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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. Audience Participation. Question One

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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 Thirteen California Regional/Surgical Neonatal Intensive Care Units

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 Participation Thirteen California Regional/Surgical Neonatal Intensive Care Units

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 stratifiedby weight, days between infections

Methods: improvement collaboratives microsystem assessment, site visits

Partner with CPQCC


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CCS/CCHA NICU Hospitals Association 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? Hospitals Association NICU

  • 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 Hospitals Association NICU

  • 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 Hospitals Association NICU

  • 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, Hospitals Association NICUand 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 Hospitals Association NICU

  • 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 Hospitals Association NICU

  • 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 Hospitals Association NICU

  • 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 Hospitals Association NICU

  • Creating your Baseline

  • Infections/1000 catheter days

  • Days between infections

  • Cost/infection (LOS, antibiotics, DX tests)

  • Morbidity

  • Mortality


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Results Hospitals Association NICU

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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Results Hospitals Association NICU

  • 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 Hospitals Association NICU

  • 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 Hospitals Association NICU

  • 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 Hospitals Association NICU High Reliability “When One is One Too Many”


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A High Risk Healthcare Environment Hospitals Association NICU

  • 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 Hospitals Association NICU

  • Preoccupation with failure

  • Reluctance to simplify interpretations

  • Sensitivity to operations

  • Deference to expertise


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Preoccupation with Failure Hospitals Association NICU

  • 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 Hospitals Association NICU

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


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Sensitivity to Operations Hospitals Association NICU

  • “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 Operations Hospitals Association NICU

  • 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 Hospitals Association NICU

  • 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 Hospitals Association NICU

  • 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 Hospitals Association NICU

  • 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 Hospitals Association NICU

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 Hospitals Association NICU

Going Where No One Has Gone Before!