Problem Statement
Catheter associated blood stream infection (CABSI) is a significant contributor to morbidity and mortality for infants receiving NICU care. Individual NICUs have increasingly discarded old presumptions that these infections are inevitable and are focusing reduction or elimination of CABSIs. In confronting the problem of CABSI, individual centers are challenged by a range of practices and variable quality expertise. Organizational commitments to the support of NICU CABSI projects are also challenged by an expanding menu of quality improvement activities required of hospitals.
Over 700 NICUs are nested in hospitals across the country. NICUs are complex microsystems that provide care in even more complex systems defined by hospital organizations, referral patterns and payers, specifically Medicaid. For these reasons the state generally defines the functional boundaries for NICU care. There are multiple stakeholders in the provision of proper line care in NICUs and a host of other perinatal care processes that these same stakeholders have interest in. There has not, however, been on organized effort to support the development of state perinatal collaboratives that would generate higher quality and value in perinatal care.
Mission
States will develop collaborative organizations and methods supporting the prevention of CABSIs in individual NICUs across their state. The state collaborative will spread CABSI quality improvement experience from centers executing the NCABSI action plan. Sharing of progress in reducing CABSI will motivate participating hospitals to excel and magnify the learning opportunities available to all as we aim to reduce CABSIs. The lessons learned at the state level will be spread amongst states via the NCABSI leadership structure. This national collaborative structure will potentially channel the experiences of 50-100 NICUs nationwide as they attempt to eliminate CABSI.
Organizing the state stakeholders in neonatal care (providers, payers, families, state leaders) will provide a framework for an organization capable of promoting the value of CABSI prevention and the conduct of future perinatal quality improvement projects. A collaborative of states creating individual organizational structures offers a series of laboratories from which to learn how best broad based, successful perinatal stakeholder collaboratives can form.
Aim:
Create and support seven statewide CABSI collaboratives committed to reducing CABSI by 75%.
Each state will develop a leadership team that provides a foundation for a stakeholder collaborative organization that seeks to include providers (neos, nurses, nurse practitioners, ICP), state leaders (DPH), payers (Medicaid and other significant payers) and family organizations.
Method:
The NCABSI Core Team (AHA and PQCNC) have developed a Charter, Action Plan and data collection system for the support of collaborative work.
Eight states committed to recruiting at least 10 NICUs, or 75% of their NICUs statewide, will participate in a collaborative committed to a 75% CABSI reduction. Each state will develop a leadership organization comprising key stakeholders in adapting the NCABSI Action Plan for their state. Participating hospitals will commit to the formation of a quality improvement team that initially includes a neonatologist, nurse and senior leader and infection control nurse. Other local team members to be added include a family leader. This team will be responsible for action plan introduction, adaptation and provision of support needed to pursue the aims.
State leaders will mentor hospitals, with support from the NCABSI Core Team, in reviewing, adapting and putting in place logistics required for NCABSI execution. The draft framework for action includes 2-3 face to face learning sessions, monthly web conferencing, weekly emails and coaching to support quality improvement teams working to reduce CABSI.
Executing the Change:
Use quality improvement science (PDSA, rapid cycle change, small tests of change etc.), CUSP methodology and a web-based data system to implement and adapt a CABSI action plan locally. Change package includes incorporation of CUSP methodology into execution at the hospital, state and national level. Use CUSP and NCABSI Leadership Team to mentor development of state collaborative organizations.
Measurement:
Documented number of CABSI/1000 line days decreased by 75% across NCABSI based on pre and post NHSN data.
Establishment of a stakeholder collaborative in all states that includes at a minimum medical, nursing, family, payer and DPH leaders.
Other process measures to be evaluated regarding progress in CABSI reduction include central lines/1000 hospital days, all or none adherence to insertion and maintenance bundles, and % of lines in place with feedings at or above 120 cc/k/d of feedings.