1. NICU CLABSI Affinity Group Meeting September 12, 2012 Denise Flook, RN, MPH, CIC HAI Collaborative Lead Vice President, Infection Prevention/Staff Engagement

2. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Learning Objectives 1.Identify what barriers have been encountered to effectively reduce CLABSI in NICU. 2.Discuss how these barriers have been overcome in other hospitals. 3.Outline what specific actions you will do in the next week based on this information. 4.Identify the action steps your team should complete before the October meeting.

3. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Framing Our Meeting Putting Patients First: Preventing All Cause Harm Think of what has worked to remove barriers to achieving the CLABSI goal. What could you add/adapt to identify and address the real barriers in your hospital Think about what insights you gained

4. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Refocus Our Goals Reduce Hospital Acquired Conditions by 40% – CLABSI HAC Rate 0.67 per 1000 discharges CLABSI: <1/1000 central line days HHS HAI Action Plan 2013 Goals – CLABSI: Standardized Infection Ratio (SIR) less than 0.5 – CAUTI: 25% reduction in rates

5. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Standardized Infection Ratio (SIR)

6. Learn. Act. Improve. Spread. Keep the Drum Beat Going. OUR PROGRESS SO FAR

7. Learn. Act. Improve. Spread. Keep the Drum Beat Going. NICU CLABSI Affinity Group 2010 Y3432.150131722.591.0580.3951 0.732, 1.478 2011Q167.52732361.850.7970.37450.293, 1.735 2011Q256.76328181.770.7390.33200.240, 1.725 2011Q358.05235611.410.6210.18650.202, 1.449 2011Q489.30340052.000.8600.41650.371, 1.694 2012Q177.04228932.420.9940.59250.400, 2.048 2012Q286.34427652.891.2610.30460.544, 2.485 summary YQ Inf Count numExpnumCL Days CLABSI Rate/1000 central line days SIRSIR_pvalSIR95CI

8. Learn. Act. Improve. Spread. Keep the Drum Beat Going. NICU CLABSI SIR * 2012Q2 Incomplete data

9. Learn. Act. Improve. Spread. Keep the Drum Beat Going. What Did You Learn When you asked 5 staff what the process is to insert a central line did they know the who, what, where, how, when and with what of the process? Did you identify any barriers to compliance to the process?

10. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Types of Barriers Provider – Knowledge, attitude – Current practice habits Guideline-related – Applicability to patient population – Evidence supporting guideline – Ease of compliance System – Supplies/equipment unavailable – Inadequate or poorly designed tools and technologies – Poor organizational structure (e.g., staffing, policies) – Inadequate leadership support – Unit/hospital culture – Inadequate feedback mechanisms – System ambiguities Other

11. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Steps of Barrier Identification and Mitigation Tool (BIM)* Step 1: Assemble the interdisciplinary team Step 2: Identify barriers – Observe the process – Walk the process – Ask about the process Step 3: Summarize barriers in a table Step 4: Prioritize barriers Step 5: Develop an action plan for each prioritized barrier. * Gurses et al. (2009) A practical tool to identify and eliminate barriers to evidence-based guideline compliance. Joint Commission Journal on Quality and Patient Safety 35(10):526-532

12. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Barrier Identification Form

13. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Barrier Summary and Prioritization BarrierRelation to Guideline SourceLikelihood Score * Severity Score † Barrier Priority Score ‡ Target for this QI cycle? Central line cart missing items (especially late in the afternoon) Hand washingObserve Ask 4312Yes Full barrier precautions and clean skin with chlorhexidine Observe Walk 339Yes *Likelihood score: How likely will a clinician experience this barrier? 1.Remote 2. Occasional 3. Probable 4. Frequent † Severity score: How likely will experiencing a particular barrier lead to non-compliance with guideline? 1.Remote 2. Occasional 3. Probable 4. Frequent ‡ Barrier priority score = Likelihood score X Severity score

14. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Development of Your Action Plan *Potential impact score: What is the potential impact of the intervention on improving guideline compliance? 0. No impact 1. Low 2. Moderate 3. High 4. Very high † Feasibility score: How feasible is it to take the suggested action? 0. Not feasible 1. Low 2. Moderate 3. High 4. Very high ‡ Action priority core = Potential impact score X Feasibility score Prioritized barriers Potential Actions SourcePotential Impact Score * Feasibility Score † Action Priority Score ‡ This QI cycle? Action Leader Performance Measure (Method) Follow- up Date Difficult for providers to cleanse their hands prior to performing central line insertion Install sinks in rooms Observe300No Place alcohol- based hand sanitizer in rooms Observe Ask Walk 4416YesKM Compliance with hand cleaning (observation) 2 months

15. Learn. Act. Improve. Spread. Keep the Drum Beat Going. All Teach – All Learn: Barriers?? What Barriers? Name one barrier you have experienced in your journey How did your hospital overcome this? What is one small step you can make in the next week to identify and address a barrier? What help do you need?

16. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Reliable Systems Process Design Education Join the HAI collaborative meeting on October 10 from 11 am – 12:30 pm. Dr. Resar will walk through an HAI example of how to have front line staff create and test the process needed to keep patients safe. If you missed the RSPD Overview presentation you can listen to the recording and download materials at the HAI meetings page. Look under July 17 meeting.HAI meetings We will have an open mic meeting from 10 -11 for those who want to call in and network but no formal presentation.

17. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Next Steps: To be completed by October 10 Meeting 1.Meet with your team to assess barriers. 2.Prioritize barriers. 3.Determine a course to improve 4.Listen to the Reliable System Process Design webinar recording. Go to the link below and go to the July 17 HAI meeting information. The link to the recording and presentation is under this.HAI meeting 5.Complete the meeting evaluation by September 18 6.Submitted August Process Measure Data collection by September 26

18. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Action Step What is one action you will take in the next week to prevent CLABSI in your unit?

19. Learn. Act. Improve. Spread. Keep the Drum Beat Going. CONTACT INFORMATION Denise Flook dflook@gha.orgdflook@gha.org. 770-249-4518