National Association of Children’s Hospitals and Related Institutions (NACHRI) Catheter-Related Blood Stream Infections (CA-BSI) Collaborative
Marlene Miller, MD, MPH (Johns Hopkins, NACHRI), Richard Brilli, MD (Nationwide Children’s), Stephen Muething, MD and Peter Margolis, MD, PhD (CCHMC)
Despite the magnitude of the problem of CA-BSIs in children, relatively little research has been done to identify effective strategies to reduce these complications. The objective of this project is to develop and evaluate effective catheter care practices to reduce pediatric CA-BSIs. Twenty nine pediatric intensive care units across the United States worked together to implement two central venous catheter care practice bundles: an insertion bundle of pediatric-tailored care elements derived from adult efforts and a maintenance bundle based on CDC recommendations. The bundles were deployed using collaborative QI teaching and methods to support adoption by teams. Average CA-BSI rates were reduced by 43% across 29 PICUs (5.4 vs. 3.1 CA-BSIs/1,000 central line days, p < 0.0001). By 9/07, compliance with the insertion bundle was 84% and compliance with the maintenance bundle was up to 82%. After adjustment for differences between centers using hierarchical cluster regression modeling, the relative risk of BSI was 0.57 (95% Confidence Interval 0.45 – 0.74), with the primary factor explaining the decrease being maintenance bundle compliance. CA-BSIs are a preventable cause of patient harm in critically ill children, predominantly by adherence to this newly described maintenance bundle for central venous catheter care.
Improving Performance in Practice (IPIP): National Center for Design, Development and Evaluation
Sheldon Horowitz, MD (American Board of Medical Specialties), Peter Margolis, MD, PhD (CCHMC), Darren DeWalt, MD, MPH (University of North Carolina)
The IPIP program was created by the specialty societies and boards of family medicine, internal medicine and pediatrics to develop common methods to assist primary care physicians, including family physicians, internists and pediatricians and their care teams, in providing care more effectively for their patients and improving outcomes. It is supported by The Robert Wood Johnson Foundation and the Boards of Pediatrics, Internal Medicine and Family Medicine. The focus is on developing large-scale systems of improvement at the level of the state. The initial focus is on diabetes and asthma. IPIP aims to help practices provide consistently high-quality care that improves the health of patients, motivates action and collaboration at the state, regional and practice level, and accelerates the pace of improvement. The conceptual design is based on collaborative improvement networks, data sharing, and education that links training in QI with specific clinical conditions. By aligning the outcome objectives of national professional organizations, the goal is to enable states to better shape state infrastructure, such as government organizations, area health education centers, managed care organizations, academic institutions, and payers, to create sustainable systems capable of supporting practices in improving health outcomes.
Pilot testing began in 2006 with 34 practices in North Carolina and Colorado. During the first two years, strong state coalitions were developed, significant human and financial resources were acquired (>$10 million) at the state level, and we began supporting practices with a prototype program. A national infrastructure was created to support the development of additional statewide programs, the state-level infrastructure capable of supporting scale-up and dissemination for implementing the prototype was developed, the practice support infrastructure was designed, and state-level QI coaches and support personnel were acquired. The most recent data from the program indicates broad improvements in process measures and improvements in outcomes in selected practices.
Consistency of QI approaches and measures enables practices to communicate effectively, simplifies training of QI staff across multiple organizations, facilitates practices’ ability to learn from one another, and accelerates the ability to learn about practice support activities. Alignment of the IPIP program’s measures with existing national measures provides a means of linking IPIP to the national movement toward performance measurement. Standardization of measures enables IPIP to make meaningful comparisons across practices and states. An evaluation proposal is in development, with planned submission to AHRQ in 2009.
Pediatric Inflammatory Bowel Disease (IBD) Network for Improvement and Research (PIBDNet): Trailblazer Collaborative
Richard Colletti, MD (University of Vermont), Peter Margolis, MD, PhD (CCHMC), Sarah Myers, MPH (CCHMC), Wallace Crandall, MD (Nationwide Children’s), Michael Kappleman, MD, MPH (University of North Carolina):
With initial sponsorship by the American Board of Pediatrics, and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, 15 pediatric gastroenterology practices (including private and academic centers) have been working together since March, 2006 to study and reduce variations in care and improve outcomes for children with IBD. To date, over 1,700 patients have been enrolled in a joint population-based registry, making this one of the largest repositories of children with IBD in the world. The group has increased the reliability of care across the network. Several centers are beginning to document improvements in outcomes, such as an increase in the number of children in remission and a reduction in the number of children on steroid therapy. To date, five abstracts, two book chapters, and one publication have resulted from this work. Health services research projects are addressing the following topics: 1) documenting the decreasing prevalence of growth failure, 2) assessing outcome measures commonly used in the field, and 3) examining the relationship between pharmacogenetic testing and disease outcomes. Improvement and implementation research is focused on testing the impact of five core chronic illness care systems on improved disease outcomes, the use of internet-based social networking tools to promote patient participation in planned care and self-management, and the application of standardized medication management on disease outcomes.
