Reducing Catheter Associated Blood
Stream Infections in Pediatric ICUs
The Collaborative Model – key to
success?
Richard J. Brilli, MD
Academy of Health
Chief Medical Officer
2009 Annual Research Congress
Nationwide Children’s Hospital
Professor, Pediatrics
The Ohio State University College of Medicine
Outline
• Why CA-BSI?
• What is CA-BSI and Why is it hard to
eradicate?
• Brief Summary of Outcome Data
• Why has this Network (Collaborative)
been successful
Every system is perfectly
designed to produce the results
it gets.
If you do not change the system
you will continue to get the
same results
Don Berwick, Institute for Healthcare
Improvement and many others
• CA-BSI is high morbidity, high
mortality, high cost
 250,000 cases per year in US
 80,000 cases per year in ICU’s
 Attributable mortality: 9-25%
 Attributable cost: $25,000-$45,000
• Regulatory - Oct08: CMS no longer
pays hospital for CA-BSI event
• To date, 19 States mandate at least
hospital reporting CA-BSI data to CDC
• CA-BSI – Catheter-associated Blood
Stream Infection
• Bacteremia (bugs in the blood) in the
presence of a centrally located venous
catheter, in the absence of another
source of the bacteremia besides the
catheter
Eliminating CA-BSI a function of Pathophysiology
 Skin contamination (insertion
& during maintenance)
 Bacterial migration through
subcutaneous tissue down
catheter track
Full Sterile Barrier - Operator
Full Sterile Barrier at Insertion
How to Fix relates to CA-BSI Pathophysiology
External catheter
colonization from within
the bloodstream
Eliminating CA-BSI a function of Pathophysiology
Intraluminal &
Extraluminal catheter
contamination /
colonization
Maintenance
Care Focus
Outcome Data
Collaborative GOALS and AIMS
Outcomes Measures
 50% decrease in CA-BSI rate per 1,000 line days for 2
consecutive quarters within 6 months of reliably
implementing infection reducing strategies (ACHIEVED)
 Eliminate CA-BSI across 30 PICU’s (FAILED)
Process Measures
 100% of units adherent with insertion and maintenance
practice changes – not done before (ACHIEVED)
 Measure compliance with bundle elements - Practices
followed 95% of the time (ACHIEVED at 90%)
•Building Block / Culture Goals
– Improvement in Mean Safety Climate Score (IN
PROCESS)
– Every clinician involved in line care receives education
(ACHIEVED)
CHARTER GOALS and SPECIFIC AIMS
Spread - Critical Care
 Engage more than 100 pediatric critical care physicians in
network activities within the first year (ACHIEVED)
 Disseminate to the ~330 PICUs in the US by the end of the
third year of the project (FAILED – up to 60, working on another
20 units)
Program Model to Assist Recertifying Subspecialists
 Part IV Maintenance of Certification for Pediatric Subspecialists
(ACHIEVED)
 Project approved by ABP (ACHIEVED)
Control Chart: Monthly BSI Rates - Baseline to Present
Phase I
Apr09
NHSH pooled mean = 2.9
AJIC Nov 2008 & dropping
254,872 line days - 29 PICUs over 2.7 yrs
Baseline rate – 5.4; current – 1.6
70% decrease in BSI rate
Monthly BSI Rates: Oct 06 – Apr 09
Phase I – Apr09
Apr09 = 1.6 rate
Catheter Care Bundle - Insertion
• Hand Washing
• Chlorhexidine Scrub at insertion site
• No Iodine use at insertion site
• Insertion Checklist
• Prepackaged or Filled Insertion cart
• Polyurethane or teflon catheters only
• Insertion training for all operators
Make it Easy to follow all steps
and do the Right Thing
Insertion Cart
Kosair Children’s Hospital
Catheter Care Bundle - Maintenance
• Daily Assessment of Line necessity &
Integrity
• Hand Hygiene before Line Care
• Catheter Site Care – dressing changes;
prepackaged dressing change kits
• Catheter Cap/Hub/Tubing care
NACHRI CA-BSI Elimination Collaborative
Dressing Change Kit
Kit Contents
NACHRI CA-BSI Elimination Collaborative
NACHRI CA-BSI Elimination Collaborative
Cap Change Kit
Cap Change Kit Contents
Aggregate Monthly Bundle Compliance Data
Oct 06 – Feb 09
Phase I – Feb09
Sustained Reliable Performance
29 PICUs CA-BSI Rates, Insertion and Maintenance Compliance - Pre-and PostCollaborative Intervention Periods
100,000 Central Line Days
Insertion Compliance Rate
Maintenance Compliance Rate
Pre-Collaborative Interventions
CA-BSI Rate
Post-Interventions
Infection Rate vs. Insertion Compliance
Insertion compliance ↑es, infection rate ↓es; but not
statistically significant association
Infection Rate vs. Maintenance Compliance
As Maintenance compliance ↑es, infection rate ↓es sharply
Highly statistically significant association (p<0.008)
TAKE HOME MESSAGE RE: Outcomes
PICU CA-BSI Collaborative impact:
 >741 CA-BSIs prevented
 >$25 million dollars saved
 > 89 deaths prevented
Reliable implementation of Maintenance care
practices
 New Knowledge for children’s
healthcare
 Measure compliance with care
practices
Model is sustainable and can create new
pediatric evidence
Why Has this Network been Effective?
