Eliminating Blood Stream Infections Project

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					                                                             Ohio Perinatal Quality Collaborative

                           Eliminating Blood Stream Infections
                                Learning Network Charter

The Ohio Perinatal Quality Collaborative (OPQC), an Ohio-based network of perinatal
care providers working to improve neonatal and perinatal outcomes, will launch a
Learning Network to eliminate late-onset, bacterial, blood stream infections among
infants in neonatal intensive care units throughout the state. A Learning Network brings
together action-oriented teams from multiple health care organizations over the course
of 12-18 months. Teams attend face-to-face meetings (Learning Sessions) where they
examine proven and recommended strategies to perfect care. Most importantly, teams
work between sessions to plan and execute iterative tests of change and share learning
across organizations.

The Challenge
Late-onset1 infections are a significant source of morbidity, mortality and added costs to
hospitalized premature infants [1, 2]. It is estimated that the majority of late onset blood
stream infections are associated with use of indwelling vascular catheters [3, 4].
According to the National Nosocomial Infection Surveillance System (NNIS) the pooled
mean catheter-associated blood stream infection (CA-BSI) rate for newborns <1000
grams birth weight was 9.1 infections per 1000 central catheter days [5].

Researchers at Johns Hopkins University have nearly eliminated CA-BSI in adult
intensive care unit patients by applying a multifaceted intervention focused on insertion
of central lines based on safety theory and the 2002 Guidelines for the Prevention of
Intravascular Catheter-Related Infection [6, 7]. These insertion related interventions are
now used broadly throughout the country and world with dissemination promoted via the
Institute for Healthcare Improvement 100,000 Lives effort (www.ihi.org). CA-BSI has
now become one of the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) core measures for quality in intensive care units.

Currently, the National Association of Children’s Hospitals and Related Institutions
(NACHRI) is sponsoring a national improvement collaborative among multiple pediatric
intensive care units. Using methods similar to those in the Johns Hopkins initiative,
PICUs are working together to reduced CA-BSI and ventilator-associated infections [6].
Preliminary results indicate approximately a 45% decrease in the overall CA-BSI rate. In
this project, participants have instituted “insertion and maintenance bundles” that
combine the practices that best evidence and safety theory have suggested will reduce
the incidence of CA-BSI. Teams have learned that adherence to catheter maintenance
protocols is especially important in pediatrics and leads to the majority of the
improvement noted. At least two NICUs in Ohio are using these methods to reduce

 Onset after 72 hours of life (late onset) is a commonly used, working definition for
hospital-acquired infection.

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                                                             Ohio Perinatal Quality Collaborative
Strategies that have demonstrated results for adults and older children may also be
useful for premature infants. However, preterm newborns present special challenges
including relative immunologic immaturity; widespread use of prophylactic antibiotics;
loss of skin integrity; frequent and long-term use of indwelling foreign bodies
(intravenous and intra-arterial devices, endotracheal tubes, etc.); early colonization with
pathogenic microbes; high humidity care environments, immune suppression and poor
nutrition related to delayed initiation and slow advancement of enteral feeding. In
addition, very low birth weight (VLBW) infants have prolonged NICU stays increasing the
opportunity for acquisition of infection.

OPQC’s first neonatal improvement project will develop and test strategies to improve
care and outcomes of VLBW infants and spread effective improvements throughout the
perinatal community. This project has four areas of focus: (1) to develop and test
strategies to reduce the rate of BSI in infants 22-29 weeks gestational age in the NICU,
(2) to spread improvements that are shown to be effective throughout the neonatal
intensive care community; (3) to enable neonatologists, via this multi-institutional
collaborative, an opportunity to fulfill Part IV of the Program of Maintenance of
Certification (PMCP), and (4) to develop a model and infrastructure for collaborative
improvement across all NICUs in Ohio.

The overarching goal of the OPQC Learning Network is to eliminate late onset, bacterial
blood stream infections among infants in neonatal intensive care units throughout the

In one year we will reduce late onset (>72 hours) blood stream/CSF infections in
infants 22-29 weeks gestational age by 50% in Ohio NICUs.

Key Driver Analysis (Figure 1)
Use of a central intravascular catheter is an important risk factor for late-onset infection
and efforts to improve decisions to use a catheter and how catheters are used have
resulted in decreased infection rates [6]. Efforts to address skin immaturity and skin
breakdown among premature infants have also resulted in decreased infection rates [8-
10]. The key driver diagram was developed in order to identify pathways to optimal
outcomes and the interventions that move care to the elimination of bloodstream
infections in preterm infants. (figure 1).

