Quality: The Stories Behind the Stats
Children's Hospitals Today, Fall 2011
by Anita Blumenthal
In September, children’s hospitals celebrated having passed a milestone in their quest to eradicate catheter-associated blood stream infections among hospitalized pediatric patients. After five years of quality improvement in pediatric intensive care and hematology/oncology units, children’s hospitals in the NACHRI Quality Transformation Network have saved lives, prevented infections and exceeded the $100 million milestone for cost savings.
The numbers are impressive. In early September, the NACHRI Quality Transformation Network (QTN), initiated in 2006, had prevented an estimated 2,964 central line infections and saved 355 lives, as well as saving $103,722,423.
The QTN includes two infection prevention collaborative programs for central line-associated bloodstream infections (CLABSI), one in pediatric intensive care units (PICU) and pediatric cardiology and a second, started in 2008, in hematology/oncology units (hem/onc). The programs involve central line insertion and maintenance bundles and include rigorous methodology, tightly coordinated implementation, and large, rich data sets gathered from monthly reports measuring process compliance and outcomes. Data from every unit are reported to all collaborative participants. A third collaborative program was launched in 2011 for dialysis centers, focusing on peritoneal and exit site infections for peritoneal dialysis patients.
“QTN is more than just professionals working on specific problems,” says Matthew Niedner, M.D., director of quality and patient safety of the PICU at the University of Michigan C.S. Mott Children’s Hospital in Ann Arbor and QTN PICU CLABSI collaborative faculty member. “QTN is learning and understanding improvement science: How to get better at getting better.”
Further, the member units have applied the QTN ethos — procedures, practices, approaches and a general improvement-oriented mindset — to a wide arena of practices and care delivery.
Measuring Rates — and Measuring Up
The transparency principle of QTN “has increased the comfort level of showing others your defects to help fix them, instead of hiding them,” Niedner says. “The goal is teamwork that transcends institutions. Let’s not compete on safety.”
“One of the most valuable things about QTN was seeing how we measure up,” says Jeanine Graf, M.D., medical director of the PICU at Texas Children’s Hospital in Houston, where infections decreased by more than half in 24 months.
Otwell Timmons, M.D., pediatric intensivist at Levine Children’s Hospital at Carolinas Medical Center in Charlotte, NC, explains he is “particularly grateful to QTN for the belief — backed by examples — that you can keep lowering your rate and not rest on your laurels. Without these examples,” he says, “I would have been happy with two infections per 1,000 line days and not gone lower. But in 2010, we had 1.2 infections per 1,000 line days.”
QTN requires rigorous tracking and measurement that was new to some members. For example, before joining QTN, the hem/onc unit at Upstate Golisano Children’s Hospital in Syracuse, NY, did not track line infections or patient line days. “We had no sense of where we were,” says Bonnie Miner, R.N., clinical nurse specialist. Since joining QTN, the unit went nearly a year without an infection and had reached 232 days by July 2011.
Tools and Teamwork for Success
To support greater compliance and constant improvement, QTN provides a range of tools, including a Listserv, meetings and webinars, for seeking and sharing advice and experiences.
“The Listserv is helpful for a variety of queries,” Niedner explains. “For borderline cases that barely meet the CDC definition, a Listserv query can ask, ‘Would you call this a CLABSI at your institution?’ There are also nuts-and-bolts questions: ‘We’re using such-and-such brand of vascular assistive device. Are others having problems with it like we are?’ With so many units on the Listserv, someone is likely to have an answer,” Niedner says.
The monthly webinars and twice-yearly meetings are forums for keeping members energized and also apprised of useful products and devices. The QTN meetings “keep us from reinventing the wheel,” Graf says. “If, for example, we see that the [Children’s Hospital of] Wisconsin cap change kits are very good, we can adopt them.”
Response to an Infection
One major component of QTN is root cause analysis — the process that comes into play when an infection occurs. As soon as the hospital’s infection control unit notifies the PICU or hem/onc unit that a positive blood culture meets the definition of a CLABSI, there is a meeting of the unit’s designated root cause analysis team plus all staff who had cared for the patient in the days preceding the positive blood culture. The analysis team is trained in positive interviewing techniques to focus on discovering what could have caused the infection and how the system failed — not how any individual did — so that the problem does not arise again.
Graf declares that root cause analysis “has been the highest-yield, single process in the whole QTN involvement. Every time, we find something we did not appreciate or understand. In one case, we found that the child with the infection had been sedated for anesthesia, but the team there was not aware of scrub-the-hub procedure. So we educated the anesthesia group.”
