NACHRI Hematology Oncology Improvement Effort Launches

NACHRI is a membership organization of 216 children's hospitals in the United States, Canada, Australia, China, Italy and the United Kingdom. NACHRI promotes the health and well-being of children and their families through support of children's hospitals and health systems that are committed to excellence in providing health care to children. It does so through advocacy, education, research, and health promotion. NACHRI is a not-for-profit membership organization. The Association and its members are driven by a vision of society in which all the nation's children achieve their health potential.

As part of its focus on promoting patient safety and quality initiatives, NACHRI launched recruitment for the Pediatric Hematology Oncology Nosocomial Catheter-Associated Bloodstream Infection Collaborative in May 2009, in partnership with the American Board of Pediatrics. The goal of this effort is to reduce the rate of nosocomial CA-BSI among pediatric hematology oncology patients. This work formally spreads the knowledge gained in NACHRI's PICU CA-BSI Collaborative by extending improvements into a new patient population and adding a focus on implanted as well as external catheters.

The Hematology Oncology Steering Committee considered a variety of foci for this collaborative, but was drawn to line-related infections because this issue potentially affects all hematology oncology patients and because of the success of the PICU CA-BSI collaborative. The 30 teams involved in Phase 1 of the NACHRI PICU CA-BSI Collaborative have achieved impressive results: an estimated 85 lives saved, 710 CA-BSI cases prevented, at a savings of over $24 million as of March 2009 (See CABSI impact graphs).

The NACHRI Hematology Oncology Steering Committee sees this initiative as a lasting one, serving as the foundation for subsequent hematology oncology quality improvement efforts beyond in-patient CA-BSI. Additional areas discussed as possible future topics include managing mucositis, thrombotic complications of central lines, and spreading improvements identified for catheter maintenance to outpatient areas, including patients' homes through partnering with home health agencies.

In addition to spreading the PICU "bundle" (See Table 1) for maintaining external lines, the Hematology Oncology Collaborative will focus on standardizing maintenance of implanted lines. This new knowledge can benefit not only hematology oncology patients but all patients with implanted lines. The Collaborative approach supports rapid discovery by standardizing care processes across all participating teams and through ongoing sharing of monthly data and ideas about optimizing these care processes using a listserv, in-person meetings, webinars and conference calls.

More than 26 institutions were involved in helping to develop the bundles and protocols that are the focus of the new project. Eight individuals will serve as faculty, all of whom will not only adopt the new care strategies in their own institutions but also support and coach participating teams. Faculty include: Amy Billett, MD (Boston Children's Hospital), David Bundy, MD (Johns Hopkins Children's Center), Richard Brown, JD, RN (Alabama Children's Hospital), Aditya Gaur, MD (St. Jude's Children's Research Center), Jeffrey Hord, MD (Akron Children's Medical Center), Eric Werner, MD (Children's Hospital of The King's Daughters) and Cindi Winkle, RN (Children's Medical Center Dallas). Marlene Miller, Vice President, Quality at NACHRI will serve as the Executive Director of the Collaborative.

The project is designed to meet the standards of the American Board of Pediatrics for performance improvement activities (MOC, Part IV). To be awarded credit, physicians must participate for 12 months, complete required project activities and submit the appropriate forms with necessary signatures from the collaborative leadership team.

For more information or to sign up to participate, contact Jayne Stuart, MPH, NACHRI Director of Quality Transformation at 919/241.4312 or jstuart@nachri.org.

Table 1:

A care bundle is a set of standardized care processes designed to improve outcomes. Teams in the Collaborative agree to test and adopt the bundle elements and report monthly data on their progress. The data are shared with all participants to facilitate sharing and learning.

BUNDLE #1: Changes related to ideal tunneled and non-tunneled external central venous catheter care maintenance practices include:

1. Daily Goals checklist asking each day to assess the total number of line entries in the previous day for lab draws and whether consideration was given to consolidating lab draws for today
2. Standardize maintenance practice across the inpatient unit- this will include training of all staff and revision of policies to reflect use of the collaborative maintenance bundle
3. Prepackaged dressing change kit/area and cap change kit/area available at each point of care
4. Standardized procedures and garb for all line entries
5. Standardized time intervals between dressing/tubing/cap changes and standardized methods to identify times to change dressings/tubing/caps

BUNDLE #2: Changes related to ideal totally implanted (e.g. Mediport/Portacath) central venous catheter care maintenance practices include:

1. Daily Goals checklist asking each day to assess the total number of line entries in the previous day for lab draws and whether consideration was given to consolidating lab draws for today
2. Standardize maintenance practice across the inpatient unit - this will include training of all staff and revision of policies to reflect use of the collaborative maintenance bundle
3. Prepackaged accession kit/area and dressing change kit/area available at each point of care
4. Standardized procedures and garb for all line entries, both with Huber needle and when accessing cap attached to Huber needle or tubing
5. Standardized time intervals between accession/reaccession and standardized method to identify times to change the Huber needle
6. Standardized time intervals between dressing/tubing/cap changes and standardized methods to identify times to change dressing/tubing/caps