news is bad news?
No news is no news?
For a HRO, no news is worrisome
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)
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
Delivering High Reliability Care
Going Where No One Has
Gone Before!