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
Do you think the rate of CABSIs in your
NICU can be reduced to zero…and stay
Audience Participation
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
5=strongly agree
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
Metrics: infections/1000 catheter days stratified
by weight, days between infections
Methods: improvement collaboratives
microsystem assessment, site visits
Partner with CPQCC
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.
Why This Project?
 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
The Goal
 Reduce catheter associated blood
stream infections in NICU patients by
25-50% over 6 months
 In specific weight groups or overall
 Zero is possible!
SMART Aim: Example
 To reduce CABSI’s by 25% in NICU
infants born weighing 1000-1500 gms
by June 30, 2007
What We Know,
and Don’t Know
 CABSIs are an important cause of increased
morbidity, mortality, and costs in hospitalized
 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
What We Don’t Know and
Need to Find Out
 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’ (
 No perfect closed system (especially umbilical
Key Interventions
 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
 Dedicated line insertion and maintenance
 Educate/collaborate outside of NICU
 RCA for each infection
Tips for Getting Started
 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)
Key Measures
Creating your Baseline
Infections/1000 catheter days
Days between infections
Cost/infection (LOS, antibiotics, DX tests)
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
 All sites improved as high functioning
 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
Improvement Process
 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
Project Team
 Virtual team
 Data Analysis: M. Seid, PhD
 Clinical expertise from known, respected MD
and RN, NNP
 Site visits
 Experience in leading large, multisite
 Active State and Association participation
Year Two: High Risk Requires
High Reliability
“When One is One Too Many”
A High Risk Healthcare
 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
High Reliability Organizations
 Preoccupation with failure
 Reluctance to simplify interpretations
 Sensitivity to operations
 Deference to expertise
Preoccupation with Failure
 Any lapse is a symptom of system
 All errors and near misses are reported
and used as learning opportunities
Reluctance to Simplify
 Our environment and patients are
complex, we need more complete and
nuanced understanding of the situation
Sensitivity to Operations
 “Latent failures”or loopholes in any system’s
defenses will always occur because we are
 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
Sensitivity to Operations
 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
Deference to Expertise
 Push decision making down to the front
 Decisions migrate to the person with
most specific knowledge of the situation
Default Position
 No news is good news?
 No news is bad news?
 No news is no news?
 For a HRO, no news is worrisome
Things to Consider in Building
 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
Building a HRO: Prevent
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
Delivering High Reliability Care
Going Where No One Has
Gone Before!

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