Abstract
Objective:
The objective of this study was to reduce central line-associated blood stream infections (CLABSIs) among 13 collaborating regional neonatal intensive care units by 25%. We tested the hypothesis that change could be attributed to the quality improvement collaborative by testing for ‘special cause’ variation.
Study Design:
Our prevention project included five features: (1) leadership commitment, (2) potentially best practices, (3) collaborative processes, (4) audit and feedback tools and (5) quality improvement techniques. Baseline (1 January 2006 to 30 August 2006) data were compared with the intervention (1 September 2006 to 30 June 2007) and post-intervention (1 July 2007 to 30 December 2007) periods and analyzed using statistical process control (SPC) methods.
Result:
We detected special cause variation, suggesting that the collaborative was associated with reduced infection rates, from 4.32 to 3.22 per 1000 line days (a 25% decrease) when comparing the baseline with the follow-up period.
Conclusion:
The collaborative's process was associated with fewer infections. SPC suggested that systematic changes occurred. The remaining challenges include sustaining or even further reducing the infection rate.
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References
Harbath S, Sax H, Gastmeier P . The preventable proportion of noscomial infections: an overview of published reports. J Hosp Infect 2003; 54: 258–266.
Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355: 2725–2732.
Kaufman D, Fairchild KD . Clinical microbiology of bacterial and fungal sepsis in very-low-birth-weight Infants. Clin Microbiol Rev 2004; 17: 638–680.
Lewis DB, Wilson CB . Developmental immunology and role of host defense in fetal and neonatal susceptibility to infection. In: Remington JS, Klein JO, Wilson CB, Baker CJ (eds). Infectious Diseases of the Fetus and Newborn Infant, 6th edn. The W.B. Saunders Co.: Philadelphia, PA, 2006, pp 88–199.
Green C, Yohannan MD . Umbilical arterial and venous catheters: placement, use, and complications. Neonatal Netw 1998; 17: 23–28.
Centers for Medicare and Medicaid Services. Press Release 1390: Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009, 14 April 2008: Available at: http://www.cms.hhs.gov/AcuteInpatientPPS/IPPS/itemdetail.asp?filterType=none&filteerByDID=0&sortByDID=4&sortOrder=descending&itemID=CMS1209719&intNumPerPage=10(accessed on 17 July 2009).
Solberg LI, Brekke ML, Fazio CJ, Fowles J, Jacobsen DN, Kottke TE et al. Lessons from experienced guideline implementers: attend to many factors and use multiple strategies. Jt Comm J Qual Improv 2000; 26: 171–188.
Ayers LR, Beyea SC, Godfrey MM, Harper DC, Nelson EC, Batalden PB . Quality improvement learning collaboratives. Qual Manag Health Care 2005; 14: 234–247.
Wilson T, Berwick DM, Cleary PD . What do collaborative improvement projects do? Experience from seven countries. Jt Comm J Qual Saf 2003; 29: 85–93.
Sharek PJ, Mullican C, Lavanderos A, Palmer C, Snow V, Kmetik K et al. Best practice implementation: lessons learned from 20 partnerships. Jt Comm J Qual Patient Saf 2007; 33 (12 Suppl): 16–26.
Horbar JD, Rogowski J, Plsek PE, Delmore P, Edwards WH, Hocker J et al. Collaborative quality improvement for neonatal intensive care. NIC/Q project investigators of the Vermont Oxford network. Pediatrics 2001; 107: 14–22.
Wirtschafter DD, Danielsen BH, Main EK, Korst LM, Gregory KD, Wertz A et al. Promoting antenatal steroid use for fetal maturation: results from the California Perinatal Quality Care Collaborative (CPQCC). J Pediatr 2006; 101: 606–612: e1.
Wirtschafter DD, Powers RJ . Organizing regional perinatal quality improvement-global considerations and local implementation. NeoReviews 2004; 5: e50–e59.
Stark AR . Levels of neonatal care. Pediatrics 2004; 114: 1341–1347. [published erratum appears in Pediatrics 2005; 115: 1118].
The National Healthcare Safety Network (NHSN). Patient Safety Component Protocol. Division of Healthcare Quality Promotion, National Center for Infectious Diseases Atlanta: GA, 2006: Available at: http://www.cdc.gov/ncidod/hip/nhsn/members/PSProtocolsMay06.pdf (accessed 17 July 2009).
Dartmouth-Hitchcock Medical Center. Clinical Microsystem Assessment Tool. Available at: http://www.clinicalmicrosystem.org/CMAT.htm(accessed 17 July 2009).
Nelson EC, Godfrey MM, Batalden PB, Berry SA, Bothe Jr AE, McKinley KE et al. Clinical microsystems-part 1. The building blocks of health systems. Jt Comm J Qual Patient Saf 2008; 34: 367–378.
Institute for Healthcare Improvement. Assessment Scale for Collaboratives. Available at: http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/AssessmentScaleforCCollaborativesIHI+Tool.htm(accessed 17 July 2009).
Kilbride HW, Powers R, Sheehan MB, Wirtschafter DD, Finer NF, Goldman D et al. NIC/Q 2000 collaborative process to develop consensus statements to prevent neonatal nosocomial bacteremia. Pediatrics 2003; 111: e504–e518.
Kilbride HW, Wirtschafter DD, Powers R, Sheehan MB . Implementation of evidence-based practices to decrease nosocomial infections-Results of the NIC/Q 2000 Collaborative. Pediatrics 2003; 111: e519–e533.