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                                       Eliminate late onset (>72 hours) bacterial blood
                                        stream and CSF infections in infants in Ohio
                                                            NICUs                                                                             Ohio
                                                                                                                    Perinatal Quality Collaborative

       Figure 1: Key Drivers                                                        Prior to insertion, assess: is catheter really necessary?
                                        Appropriate and
                                        safe use of central                         Insertion Bundle
                                                                                    Excellent Hand Hygiene
                                        lines                                       Use of maximal sterile barriers
                                                                                    Appropriate use of CHG for site preparation
                                                                                    No Iodine skin prep
                                                                                    Use of observer and Insertion checklist

                                        Excellent hand                              Catheter Maintenance Bundle
                                        hygiene                                     Excellent Hand Hygiene
                                                                                    No Iodine ointment used
                                                                                    Catheter Hub/Cap/Tubing Care per CDC Guidelines
                                                                                    Dressing Change per CDC Guidelines
SMART Aim: In one                                                                   Lipid infusions complete within 24 hours
year we will reduce                                                                 Daily Assessment if line is necessary
late onset (>72                         Culture of quality
hours) blood
stream/CSF                              and safety                                   Knowledge & Awareness
                                                                                          Coaches
infections in infants                                                                     Educate all staff
22-29 weeks                                                                               Skills labs
                                                                                          “secret” observers
gestational age by                                                                        Data feedback
50% in Ohio NICUs.                                                                   Proximity & Availability of Supplies
                                        Protect infant’s                             Personal Hygiene
                                        skin integrity                               Daily Scrubbing
                                                                                     Hand Washing Indications & Technique
                                                                                     “See and speak” re: hand washing

                                        Maintain optimal                             Collect and report outcome data
                                                                                     Benchmark unit results with other units
                                        nutritional level                            Exchange best practices with other units
                                                                                     Evaluation of root causes and common causes of all BSI
                                        Appropriate and                              See and speak culture
                                        safe use of
                                        endotracheal                                 Handling protocols
                                        tubes                                        Safe use of tape and other adhesives
                                                                                     Appropriate and safe peripheral line use
                                                                                     Reduce the number of skin punctures

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                                                             Ohio Perinatal Quality Collaborative
OPQC Learning Network Goals
We have established the following goals for the Learning Network based on the key
driver analysis and expert consensus. Each participating NICU will be asked to
establish aims consistent with the goals of OPQC.
         100% of catheter insertions are performed using the catheter insertion
                     Is the catheter really necessary?
                     Excellent hand hygiene
                     Use of maximal sterile barriers
                     Appropriate skin preparation
                     Use of observer and insertion checklist
         100% use of catheter maintenance care bundles:
                     Is the catheter still needed?
                     Excellent hand hygiene
                     No iodine ointment used
                     Catheter Hub/Cap/Tubing Care per CDC Guidelines
                     Dressing change per CDC guidelines
                     Lipid infusions complete within 24 hours
                     Daily assessment if line is necessary
         At least a 50% decrease in the late onset bacterial BSI rate per 1000 patient
            days among infants 22-29 weeks gestation
         At least a 50% reduction in the infection rate per 1000 line/device days
            among infants 22-29 weeks gestation
         A 25% reduction in the proportion of patient days in which a central line was
         A 100% increase in days from last late onset blood stream infection (catheter
            and non-catheter associated)
         At least a 50% decrease in the percent of infants 22-29 weeks gestation with
            ≥ 1 late-onset bacterial bloodstream/CSF infection

Other potential goals for segments of the 22-29 week population to be addressed
as OPQC outcomes are achieved.
        Increase in days from last ventilator-associated infection
        Decrease in blood stream and CSF infections with onset after 72 hours of life
          in infants 22-29 weeks gestational age on the ventilator at the time of the
          infection in Ohio NICUs.
        Handwashing
        Increase in the percent of observations compliant with handwashing
        Culture of Quality and Safety: Introduce evidence based policies and
          procedures to improve organizational culture
        Decrease in the average number of skin punctures per patient
        Improvement in the average skin integrity score for infants 22-29 weeks
          Policies and procedures are in place regarding frequency of intravascular
          device entry (i.e. blood draws and medication administration, etc), cleaning
          intravascular devices prior to line access, intravascular device cap changes,
          cap changes after blood or lipid administration and use of antibiotic ointments
          at catheter entry site.
        Gestation in the first week of life

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                                                             Ohio Perinatal Quality Collaborative
All NICUs in Ohio will be invited to participate in OPQC. OPQC leadership including the
Center for Health Care Quality (CHCQ) will assist participating NICUs in testing changes
to the process of care delivery using the key driver model (Figure 1).

