Eliminating Pediatric CA-BSIs
Marlene R. Miller, MD, MSc
Vice Chair, Quality and Safety
Johns Hopkins Children’s Center
Vice President, Quality Transformation, NACHRI
GOALS
 Explain how and why this effort started
 What have we achieved and learned in first year?
 Where are we now in NACHRI’s PICU CA-BSI
Collaborative efforts?
Why CA-BSI ?
The Problem: Adults and Children
 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
 National groups asking for solutions
 Allows us to focus sharply on specific problem
Baseline Variation Across PICUs – We HAVE MUCH to
fromBSI
each
Mean learn
and Median
Rateother
by PICUs
NNIS 90%
12
10
BSI Rate
8
NNIS 50%
6
4
NNIS 10%
2
0
22
9
4
16 28 15 19 10
2
5
11 25
7
3
20 14 26 27 29 13 21
PICUs
Mean BSI rate
Median BSI rate
6
23 17 12
NACHRI PICU CA-BSI Collaborative:
How Did We Form?
 Began as small expert meeting where several PICUs
presented their efforts on CA-BSI
 PICUs realized that focusing on adult-based CA-BSI efforts
was NOT reducing pediatric CA-BSI rates
 Larger planning meeting with ~20 PICU experts to help
develop actual bundles
 Wrote up Charter and began recruiting PICUS
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
 Co-Chairs and Faculty from Diverse Institutions
– Content experts AND Process improvement experts
PICU 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 MD, Miller MD
Members: Huskins MD; Rice MD;
Campbell RN; Ridling RN;
Moss MD; Niedner MD;
Phase I
29 units
Began 9/2006
Phase II
33 units
Began 5/2008
PICU CA-BSI Collaborative:
Long Term Goals and Commitments
 Produce effective and sustained changes in your ICUs
via reliably doing best practice and building colleagues
– Engage and educate providers in QI
– Develop and sustain ABP MOC effort
– Improve PICU safety culture and teamwork
 Spread to all PICUs in USA
 Generate new knowledge
 Focus on minimizing costs while achieving and sustaining
gains
CHARTER: Specific Goals
Eliminate CA-BSI attributed to the PICU
First year goals:
– Decrease CA-BSI by 50%
– 90% of central venous line insertions completed using
collaborative insertion bundle
– 70% of all central venous line catheter maintenance
care performed using collaborative maintenance care
bundle
Improvement in PICU team function between physicians,
nurses and other team members that results in a 10-point
increase in Safety Culture score
Phase One: 29 PICU Teams in
CA-BSI Collaborative
Children’s
Hosp &
Regional
Medical
Center, Seattle
U. of MN
Children’s
Hospital,
Children’s Hospitals & Fairview
Clinics of Minnesota
(Minneapolis/ St. Paul)
Children’s
Hospital
Illinois
Children’s
Hosp of
Wisconsin
DeVos
Children’s
Hospital
Penn State
Children’s
Hospital
Children’s
Hospital
Boston
UC Davis
Health System
Beth
Israel
Mayo Eugenio
Litta Children’s
Hospital
All 29 PICUs are Fully
Transparent to Each Other
Univ of
New
Mexico
Hospital
Children’s
Mercy
Hospital
U. of Mich,
CS Mott
Children’s
Hospital
Duke
Univ.
Joseph M. Sanzari
Children’s
AI DuPont
Hospital for
Children
Johns Hopkins
Children’s Center
Children’s
Hospital of Los
Angeles
Cincinnati
Children’s
Hospital
Cook
Children’s
Hospital
Kosair
Children’s
Hospital
Children’s
Hospital of
Austin
Arkansas
Children’s
Hospital
Akron
Children’s
Hospital
Children’s
National
Medical Center
INOVA
Fairfax
Hosp for
Children
PICU CA-BSI Phase I Members
Arkansas Children’s Hospital – PICU
The Children’s Mercy Hospital
Children’s Hospital of New Jersey at Newark Beth Israel
Medical Center
Children’s Hospital Los Angeles
University of California Davis Children’s Hospital
The Joseph M. Sanzari Children's Hospital Hackensack University Medical
Center
University of New Mexico Children's Hospital
Children’s National Medical Center
Alfred I duPont Hospital for Children
Duke Children's Hospital and Health Center
Cincinnati Children’s Hospital Medical Center – PICU
Children’s Hospital of Illinois at OSF Saint Francis Medical Center
Kosair Children’s Hospital Norton Healthcare
Children’s Hospital Medical Center of Akron
Penn State Children’s Hospital at The Milton S Hershey Medical
Center
Johns Hopkins Children’s Center
Children’s Hospital Boston
Cook Children’s Medical Center
Dell Children’s Medical Center of Central Texas
CS Mott Children’s Hospital University of Michigan Health System
Helen DeVos Children’s Hospital
Inova Fairfax Hospital for Children
Children’s Hospital & Regional Medical Center
Mayo Eugenio Litta Children’s Hospital Mayo
Children’s Hospitals and Clinics of Minnesota
Children’s Hospital of Wisconsin
Arkansas Children’s Hospital – CICU
Cincinnati Children’s Hospital Medical Center – CICU
University of Minnesota Children's Hospital, Fairview
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 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)
Insertion Bundle
(Mainly MD practice)
 Insertion Checklist
 Empowerment of staff to interrupt unsafe practices





Hand washing immediately prior
CHG scrub (no iodine) at insertion site
Full sterile barriers for all operators
Maximal drapes for patient & bed
Acceptable to use Femoral site
 Procedure cart / tray
 Polyurethane or Teflon catheters only
 Standardized training for all providers
Maintenance Bundle
(mainly RN practice)
 Daily assessment whether catheter is needed
 Catheter Site Care
– Adhere to CDC-rec’d dressing change intervals/indications
– CHG scrub (not iodine) with dressing changes
– Prepackaged dressing change kit
 Catheter Hub / Cap / Tubing Care
 Adhere to CDC-rec’d tubing/cap change intervals/indications
 Prepackaged Cap Change Kit/Cart/Central Location
What have we achieved & learned in
the first year?