• The Collaborative – Just Getting Together
 Absent “Perserveration with Perfection”
 Absent “Paralysis of Analysis”
• Transparency of Data
 Rapid Exchange of new ideas or best
practice; Key to moving quickly
• Standard Method for Improvement
 Reliable Implementation - measured
 Data Driven but not Data Paralyzed –
planned experimentation
Collaborative Model – Organization
Sponsors and Contributors
 Key Sponsors of Collaborative
–
–
–
–
–
NACHRI
American Board of Pediatrics
CHCQ: Center for Health Care Quality
Johns Hopkins Bloomberg School of Public Health
Johns Hopkins Quality and Safety Research Group
 Involved Parties
– CDC: Centers for Disease Control
– NOC: National Outcomes Center
– VPS: Virtual PICU Performance System
 Collaborative Leadership from Diverse
Institutions and Disciplines
– Content experts AND Process improvement experts
Improvement Collaborative
Model
Select
Topic
Participating
PICU’s
Prework
Printed Reports
P
P
Changes
Strategies
A
D
A
S
Design
Meeting
Planning
April 19, 06
LS 1
Sept 06
D
S
LS 2
Jan 07
Spread
LS 3
Phase II
Oct 07
Jul 08
Decision to focus on
Maintenance Care
What Do We Think has Made this work
• The Collaborative – getting together
 Absent “Perserveration with Perfection”
 Absent “Paralysis of Analysis”
• Transparency of Data
 Rapid Exchange of new ideas or best
practice; Key to moving quickly
• Standard Method for Improvement
 Reliable Implementation - measured
 Data Driven but not Data Paralyzed –
planned experimentation
One Bundle – Two Parts
Insertion & Maintenance
• Where did the bundles come from?




Pediatric literature (sparse)
Extrapolated from adult literature (esp. for “insertion”)
Pathophysiology-driven (esp. for “maintenance”)
Consensus opinions of experts and thought-leaders
• Uncertain if these bundles were “best practice”
 But if these bundled practices were standardized &
reliably implemented, then…
• Initial PICUs could assess impact on BSI rates
• Additional Maintenance practices could be “tested”
What Do We Think has Made this work
• The Collaborative – getting together
 Absent “Perserveration with Perfection”
 Absent “Paralysis of Analysis”
• Transparency of Data
 Rapid Exchange of new ideas or best
practice; Key to moving quickly
• Standard Method for Improvement
 Reliable Implementation - measured
 Data Driven but not Data Paralyzed –
planned experimentation
29 Collaborating PICUs
PICU CA-BSI Phase II Members
Levine Children’s Hospital (NC)
Texas Children’s Hospital – PICU (TX)
Methodist Children’s Hospital of South Texas (TX)
Texas Children’s Hospital – CVICU (TX)
Children’s Hospital of Philadelphia – PICU/PCU
(PA)
CHRISTUS Santa Rosa Children's Hospital (TX)
Children’s Hospital of Philadelphia – CICU (PA)
Children’s Medical Center at Presbyterian Hospital (NM)
Medical City Children’s Hospital (TX)
Children’s Hospital (Denver) – PICU and CICU (CO)
Children’s Hospital of Michigan (MI)
Cabell Huntington Hospital (WV)
Maria Fareri Children’s Hospital (NY)
Arnold Palmer Hospital for Children – CICU (FL)
Yale-New Haven Children’s Hospital (CT)
Arnold Palmer Hospital for Children – PICU (FL)
Children’s Hospital, Cleveland Clinic (OH)
CS Mott Children’s Hospital University of Michigan – CICU
(MI)
Children’s Hospital of Central California (CA)
Children’s Hospital of Alabama (AL)
Schneider Children’s Hospital (NY)
SSM Cardinal Glennon Children’s Medical Center (MO)
Riley Hospital for Children (IN)
Children’s Medical Center Dallas - PICUs (TX)
Univ of Virginia Children’s Medical Ctr (VA)
Children’s Medical Center Dallas – CICU (TX)
Deaconess Hospital (IN)
Nationwide Children’s Hospital – PICU (OH)
Mary Bridge Children’s Hospital (WA)
Nationwide Children’s Hospital – CICU (OH)
Transparency Barriers & Excuses
• Typical excuses I have used and have heard used:







The data is wrong – inconsistent definitions
Our patients are sicker (old severity of illness argument)
Our hospital is busier than yours
Our patient population is different than yours
Your data makes our unit look bad !
