The Quality Transformation Network (QTN) of Children's Hospital Association has brought some major transformations at the hematology/oncology unit of Akron Children’s Hospital since it joined the network in 2009. “We built a team of nurses, doctors and the infection control staff to focus on central line care,” says Jeffrey Hord, M.D., director, Showers Family Center for Childhood Cancer and Blood Disorders. “This was new for our institution. We built a relationship with the infection control officer that did not exist before. And we have line care on our mind much more.”
He credits nurses with doing most of the work, including training new unit staff and also the float nurses. “Doctors can be most involved in reducing line entries,” he says, “following the standard work orders to ask every day with every patient, what can we do to reduce line entries?”
Before QTN: Limited Data, No Analysis
As for data collection, a rigorous requirement of QTN, Hord admits, “Before joining, we did not have good ongoing data collection about line days in our inpatient unit, much less elsewhere. Now, we have built a system to track line days of our entire patient population anywhere.”
When a central line-associated bloodstream infection (CLABSI) occurred, the unit did not have any particular follow-up, much less the root cause analysis required by QTN. “Now, when a positive culture comes back, the team receives an email notification, and nurses involved in the care of the patient are quickly interviewed,” says Hord. “Two or three days later, the team convenes for the root cause analysis, and we go through a checklist of questions.”
He cites a case of a positive culture for a bone marrow transplant patient. These patients need to be bathed to get the chemo off their skin, so the infection could have been from a waterborne pathogen. During the root cause analysis, the question arose: How is the line cared for during bathing? And the next question was, what are others doing?
Thanks to personal relationships developed through QTN’s Listserv and meetings, Hord says, “We can quickly phone two or three people and ask how they do baths. And the subjects we discuss go far beyond central line issues. We depend on one another for hints and ideas. Colleagues see, know and trust each other.”
Hord stresses the power of the collaborative. “Line infections are rare in our small population,” he says. “It could take a very long time for us to reach 1,000 line days, the standard measure. It’s only when you see the numbers for many units that you—and hospital administrators—can see the progress that is being made, the infections prevented, the lives saved.”
Following the QTN Plan
Finally, Hord says that another major benefit of joining QTN lies in the wisdom of the Association's plan: Take small steps first and build on success.
“Because we listened to their advice,” he says, “we have developed the level of experience needed to expand the program. Now, we are able to collect data on CDC-defined CLABSI, secondary infections and single-positive cultures. “Before, we would have been overwhelmed if we’d tried to cover all the places where central lines are cared for,” Hord says. “Now we are ready to go beyond the inpatient setting. We’re teaching bundle elements to parents, as well as to homecare agencies. We’re tackling the huge issue of how to ensure all providers know the bundle protocol and reliably carry it out. Thanks to QTN, we are now prepared to move toward the target we had in mind from the start.”