Where are we now in NACHRI’s PICU
Ca-BSI Collaborative efforts?
Where are we going?
What Have We Achieved and What
Have We Learned?
 Have our efforts on Insertion and Maintenance had an
effect on pediatric CA-BSI rates?
 Which components -- Ideal Insertion versus Ideal
Maintenance – have greater effect on pediatric CA-BSI
rate reduction?
Infection Rate, Insertion & Maintenance Compliance
Data reflects first 12 months
of effort with first 29 PICUS
PreCollaborative
Collaborative
Table 2. Results of negative binomial model assuming constant baseline
infection rate and adding compliance variables
Main driver for pediatric
CA-BSI reduction is
Covariate
Maintenance
Bundle not
insertion practices
Unadjusted Relative Rate (RR)
Adjusted Relative Rate (RR)
Estimated
RR
95% CI for RR
Estimated RR
95% CI for RR
Stable Effect vs. Q12
0.703
(0.541,0.913)
0.981
(0.73,1.319)
Northeast Region
0.880
(0.434,1.785)
0.746
(0.456,1.219)
Midwest Region
0.919
(0.458,1.844)
0.752
(0.508,1.114)
South Region
1.184
(0.575,2.438)
1.015
(0.629,1.638)
West Region
1.000
(1,1)
1.000
(1,1)
Bed capacity (per 100 beds)
6.376
(0.209,194.981)
8.219
(0.274,246.559)
Average length of stay
(per day)
1.009
(0.867,1.174)
1.008
(0.854,1.189)
Insertion Compliance
0.640
(0.208,1.971)
0.885
(0.221,3.547)
Maintenance Compliance
0.382
(0.188,0.774)
0.409
(0.197,0.851)
NOTE: model is adjusted for stable vs. ramp-up effect, geographic region, bed
capacity, and average length of stay.
Where are we now in
NACHRI’s PICU CA-BSI
Collaborative efforts?
Phase I Efforts as of May 2009
We can sustain
Phase II Efforts as of May 2009
We can spread!
New focus after achieving reliable
insertion & maintenance
Supplemental Maintenance-Related Factors (SMRFs)
We need to improve the collaborative
bundles…..PICUs are in a factorial trial
evaluating these 4 additional practice groups
•
•
•
•
Biopatch
CHG scrub for all line entries
Both Biopatch and CHG
Neither Biopatch and CHG
• SMRF graphs
To date, no clear significant differences in pediatric CA-BSI
rates between these 4 groups evaluating comparative
effectiveness of biopatch and CHG; trial ended in June 2009
and formal statistical analysis pending
PICU CA-BSI ‘Take Home’
Messages
• PICU CA-BSI Collaborative impact:
• > 775 CA-BSIs prevented
• > $27 million dollars saved
• > 93 deaths prevented
• Reliable use of ideal Maintenance practices seems to
have greatest impact
• New knowledge for children’s
healthcare
• Model is sustainable and can uniquely support needed
comparative effectiveness trials to create pediatric
evidence
TAKE HOME MESSAGE
KEY for Pediatric
CA-BSI efforts
Reliable Performance of Insertion
and Maintenance Bundles
Top 10 Money-Smart Reasons to Join
National Pediatric QI Collaboratives
1. Improve patient care and outcomes
2. Achieve Improvement faster by sharing pediatric
specific and relevant ideas
3. Implement what works for children
4. Save Design and Development $$
5. Reduce Costs – Share Infrastructure and Tools
6. Solves small sample, rare event problems
7. Multi-disciplinary and multi-institutional pediatric
Faculty
8. Expand QI Knowledge and Capacity
9. Create effective Multidisciplinary Teams
10. American Board of Pedaitrics MOC Credit for
Physicians
Who Do I Contact to Join?
Jayne Stuart, MPH
Director of Quality Transformation
NACHRI
Email jstuart@nachri.org
Phone 919.241.4312
www.childrenshospitals.net
Speaker Information
Marlene R. Miller, MD, MSc
Title: Vice Chair Quality and Safety
Hospital: Johns Hopkins Children’s Center
Title: Vice President, Quality Transformation
Organization: NACHRI
Email: mmille21@jhmi.edu
Phone: 410-955-5089 (Assistant: Lorraine Kelly)
Dr. Marlene R. Miller is Vice Chair, Quality and Safety at Johns Hopkins Children’s
Center and serves as Vice President, Quality Transformation at NACHRI. In these
roles she oversees, coordinates, and expands ongoing quality and safety initiatives
within the Children’s Center and serves to develop and expand the quality
programmatic areas within NACHRI, especially the quality improvement and
patient safety collaboratives. Dr. Miller is an associate professor of pediatrics at
the Johns Hopkins University School of Medicine and an associate professor at the
Johns Hopkins Bloomberg School of Public Health Department of Health Policy and
Management.
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