My CEO, CFO, hospital attorney say I can’t share data
It can’t be true I am in a world famous center
• Probably all relevant and maybe even true
• What if I could go to your website and learn from
you because you are doing it better?
Some systems really are better than
others
 We can learn from the best
 As a result – all will improve more quickly
35
01/04 n=13
02/04 n=12
03/04 n=12
04/04 n=14
05/04 n=14
06/04 n=14
07/04 n=14
08/04 n=14
09/04 n=15
10/04 n=17
11/04 n=17
12/04 n=17
01/05 n=19
02/05 n=20
03/05 n=20
04/05 n=18
05/05 n=19
06/05 n=18
07/05 n=19
08/05 n=19
09/05 n=19
10/05 n=18
11/05 n=18
12/05 n=18
01/06 n=21
02/06 n=21
03/06 n=21
04/06 n=20
05/06 n=20
06/06 n=21
07/06 n=19
08/06 n=19
09/06 n=19
10/06 n=22
11/06 n=22
12/06 n=21
01/07 n=25
02/07 n=24
03/07 n=25
04/07 n=25
05/07 n=25
06/07 n=24
07/07 n=25
08/07 n=26
09/07 n=26
10/07 n=27
11/07 n=27
12/07 n=27
01/08 n=27
02/08 n=27
03/08 n=27
04/08 n=15
BSI Rate
NACHRI Collaborative Variation BSI Rates by Unit
BSI Rate By Month
40
Systems are perfectly designed to get the results they
get and by the way some systems are better designed
than others, for example …..
Max
75th Percentile
Median
25th Percentile
Min
30
25
20
15
10
5
0
Data entered as of 1/16/2007 (updated October and November)
December 2006 CA-BSI Rate per 1000 Line Days - Ordered by Rate
Note: October was the first month of data submission; November the first month of full verification
of number of events
25.0
20.0
What would you do if this was your hospital?
Rate
15.0
10.0
OctAgg (n=25)
5.0
0.0
Nov Agg (n=25)
NovAgg (n=29)
DecAgg (n=29)
Wis Cin Ark
Oct Nov Nov Dec
Unit Unit Unit Unit May Unit Unit Kos Unit Unit Unit Sea Unit
Unit Unit Hop Unit Unit Unit Unit Unit Unit Unit Unit Unit Unit
con cinn ans
Agg Agg Agg Agg
18 3 27 15 o 11 20 air 16 4 23 ttle 9
2 6 kins 10 13 17 19 22 25 26 30 31 5
sin ati as
(n= (n= (n= (n=
23.3 18.0 10.8 8.7 8.1 5.8 5.3 4.2 3.8 3.6 3.4 2.6 2.4 2.3 2.0 0.0 0.0 0.0 0.0 0.0 0.00 0.0 0.0 0.0 0.0 0.0 0.0 0.0
5.1 3.5 3.4 3.0
Line Days 86 222 185 231 123 172 375 236 264 563 292 389 425 429 498 368 192 302 259 265 367 93 102 202 329 313 236 252
6,44 6,30 7,35 7,79
Rate
Infections
2
4
2
2
1
1
2
1
1
2
1
1
1
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
33 22 25 23
What Do We Think has Made this work
• The Collaborative – getting together
 Absent “Perserveration with Perfection”
 Absent “Paralysis of Analysis”
• Transparency of Data
 Rapid Exchange of new ideas or best
practice; Key to moving quickly
• Standard Method for Improvement
 Focus on Reliable Implementation measured
 Data Driven but not Data Paralyzed –
planned experimentation
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
Significant time
devoted to
Teaching
improvement
science – very
important.
What change can we make that
will result in improvement?
Act
Plan
Study
Do
Key Driver Diagram - Analysis
Outcomes
Key Drivers
Intervention/Change Concepts
What Do We Think has Made this work
• Collaborative Model
• Data Transparency
• Standard Method for Improvement
Collaborative Faculty
Co-Chairs: Richard J. Brilli, MD; Marlene Miller, MD
Faculty: Debra Campbell, RN; Charlie Huskins, MD;
Michelle Moss, MD; Matthew Niedner, MD; Tom Rice, MD;
Debra Ridling, RN
QI – Informatics: Mitch Harris, PhD; Peter Margolis, MD;
Steve Muething, MD; Jayne Stuart, RN
NACHRI Staff: Mary Kelly, Gloria Lukasiewicz, RN
CA-BSI Collaborative Structure
NACHRI
Project Staff
Clinical,
Statistics
Improvement
and Data
Science
and
Operational
Mitch
Jayne
Gloria
Mary K
JHU SOPH
JHU-SAQ
CHCQ
STEERING COMMITTEE
Chairs: Brilli, Miller
Members: Huskins; Rice;
Campbell; Ridling; Moss; Niedner;
others from Phase II
Phase I
29 units
Began 9/2006
Phase II
33 units
Began 5/2008