Quality and Safety

Happy girl in hospital bed surrounded by doctors

Addressing MB-CLABSI through innovation – and dedication – to pediatric safety

Happy girl in hospital bed surrounded by doctors

With mucosal barrier central line-associated blood stream infections (MB-CLABSI) posing a serious risk to cancer and other immunocompromised patients, Children’s National Health System was intent on finding a way to prevent them. Through a focused initiative led by Rose Szeles, M.S., R.N., N.E.-B.C., director of nursing for the Center for Cancer and Blood Disorders, the hospital experienced great success, cutting infection rates by more than half.

This was a daunting proposition. Historically MB-CLABSI has not been viewed as a preventable infection due to the side effects typically associated with bone marrow transplants in this patient population. Sores and mucosal disruption that develops in the oral cavity post-transplant are fairly common and make it exceedingly difficult to keep the mouth clean and clear of bacteria. Without regimented oral hygiene in this type of environment, the mouth can quickly develop bacteria putting the patient at risk of a MB-CLABSI.

“We challenged the notion that we could not prevent MB-CLABSI and set out on a journey to try to prevent these types of infections from occurring,” says vice president and chief quality and safety officer, Rahul Shah, M.D. “With leadership from our nursing teams and the infection control and prevention group working together with the physicians, we were able to approach this issue from a unique perspective.”

In 2013, Children’s National launched a MB-CLABSI prevention program focused around saline rinses to improve oral hygiene. The goal was to keep the mouth cleaner to avoid bacteria from forming and ultimately entering the blood stream.

Children’s National put the plan into action through the following measures:

Provider

  • Simplified ordering of saline rinses to increase accountability and compliance with the practice and make it easier for providers
  • Implemented reminders to order saline rinses during daily rounds
  • Added saline rinses to the Medication Administration Record to drive compliance in administration of the task

Administrative

  • Saline rinses were chosen as an indicator to be displayed on public-facing quality boards throughout the hospital
  • Implemented daily audits of the quality board to track opportunities for improving compliance and reducing omissions and errors
  • Standardized daily medical rounds to include review of the quality boards

Patient/Caregiver

  • Implemented discussion of saline rinses of the mouth for oncology and bone marrow transplant patients during daily rounds
  • Standardized education for caregivers of children with central lines

“Through strategic programs like this, our patients are safer and Children’s National continues to be a national pediatric quality leader,” says Dr. Shah.

Children's National Red Badge Project

The Red Badge Project: expediting ED care

Children's National Red Badge Project

A red badge allows newly diagnosed cancer patients and BMT patients to bypass security and triage so they can receive lifesaving antibiotics within an hour of fighting fever.

Chemotherapy and bone marrow transplant procedures leave cancer patients with compromised immune systems, leading many to develop life-threatening infections or other complications. In particular, neutropenia, or abnormally low levels of white blood cells that are critical to fighting off infections, is prevalent among this population. Fever with neutropenia can be fatal.

As part of the Children’s National Health System commitment to deliver better outcomes and safer care through innovative approaches, the Hematology/Oncology/Bone Marrow Transplant (BMT) Family Advisory team developed a protocol to rapidly identify BMT and cancer patients with suspected neutropenia to receive antibiotics within 60 minutes of arriving at the Emergency Department (ED). The Red Badge Project was born with the following goals:

• Decrease the median triage-to-antibiotic time in cancer patients with fever and suspected neutropenia or bone marrow transplant patients to 30 minutes
• Increase the proportion of patients receiving antibiotics within one hour to 90 percent

As part of the protocol, newly diagnosed cancer and bone marrow transplant patients receive a Red Badge and education regarding how to use it. If they run a fever and need medical attention, the patient and family present the Red Badge upon arrival at the ED in order to bypass the welcome desk and ED triage. This action accelerates the process, keeps the child from waiting in an area where there are other sick children and ensures the patient receives lifesaving antibiotics as fast as possible.

