Hospital Acquired Infection

Years Active: 2014-2016

Following completion of the TIPQC NICU Central Line Associated Blood Stream Infection (CLABSI) reduction projection, Tennessee NICUs monitored sustainment of the successful reduction of CLABSI episodes through CDC/NHSN data reported to the Tennessee Hospital Association and the Tennessee Department of Health. Though improvements remained sustained, evidence suggesting opportunities for further improvements in the NICU CLABSI rate as well as broader NICU Hospital Acquired Infection (HAI) rates emerged from reports from other large-scale neonatal improvement collaboratives. In 2013, the TIPQC membership voted to develop a new project (HAI 2.0) to build on the successes of TIPQC’s CLABSI project by expanding the aim of the project to include reduction of NICU HAI episodes. The HAI 2.0 Project Kickoff was held on February 24, 2014 with 70 attendees from 11 TN hospitals as well as representatives from other state collaboratives, and additional stakeholders.

Monthly aggregate CDC/NHSN CLABSI episodes/1000 line days, preliminary provisional data in u-chart format subject to revision
Monthly aggregate VON Nosocomial Infections in Very Low Birthweight infants (birthweight < 1500 grams), preliminary provisional data in p-chart format subject to revision
Monthly aggregate percentage of infants receiving antibiotics, preliminary provisional data in p-chart format subject to revision

Project Aim

The aim of this project is to further reduce the burden of hospital acquired infections in participating NICUs in an effort to improve outcomes in Tennessee NICUs. While it remains unclear whether total elimination is possible in the NICU population, further progress appears to be possible. Thus the immediate aims of this project are:

  1. to achieve a statistically significant reduction in aggregate monthly VON Nosocomial infection rate,
  2. sustainably reduce the aggregate CDC/NHSN CLABSI rate in Tennessee NICUs to less than 1.0 episodes/1000 line days by
  3. achieving high-reliability (>90%) implementation of potentially better practice bundles on process measure audits.

Active Participating Hospital Teams

  • Baptist Memorial Health Care
  • East Tennessee Children’s Hospital
  • Jackson-Madison County General Hospital
  • Monroe Carell Jr. Children’s Hospital at Vanderbilt
  • Niswonger Children’s Hospital
  • Regional One Health
  • TriStar Centennial Medical Center
  • The University of Tennessee Medical Center