COMMENTARY:

Fresh ap­proaches sorely needed to ex­pand pe­di­atric HAI pre­ven­tion ef­forts

Modern Healthcare - - EDITORIAL MODERN HEALTHCARE - Dr. Mar­lene Miller and Mark Wi­etecha

Fresh ap­proach needed for pe­di­atric HAI ef­forts

Dur­ing the past decade, U.S. hos­pi­tals have made tremen­dous strides in pre­ven­tion of hos­pi­tal-ac­quired in­fec­tions, such as cen­tral-line as­so­ci­ated blood­stream in­fec­tions. We have stud­ied, de­vel­oped and im­ple­mented sim­ple pro­to­cols that slash in half in­fec­tion risk, mor­bid­ity, mor­tal­ity and re­lated costs. As this good work con­tin­ues, we con­tinue to fall woe­fully short in one area: im­prov­ing HAI pre­ven­tion for all U.S. chil­dren.

The suc­cesses in CLABSI pre­ven­tion have been fu­eled in large part by fed­er­ally sup­ported national ef­forts in part­ner­ship with state­based in­dus­try groups. How­ever, these sup­ported pro­grams have fo­cused pre­dom­i­nantly on adult pa­tients. When it comes to CLABSI pre­ven­tion in chil­dren, pol­i­cy­mak­ers and fund­ing agen­cies oper­ate un­der the mis­in­formed as­sump­tion that what works to re­duce in­fec­tions in adults will pro­vide the same “bang for the buck” in chil­dren.

Chil­dren are not “small adults,” and treat­ing a child re­quires more than sim­ply tweak­ing a med­i­ca­tion dose. Chil­dren are phys­i­o­log­i­cally, psy­cho­log­i­cally and so­cially dif­fer­ent from adults. They are vul­ner­a­ble in dif­fer­ent ways and re­spond to dis­ease dif­fer­ently. Ac­cord­ingly, pe­di­atric qual­ity im­prove­ment ef­forts need to be tai­lored to chil­dren’s needs.

Un­der­stand­ing this, a group of pe­di­atric hos­pi­tals in 2006 took mat­ters into its own hands and, spear­headed by the National As­so­ci­a­tion of Chil­dren’s Hos­pi­tals and Re­lated In­sti­tu­tions, formed the Qual­ity Trans­for­ma­tion Net­work. Funded by par­tic­i­pat­ing hos­pi­tals and NACHRI, the net­work set out to study strate­gies for re­duc­ing CLABSI in pe­di­atric in­ten­sive-care units.

In five years, the Qual­ity Trans­for­ma­tion Net­work has achieved im­prove­ments: more than 3,000 CLABSI averted, re­sult­ing in 362 pa­tients’ lives saved and cost sav­ings of more than $105 mil­lion. En­cour­aged, more hos­pi­tals joined, and the pro­gram spread to pe­di­atric on­col­ogy and bone mar­row trans­plant units. To date, 163 units in 89 chil­dren’s hos­pi­tals have joined the net­work’s in­fec­tion pre­ven­tion pro­grams.

The Qual­ity Trans­for­ma­tion Net­work has proven that pre­vent­ing pe­di­atric CLABSI re­quires ap­proaches dif­fer­ent from those that work in adults. In chil­dren, pre­ven­tion re­lies on the sub­tleties of daily cen­tral-line care, in con­trast to the adult ap­proach fo­cused mainly on cen­tral-line in­ser­tion prac­tices.

Chil­dren are not “small adults,” and treat­ing a child re­quires more than sim­ply tweak­ing a med­i­ca­tion dose.

This is a real game-changer. We have es­sen­tial new knowl­edge on how to pre­vent CLABSI in chil­dren. With one-third of the na­tion’s chil­dren’s hos­pi­tals par­tic­i­pat­ing in the net­work, we know these tech­niques can be im­ple­mented in di­verse hos­pi­tal set­tings. We know these tech­niques can be re­li­ably im­ple­mented long term (Qual­ity Trans­for­ma­tion Net­work hos­pi­tals have sus­tained their gains five years and run­ning).

Un­for­tu­nately, these ap­proaches may be doomed to be lim­ited. Qual­ity Trans­for­ma­tion Net­work work has been fi­nanced by the chil­dren’s hos­pi­tals them­selves, while adult pa­tients in all 50 states have ben­e­fit­ted from fed­eral con­tract sup­port for in­fec­tion pre­ven­tion. Chil­dren’s hos­pi­tals can­not con­tinue as the sole source of sup­port for national pe­di­atric im­prove­ment ef­forts; many can­not af­ford it now.

The eco­nomic ben­e­fits of in­fec­tion pre­ven­tion flow di­rectly to health­care pay­ers. Given that one-third of U.S. chil­dren have govern­ment health­care as­sis­tance via Med­i­caid, states have al­ready en­joyed more than $50 mil­lion in cost sav­ings. Ap­ply­ing lessons learned from the Qual­ity Trans­for­ma­tion Net­work across all hos­pi­tals car­ing for chil­dren would mean hundreds of mil­lions in sav­ings to fi­nan­cially strapped state pro­grams, not to men­tion thou­sands of lives saved.

The White House an­nounced this year an am­bi­tious goal—re­duc­ing HAIS by 40% in the next two years. The CMS pro­poses to spend $500 mil­lion to achieve this goal. To suc­ceed, all pa­tients—young and old—must re­ceive ap­pro­pri­ate, uni­form, ev­i­dence-based care. Our ef­forts make it clear that ex­pan­sion of HAI pro­grams in pe­di­atric set­tings would cre­ate sub­stan­tial Med­i­caid sav­ings and im­prove qual­ity. But even as the fed­eral govern­ment pre­pares to ex­pand HAI pro­grams, frag­men­ta­tion caused by the au­ton­omy of state Med­i­caid pro­grams re­mains an ob­sta­cle to com­pa­ra­ble national HAI pro­grams for chil­dren. The fed­eral govern­ment cov­ers more than half of states’ Med­i­caid costs, but has re­peat­edly ab­stained from re­quir­ing states to adopt uni­fied ap­proaches to is­sues such as HAI.

The pol­icy quag­mire means that no one is ac­count­able at a national level for chil­dren’s health­care qual­ity; no one is ac­count­able for the re­al­ity that chil­dren in some hos­pi­tals have a much higher like­li­hood of get­ting a CLABSI. The quag­mire means that no one is ac­count­able for avoid­ing hundreds of mil­lions of dol­lars in Med­i­caid spend­ing to treat pre­ventable in­fec­tions in chil­dren.

Now that the net­work’s meth­ods have proven ef­fec­tive, we need pol­i­cy­mak­ers in Washington to sup­port ef­forts to ex­pand HAI ini­tia­tives for chil­dren to a national scale. This ac­tion would save lives and costs.

Congress has the power and, ar­guably, the obli­ga­tion to do for chil­dren what has been done for adults. The re­peated re­fusal to do so is self-de­feat­ing and costly for the Amer­i­can pub­lic. The fed­eral govern­ment has al­ready shown mus­cle and com­mit­ment in push­ing qual­ity im­prove­ment ef­forts through­out the coun­try via Medi­care and, in do­ing so, it has tremen­dously im­proved pa­tient safety for adults na­tion­wide. Chil­dren de­serve no less.

Dr. Mar­lene Miller is vice pres­i­dent for qual­ity trans­for­ma­tion and Mark Wi­etecha is pres­i­dent and CEO of the National As­so­ci­a­tion of Chil­dren’s Hos­pi­tals and Re­lated In­sti­tu­tions.

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