OPQC leadership will provide support to NICUs through training, the creation of tools
and materials, and ongoing coaching and support. NICUs will set specific goals for the
improvement of care at the level of the individual patient, the unit, and the
health care organization and to test specific changes in care delivery. NICUs will receive
continuous feedback and coaching designed to help teams assess the potential value of
specific changes.

Through focus, hard work and data-driven decision making, we will eliminate
late-onset blood stream infections in the NICU.

OPQC and CHCQ will:

       Provide evidence-based information on BSI
       Teach participating centers how to apply a care model for reducing BSI
       Teach the Model for Improvement
       Offer coaching to NICUs on implementing and evaluating changes
       Coordinate communication activities to keep participants connected to OPQC
        leaders and to colleagues participating in the infection project
       Develop a framework for testing changes in care delivery
       Provide tools, forms, and other aids to help with implementation of key areas of
        care for reducing BSI

Participating organizations and teams are expected to:

       Provide a senior leader, for example a unit medical/nursing director, department
        administrator, etc, to serve as sponsor for the team working on the collaborative
        improvement project
       Send three team members, including the physician champion (a physician leader
        in your unit who is enthusiastic and committed to this improvement effort), to
        workshops (learning sessions)
       Provide resources and support to the practice team (including support to attend
        the workshops, time to devote to testing and implementing changes in the center,
        and active senior leadership involvement)
       Perform pre-work activities to prepare for the first workshop
       Connect the goals of the OPQC work to the work of the organization.
       Participate in monthly conference calls and the listserv to share with and learn
        from others
       Make well-defined measurements that relate to their aims at least monthly and
        share them with the other teams in the collaborative
       Share information with project participants through a quarterly report that
        includes details of changes made and data to evaluate the impact of these

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                                                             Ohio Perinatal Quality Collaborative
         Use a standardized data collection tool provided by OPQC to track changes in
          processes and outcomes of care


1.        Makhoul, I., et al., Epidemiological, clinical, and microbiological
          characteristics of late-onset sepsis among very low birth weight infants in
          Israel: A National Survey. Pediatrics, 2002. 109(1): p. 34-39.
2.        Stoll, B., et al., Late-onset sepsis in very low birth weight neonates: The
          experience of the NICHD Neonatal Research Network. Pediatrics, 2002.
          110(2): p. 285-291.
3.        Chien, L., et al., Variations in central venous catheter-related infection
          risks among Canadian neonatal intensive care units. Pediatr Infect Dis J,
          2002. 21(6): p. 505-511.
4.        Perlman, S., L. Saiman, and E. Larson, Risk factors for late-onset health
          care-associated bloodstream infections in patients in neonatal intensive
          care units. Am J Infect Control, 2007. 35(3): p. 177-182.
5.        CDC, National Nosocomial Infections Surveillance (NNIS) System Report
          - data summary from January 1992 through June 2004. Am J Infect
          Control, 2004. 32: p. 470-485.
6.        Berenholtz, S., et al., Eliminating catheter-related bloodstream infections
          in the intensive care unit. Crit Care Med, 2004. 32(10): p. 2014-2020.
7.        O’Grady, N., et al., Guidelines for the prevention of intravascular catheter-
          related infections. Pediatrics, 2002. 110(5): p. e51.
8.        Cordero, L., et al., Surveillance of ventilator-associated pneumonia in
          very-low-birth-weight infants. Am J Infect Control, 2002. 30(1): p. 32-39.
9.        Elward, A., D. Warren, and V. Fraser, Ventilator-associated pneumonia in
          pediatric intensive care unit patients: risk factors and outcome. Pediatrics,
          2002. 109(5): p. 758-764.
10.       Long, M., et al., Prospective, reandomized study of ventilator-associated
          pneumonia in patients with one versus three ventilator circuit changes per
          week. Infect Control Hosp Epidemiol, 1996. 17(1): p. 14-19.

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