A root cause analysis led by Timmons found that the patient with the infection perspired a lot, and staff had had trouble keeping the dressings on. In response, the PICU defined a group of patients with this problem and changed the dressings for this group so that they would stay on more reliably and protect the line.
At Mott, the family is invited to take part in the child’s root cause analysis to share their insights and observations. Niedner explains, “When a CLABSI occurs, it is disheartening, but it also reaffirms that we still have work to do.”
Units Expand Practices and Ethos
The drop in infection rates for QTN members is impressive, but Niedner declares, “Statistics are the floor of what we have saved; participation in QTN has had so many more far-reaching benefits.” These include changes in the culture of the unit as it extends the procedures and practices of the bundles to address other clinical issues. In many cases, these new procedures have been adopted hospitalwide.
For example, at Children’s Hospital Colorado in Aurora, PICU clinical practice specialist Beth Wathen reports that the bundle’s checklist for inserting central lines is now on the hospitalwide electronic medical records system. In the hem/onc unit, clinical assistants (nurse’s aides) have been included in developing bundle-style, standardized processes for hygienic practices related to central line care, such as linen changing.
“When hem/onc first implemented QTN, they realized there was no standardized way to deal with the central lines to keep them dry during bathing/showering,” reports Kelly West, M.S., R.N., CPON, former clinical nurse specialist for the project. “We introduced AquaGuard, a disposable moisture barrier, to cover the site of the central line along the chest and dressing, and we used Glad Press’n Seal, a common plastic wrap, to keep connections along the tubing dry.” This policy was written for use throughout the whole hospital.
Hem/onc success sparked positive changes in the neonatal ICU. The NICU has now adopted the bundles and dressing-change procedure and is doing its own audit. Scrub-the-hub is now part of the NICU standard education, and its infection rate is down.
Further, Edythe Albano, M.D., director, clinical oncology, reports that Children’s Colorado is using bundles in outpatient situations and is tracking line days and infection rates in the outpatient units. In fact, she says that there was pressure to use these bundles from patients and families who were used to seeing that level of line care in the inpatient unit and wanted the same standard in outpatient units.
At Golisano Children’s, Diane Kwaczala, B.S., R.N., P.S.M., notes that the PICU trained the general pediatric and pediatric surgery units in the bundles; then the entire Upstate University Hospital went through the training. The PICU also shared its root cause analysis form with the central line teams of the whole hospital.
The QTN maintenance bundles are also standard throughout the children’s and adult hospitals at Carolinas Medical Center. Timmons explains, “We improved our PICU standards so much that our staff became upset when staff from other units did things in a less rigorous way. We had gone from pre-systematic to systematic, and then we became relentless.”
There have been, and continue to be, some bumps in the road. For example, Timmons says, "Several years ago, some operating room staff thought the OR was sterile enough, so there was no need for full draping and no need to be compulsive about inserting or accessing lines. To their credit,” he says, “the OR adopted the QTN insertion bundle and came up to QTN standard. Because many PICU patients come in from the OR, their progress has a lot to do with our infection rates.”
Also, Timmons reports that the PICU reduced the frequency of entering the central line by bundling lab studies into once or twice a day. And staff members have become more systematic in asking every day if the line is still necessary. Over time, Timmons says, “the PICU has reduced the number of days the line stays in place and the number of patients who have a central line to begin with.”
In another offshoot of the QTN project, Texas Children’s is running a CPR resuscitation performance improvement project, using the same principles to improve various facets of performance.
In addition, QTN’s culture of transparency has spread to the individual hospitals. For example, Mott regularly posts data in public areas about adverse events—CLABSI, ventilator-associated pneumonia, unplanned extubations, etc.
“This practice engenders trust,” Niedner says. “It shows we recognize threats in the care environment. It also empowers patients and families to speak up about concerns, and it creates greater accountability.”
Retreat of the Skeptics
QTN often met with initial skepticism. Miner says, “Some providers would say, ‘Show me the evidence’ and complain that the processes in the bundles were not based on multilevel studies.” Some providers, Timmons says, “were convinced that line infections were inevitable and impossible to eradicate, so why bother.” But, as the providers interviewed for this article agreed, success converted the skeptics.
Anita Blumenthal is a freelance writer in Potomac, MD, and writes frequently for Children’s Hospitals Today. Most recently she wrote “Everyone Wins: Collaborations Extend Access, Expand Opportunities” in spring 2011.