Pronovost PJ, Berenholtz SM, Goeschel CA, Needham DM, Sexton JB, Thompson DA et al. Creating high reliability in health care organizations. Health Serv Res 2006; 41: 1599–1617.
Montgomery DC . Introduction to Statistical Process Control, 4th edn. John Wiley and Sons: Hoboken, NJ, 2001.
McCarty T, Daniels L, Bremer M, Gupta P . The Six Sigma Black Belt Improvement Handbook. McGraw-Hill: New York, 2005.
Baily MA . Harming through protection? N Engl J Med 2008; 358: 768–769.
Institute for healthcare improvement: leadership topics. Available at: http://www.ihi.org/IHI/Topics/LeadingSystemImprovement/Leadership(accessed 17 July 2009).
Nelson EC, Batalden PB, Godfrey MM . Quality by Design: A Clinical Microsystems Approach. John Wiley & Sons, Inc.: Hoboken, NJ, 2007.
Berwick DM . The science of improvement. JAMA 2008; 299: 1182–1184.
Bate P, Mendel P, Robert G . Organizing for Quality: The Improvement Journeys of Leading Hospitals in Europe and the United States. Radcliff Publishing: Oxford and New York, 2008.
Division of Healthcare Quality Promotion, National Center for Infectious Diseases. The National Healthcare Safety Network (NHSN): Manual-Patient Safety Component Protocol. March 2009 Available at: http://www.cdc.gov/nhsn/PDFs/pscManual/pscManual_current.pdf(accessed on 17 July 2009).
Schulman J . Evaluating the Processes of Neonatal Intensive Care. BMJ Books: London, 2004, pp 84–105.
Benneyan J, Lloyd R, Plsek P . Statistical process control as a tool for research and healthcare improvement. Qual Saf Health Care 2003; 12: 458–464.
Schulman J, Wirtschafter DD, Kurtin P . Neonatal intensive care unit collaboration to decrease hospital-acquired infections: from comparative performance reports to improvement networks. Pediatr Clin North Am 2009; 65: 865–892.
Acknowledgements
We acknowledge the leadership of the California Children's Hospital Association for their support of this project, and, in particular, Ms Charity Bracy, Vice President for Government Relations and Policy, for her superb organizational support. We also acknowledge Mr Steven Kloman for his extraordinary efforts in helping to design the fishbone presentations.
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Appendix
Appendix
Multidisciplinary teams from participating hospitals
Children's Hospital Central California, Madera, CA:
Judie Spafford, RN, MSN; Gregg Pullen, MT(ASCP)M, RM(NRM), CIC; Krishkumar Rajani, MD; Stacie Venkatesan, RN, MSN
Children's Hospital Los Angeles, Los Angeles, CA:
Beverly Drummond, RN; Sharon Fichera, RNC, MSN, CNS, NNP; Janine Gaul, RNS, BSN; Lisa Kelly, MD
Children's Hospital Oakland. Oakland, CA:
Susie Adams, RN; David Durand, MD; Lily Labar, RN; Nick Mickas, MD; Teresa Proctor, NNP
Children's Hospital of Orange County, Orange, CA:
Vijay Dhar, MD; Helen Case, MA, RN; Linda Glenn, MN, RNC
Loma Linda University Children's Hospital, Loma Linda, CA:
Elba Fayard, MD; Debbie Hewitt, RN, MSN; Jean Newbold, RN, CNS, MS; Betsy Tan, RN, MS
Lucile Packard Children's Hospital at Stanford, Palo Alto, CA:
Karen Azevedo, RN; Heather Freeman, RN, MS; Bill Rhine, MD
Mattel Children's Hospital at UCLA, Los Angeles, CA:
Uday Devaskar, MD; Anahit Saringulian, RN, BSN, Pat Getzen, RN, BSN; Isabell Purdy, PhD, PNP, Marilyn Harris, RN, NNP, Anne McNeil, RN, BSN; Anne George, RN, BSN; Mary Alice Melwak PhD, PNP; Vladana Milisavljevic, MD
Miller Children's Hospital at Long Beach Memorial Medical Center, Long Beach, CA:
Susan Bowles, MSN, RNC; Leonel Guajardo, MD; Edward Reyes, RN, ICP; Mark Roberts, MD, CMO
Rady Children's Hospital and Health Center, San Diego, CA:
Peggy Grimm, RNC, MS; Barbara Lowe-Holt, RN, MBA; Mark Speziale, MD, PhD
Sutter Medical Center, Sacramento, CA:
Margaret Crockett, MSN, RN; Karen L. Semkiw, RN, MPA; Andrew Wertz, MD
University of California Davis Health System, Davis, CA:
Deborah Baker, MSN, RN; Joan Callao, RN; Patty Doolin, RN; Jeanette Harrison, MSN, RN; Jay Milstein, MD; Sherri Reese, RN, BSN, CIC
University of California Irvine, Irvine, CA:
Robin Koeppel, MS, RNC, CPNP, CNS; Nancy Lee, NNP; Kathleen Quan, RN, CIC, CPHQ; Cherry Uy, MD
University of California San Francisco Children's Hospital, San Francisco, CA:
Michelle Cathcart, RN; Steven Kloman, RN, CNS; Sally Sehring, MD
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Wirtschafter, D., Pettit, J., Kurtin, P. et al. A statewide quality improvement collaborative to reduce neonatal central line-associated blood stream infections. J Perinatol 30, 170–181 (2010). https://doi.org/10.1038/jp.2009.172
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DOI: https://doi.org/10.1038/jp.2009.172
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