Rapid cycle development of a multifactorial intervention achieved sustained reductions in central line-associated bloodstream infections in haematology oncology units at a children's hospital: a time series analysis.

BACKGROUND: Immunocompromised children are at high risk for central line-associated bloodstream infections (CLABSIs) and its associated morbidity and mortality. Prevention of CLABSIs depends on highly reliable care. PURPOSE: Since the summer of 2013, we saw an increase in patient volume and acuity in our centre. Additionally, CLABSIs rates more than tripled during this period. The purpose of this initiative was to rapidly identify and mitigate potential underlying drivers to the increased CLABSI rate. METHODS: Through small tests of change, we implemented a standard process for daily hygiene; increased awareness of high-risk patients with CLABSI; improved education/assistance for nurses performing high-risk central venous catheter procedures; and developed a system to improve allocation of resources to de-escalate system stress. RESULTS: The CLABSI rate from June 2013 to May 2014 was 2.03 CLABSIs/1000 line days. After implementation of our interventions, we saw a significant decrease in the CLABSI rate to 0.39 CLABSIs/1000 line days (p=0.008). Key processes have become more reliable: 100% of dressing changes are completed with the new two-person standard; daily hygiene adherence has increased from 25% to 70%; 100% of nurses are approached daily by senior nursing for assistance with high-risk procedures; and patients at risk for a CLABSI are identified daily. CONCLUSIONS: Stress to a complex system caring for high-risk patients can challenge CLABSI rates. Identifying key processes and executing them reliably can stabilise outcomes during times of system stress.

Developing and evaluating the success of a family activated medical emergency team: a quality improvement report.

BACKGROUND: Family-activated medical emergency teams (MET) have the potential to improve the timely recognition of clinical deterioration and reduce preventable adverse events. Adoption of family-activated METs is hindered by concerns that the calls may substantially increase MET workload. We aimed to develop a reliable process for family activated METs and to evaluate its effect on MET call rate and subsequent transfer to the intensive care unit (ICU). METHODS: The setting was our free-standing children's hospital. We partnered with families to develop and test an educational intervention for clinicians and families, an informational poster in each patient room and a redesigned process with hospital operators who handle MET calls. We tracked our primary outcome of count of family-activated MET calls on a statistical process control chart. Additionally, we determined the association between family-activated versus clinician-activated MET and transfer to the ICU. Finally, we compared the reason for MET activation between family calls and a 2:1 matched sample of clinician calls. RESULTS: Over our 6-year study period, we had a total of 83 family-activated MET calls. Families made an average of 1.2 calls per month, which represented 2.9% of all MET calls. Children with family-activated METs were transferred to the ICU less commonly than those with clinician MET calls (24% vs 60%, p<0.001). Families, like clinicians, most commonly called MET for concerns of clinical deterioration. Families also identified lack of response from clinicians and a dismissive interaction between team and family as reasons. CONCLUSIONS: Family MET activations were uncommon and not a burden on responders. These calls recognised clinical deterioration and communication failures. Family activated METs should be tested and implemented in hospitals that care for children.

A quality-improvement collaborative project to reduce pressure ulcers in PICUs.

BACKGROUND AND OBJECTIVE: Pediatric patients are at risk for developing pressure ulcers (PUs) and associated pain, infection risk, and prolonged hospitalization. Stage III and IV ulcers are serious, reportable events. The objective of this study was to develop and implement a quality-improvement (QI) intervention to reduce PUs by 50% in our ICUs. METHODS: We established a QI collaborative leadership team, measured PU rates during an initial period of rapid-cycle tests of change, developed a QI bundle, and evaluated the PU rates after the QI implementation. The prospective study encompassed 1425 patients over 54 351 patient-days in the PICU and NICU. RESULTS: The PU rate in the PICU was 14.3/1000 patient-days during the QI development and 3.7/1000 patient-days after QI implementation (P < .05), achieving the aim of 50% reduction. The PICU rates of stages I, II, and III conventional and device-related PUs decreased after the QI intervention. The PU rate in the NICU did not change significantly over time but remained at a mean of 0.9/1000 patient-days. In the postimplementation period, 3 points were outside the control limits, primarily due to an increase in PUs associated with pulse oximeters and cannulas. CONCLUSIONS: The collaborative QI model was effective at reducing PUs in the PICU. Pediatric patients, particularly neonates, are at risk for device-related ulcers. Heightened awareness, early detection, and identification of strategies to mitigate device-related injury are necessary to further reduce PU rates.

A hospital-wide quality-improvement collaborative to reduce catheter-associated bloodstream infections.

BACKGROUND: Catheter-associated bloodstream infections (CA BSIs) are associated with increased hospital length of stay, total hospital costs, and mortality. Quality-improvement collaboratives (QICs) are frequently used to improve health care quality. Our PICU was previously involved in a successful national QIC to reduce the incidence of CA BSI in critically ill children. OBJECTIVE: We hypothesized that the formation of a hospital-wide QIC would reduce the incidence of CA BSI throughout our institution. METHODS: We retrospectively reviewed the incidence of CA BSI from March 2006 to March 2010. The collaborative approach included hospital-wide implementation of central-line insertion and maintenance bundles that emphasized full sterile barrier precautions and chlorhexidine skin preparation during line insertion, daily discussion of catheter necessity, and meticulous site and tubing care. The hospital units involved were our 3 critical care units, the oncology unit, the bone marrow transplant unit, and wards. Each individual unit was responsible for collecting unit-specific data and performing event-cause analysis within 48 hours of identifying a CA BSI. These results were shared with the other hospital units during monthly meetings. Compliance with the insertion and maintenance bundles was monitored and reported to each unit monthly. RESULTS: The hospital-wide CA-BSI rate decreased from a baseline of 3.0 to <1.0 CA BSI per 1000 line-days after implementation of the QIC. CONCLUSIONS: Our hospital-wide QIC resulted in a significant reduction in the incidence of CA BSI at our children's hospital. A collaborative model based on improvement science methodology is both feasible and effective in reducing the incidence of CA BSI.