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“Infection rejection perfection” while treating 1,647 patients
Published: 07/22/2010
(North Shore-LIJ: New Hyde Park, NY) -- The Steven and Alexandra Cohen Children’s Medical Center of New York announces it has gone an entire year without a central-line infection in its Pediatric Intensive Care Unit (PICU) – the only children’s hospital in New York to achieve this milestone and one of only several in the nation.
Dr. Arthur Klein, the hospital’s executive director and chief of staff, said hospital and PICU staff celebrated what they called “infection rejection perfection” on July 7, which marked a full year without an infection, during which time the PICU treated 1,647 patients.
Dr. Peter Silver, chief of critical care medicine at Cohen Children’s Medical Center, formerly known as Schneider Children’s Hospital, said the achievement is part of a collaborative effort, orchestrated by the National Association of Children’s Hospitals and Related Institutions (NACHRI), to eliminate pediatric catheter-associated bloodstream infections (CA-BSI). They are thought by many in the medical community to be an unavoidable reality of central line catheter insertion—a process in which infections can be managed but never fully eliminated.
“When we started our project to eliminate CA-BSI, our infection rate was 4.7 infections per 1,000 central-line days, and we were experiencing a central-line infection every 28 days,” says Silver. “Our goal was to reduce our infection rate by 50 percent, and double the time interval between infections. Many of us who are part of the national collaborative effort thought that these were lofty goals, and that the concept of central-line infection eradication was a long shot. Fortunately, we seriously underestimated just how much teamwork and shared responsibility could accomplish.”
Efforts to reduce the incidence of CA-BSI in adult patients have been successful mostly by improving insertion techniques. “Pediatric CA-BSI is completely different,” Silver explains. “In children, insertion of the central line is the cause of only 10 percent of infections. The remaining 90 percent is attributable to maintenance procedures.”
The key to combating the infection in pediatric populations meant focusing on those maintenance procedures. These improvements included a lengthy scrub of the catheter port (“scrub the hub”) with a special cleansing solution for each entry into the catheter (to either administer a medication or to sample blood), very frequent changes of the catheter tubing, and a new protocol for changing the catheter dressing. Additionally, the necessity of the catheter itself became a topic for discussion on daily rounds; and an open conversation between the team of nurses and physicians caring for the patient became a must at the first warning sign of a brewing infection. To implement these last two aspects, however, a culture shift away from the more traditional hierarchical medical model was necessary.
“The shift can best be summarized with the catchphrase, ‘if you see something, say something,’” says Silver. “Our success is directly linked to the creation of a culture of safety and mutual responsibility where the opinion of all is actively sought and welcomed. Nurses are able to tell physicians that they contaminated their glove during a line insertion or that the line site looks red and needs to be removed. That ability to freely communicate has spread and improved the functioning of our PICU team throughout all aspects of patient care and has become a standard of quality and safety reengineering at Cohen Children’s Medical Center.”
The results of the culture shift speak for themselves: From July 7, 2009, to July 7, 2010, Cohen Children’s Medical Center had zero infections for 2,574 central-line days. The national average is 2.9 infections per 1,000 central-line days.
The hospital’s infection control efforts have already saved the lives of children and have avoided significant costs to the health care system.
Silver said an added benefit of the collaborative was an improvement in employees’ job satisfaction and a concerted effort to function as a team that takes great pride in its performance.
“We have a sign in our unit that says how many days it has been since our last central-line infection,” notes Silver. “Right now that sign says 366 days. We have over 100 staff members, from all parts of our team, who are responsible for that achievement and it only takes one mistake to bring it back down to zero. Everybody is focused on doing everything in their power to make sure that avoidable mistakes do not happen—especially on their watch.”
For four consecutive years, U.S. News & World Report magazine has ranked the Steven and Alexandra Cohen Children's Medical Center as one of the best in the country. Opened in 1983 and known as Schneider Children’s Hospital until March 2010, the facility has nearly 600 pediatricians, including 120 full-time physicians and a total workforce of 1,330, including about 400 nurses. Annually, the children’s medical centers on the two New York campuses—New Hyde Park and Manhasset—treat nearly 12,000 inpatients, about 170,000 outpatients, nearly 70,000 emergency patients, and about 2,500 neonates, and perform about 6,500 surgeries. The New Hyde Park facility is one of only two pediatric trauma centers in the New York area.
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