COMMENTARY:
Fresh approaches sorely needed to expand pediatric HAI prevention efforts
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.