Work done before the patient walks through the ED doors contributes to the success of this program. When a patient runs a fever, the family is instructed to call the Hematology Oncology Fellow on-call. If it is determined that the patient needs to come to the ED, the Fellow then: 1) receives the patient’s estimated arrival time so that staff can clean and prep a room 2) reminds them to apply their topical analgesia to numb the port site where the antibiotic will be administered 3) reminds them to bring their Red Badge.

From there, swift action is taken. By the time the patient arrives, he or she has already been registered and the appropriate medications have been ordered. The patient bypasses security and triage using their Red Badge as a visual cue and is then directed to a prepped room complete with medications ready for administration.

To date, the median time from triage to administration of antibiotics has decreased nearly 50 percent while the proportion of patients who received antibiotics within 60 minutes of triage improved to 90 percent.

Leveraging that success, the next step is to develop education for non-English speaking families in order to extend the reach of this lifesaving practice.

Children’s National receives top safety and quality award

John M. Eisenberg Patient Safety and Quality Awar

As part of a collaborative of researchers, hospitalists and medical education specialists, Children’s National Health System was recently recognized with the highest patient safety and quality award in the country: The prestigious John M. Eisenberg Patient Safety and Quality Award. Administered by The Joint Commission and the National Quality Forum (NQF), two leading organizations that set standards in patient care, this award recognizes Children’s commitment to ensure safe and high-quality care for all patients.

The team at Children’s National helped develop a package of interventions used by more than 50 leading hospitals in the U.S. as part of a collaborative initiative called the I-PASS Study Group. The group helps standardize communications during handoffs of patients from one care team to another. This award-winning program was also shown to reduce harmful medical errors in a multi-center study published in the New England Journal of Medicine.

Patient handoffs happen multiple times per day in every hospital in the country, making it vitally important that the process is seamless and free of miscommunications.

Children’s National safety experts share strategies

Rahul Shah

Rahul Shah, M.D., Vice President and Chief Quality and Safety Officer at Children’s National Health System (CNHS), and his team joined pediatric quality and safety leaders from across the country in Orlando, Fla. for the Children’s Hospital Association’s 2017 Quality & Safety in Children’s Health Conference.

Earlier this month, Rahul Shah, M.D., Vice President and Chief Quality and Safety Officer at Children’s National Health System (CNHS), and his team joined pediatric quality and safety leaders from across the country in Orlando, Fla. for the Children’s Hospital Association’s 2017 Quality & Safety in Children’s Health Conference. Dr. Shah shared findings and strategies that have led Children’s National to be a leader in this field, and collaborated with peers to move the needle on pediatric safety in hospitals and improving the quality of care hospitals deliver.

Notable presentations from the Children’s National team included:

  • The Children’s National utilization of a safety culture survey called the Safety Attitude Questionnaire (SAQ), and the crucial role of ensuring leadership alignment in the survey process. Obtaining leadership buy-in and alignment allowed Children’s to accelerate the spread of identified opportunities for improvement within the organization.
  • The importance of an ongoing multi-disciplinary approach to care for psychiatry patients, a patient population that that continues to increase in American pediatric healthcare and requires innovative approaches. Children’s National team members emphasized the importance of training the hospital’s security teams and front-line caregivers in therapeutic interventions to seek optimal outcomes for patients, while respecting the complexity of their diagnoses.
  • How to drive reliability through apparent cause analyses. Kristen Crandall, Director of Patient Safety at Children’s National, shared examples of how to leverage data to effectively drive change in cause analyses. Cause analyses are fundamental tools for implementing improvement. The team highlighted the upcoming launch of a High Reliability Toolkit© developed at CNHS to ensure that action plans created from cause analyses are of adequate depth and sophistication to drive improvements.

Dr. Shah and his team also had the honor of delivering an Impact session on the final day of the conference, in which they discussed the applications of merging patient safety with patient experience. The team also shared the Children’s National approach to safety and service, which includes delivering a unified framework of high reliability through consistent messaging to demonstrate that when safety and service integrate and align, the sum is greater than the parts.