Catheter-associated blood stream infections (CA-BSIs) are infections that occur in hospitalized children’s central venous catheters (a catheter is flexible medical tubing inserted into the body). They are also a preventable harm that carries a price tag of at least $50,000 per event and a 10 percent to 20 percent mortality risk for children. In October 2006, a group of 29 pediatric intensive care units (PICUs) in 27 children’s hospitals across the country began working together and studying how to eradicate CA-BSIs in PICU patients. Through a quality transformation collaborative formed by the National Association of Children’s Hospitals and Related Institutions (NACHRI), these PICU teams have prevented 121 deaths, 1000 CA-BSI infections and saved $35 million in infection-related costs, as of December 2009.
In a soon to be published Pediatrics article (February print issue) on the NACHRI quality transformation collaborative’s outcomes from the first 12 months of work through September 2007, lead author and NACHRI Quality Transformation Vice President Marlene Miller, MD, MSc and her co-authors assert that significantly reducing the risk of CA-BSIs in pediatric patients is possible and requires a different focus than what works to reduce the risk of these infections in adult patients. They have learned that reducing CA-BSI events requires an approach combining evidence-based guidelines for catheter insertion with daily maintenance care for central lines. In fact the main driver in reducing CA-BSI infections by almost 50 percent in 12 months was the reliable use of the recommended daily maintenance care for central lines. The collaborative study is the first to clearly differentiate the affect of insertion-related practices, well documented in adult-patient academic literature as driving the reduction of CA-BSIs in intensive care, from maintenance-related practices that are predictive of being able to reduce children’s CA-BSI rates.
During the study period, October 2006 to September 2007, average CA-BSI rates were reduced by 43 percent across the 29 PICUs: 5.4 versus 3.1 CA-BSIs per 1000 central-line days primarily through daily maintenance-bundle compliance, “what the nurse does when handling the central line to introduce medications, fluids, flushes, etc. and what the physician does in terms of orders that require entry of the central line every day such as frequencies of blood sample draws and number of medications given each day” says Miller. “In pediatric intensive care, we access our central lines more often than adult intensive care unit providers, so day-to-day maintenance practices really matter.” More than 30 additional PICU teams joined the quality transformation effort in June 2008 for its second phase and 17 more PICU teams joined for its third phase, which began in fall 2009. “Soon this quality transformation effort will publish its findings after three years of work which will show even further and substantial reductions in CA-BSI rates with PICU teams working on reliably doing best practices for central line insertion and, more importantly, the day to day care of the central line or maintenance practices,” adds Miller.
According to NACHRI quality transformation faculty, a key factor in the progressively successful outcomes is the number of PICUs involved. “Because of the larger sample size, outcomes can be understood more rapidly,” notes Debra Ridling, RN, MS, co-author and director of nursing quality and evidence-based practice at Seattle Children’s Hospital in Washington.
Another key feature, according to faculty, is transparency. Every PICU involved knows how everyone else is doing – not only rates of infection, but also rates of compliance with both the insertion and maintenance bundles. Quality transformation efforts “offer the opportunity to learn from one another more quickly,” says Richard Brilli, MD, chief medical officer at Nationwide Children’s Hospital in Columbus, OH and who, along with Miller, is co-chair of the NACHRI PICU CA-BSI quality transformation collaborative and also co-authored the article in Pediatrics.
Modeled on the success of this PICU CA-BSI project, a NACHRI hematology oncology quality transformation effort was launched in fall 2009 to reduce the rate of nosocomial CA-BSI among pediatric hematology oncology patients. Thirty-three pediatric hematology oncology teams from 28 children’s hospitals are participating. This represents a first step toward a goal recently articulated by the federal government’s Agency for Healthcare Research and Quality to spread the national effort to reduce CA-BSIs outside intensive care units to all the patients in the U.S. who have chronic central lines such as children with oncologic diseases. Miller believes this work will open the door to learning how to prevent CA-BSIs in community hospitals, ambulatory clinics, home care agencies and even the home setting.
According to Lawrence McAndrews, president and CEO of NACHRI, “Quality Transformation efforts are innovative, productive, and nimble vehicles to test new practices, discover new evidence and allow improvement to take place and spread more quickly. NACHRI leads this effort to improve the quality of children’s patient care because it’s in our DNA – we want all children to reach their full health potential.”