CCMC Diaper Protocol

SPS Texas Regional MeetingJenny Riddle, RN, BSN, MHA, CPHQ, CSSGB

Director, Quality Clinical Collaboratives

Cook Childrens Medical Center

March 28, 2019

Cook Children’s Medical Center

449 beds

10,337 Admissions per year

13,021 Observation stays.

106-bed Level IV NICU

43 Bed PICU

10 Bed CICU

37 Bed Hem/Onc Unit

• 9 stem cell transplant/1 MIBG suite

One Hospital’s Experience ….

In 2010 Advocate

leaders noted & analyzed ↑

ICU CVL Infections.

Found ↑ GI Organisms

Identified opportunities in diapering

protocol

Standardized diapering and

storage of supplies

60% reduction in GI CLABSIs

In 2011 Presented

findings in a conference

poster presentation

One Hospital’s Experience ….

IncreasedStaff

Awareness

Positive Culture Change

Positive Parental

Feedback

Reduction in CLABSIs

OUTCOMES

Our Experience ….

CCMC CVICU ↑ GI CLABSIs

Suspected diapering

process cross-contamination

Observed staff

Noted cross-contamination of patient supplies

RememberedAdvocate’s

Success

Tweaked protocol &

implemented

2015CVICU

Our Experience ….

OUTCOMES

Ingrained in culture

CLABSI K-Card Rounds

Increased staff awareness

Positive Parent Feedback

Decrease in GI CLABSIs

Our Experience ….

50%GI organisms

Hem/Onc Analyzed CLABSIs

Taught 8 Step

Problem Solving

Technique

Joined Toyota/SPS

Initiative

Develop Counter-

measures

Found no standardized

diapering process

Completed Root Cause

Analysis

50%

diapered & <3 years

old

Monitored results

through K-Card

rounding

Put action plan in place

Developed Action Plan: Implement

diaper protocol

Toyota’s 8 Step Problem Solving Process• Define goal

• Assess current situation

• Assess gap

Step 1

Clarify the Problem

• Break down the problem

• Identify the Prioritized Problem

• Specify the Point of Occurrence

Step 2

Break down the Problem

• Make a commitment

• Set targets

Step 3

Set a Target

• Gather facts• Specify root cause

Step 4 Analyze Root Cause

• Develop & select best countermeasures

• Build consensus

• Create action plan

Step 5 Develop Countermeasures

• Implement countermeasures

• Inform, report & consult

• Never give up

Step 6See Countermeasures

through

• Evaluate results

• Share with staff

Step 7Monitor Results and

Processes

• Set as new standards

• Share new standardStep 8

Standardize

Step 5 CountermeasuresProposed

Countermeasures

Cost Safety Ease of

Implementation

Staff Buy-in Overall

Evaluation

Diaper Protocol o o ^ ^ ^

Use Chux for all Diaper

Changes

o o ^ o o

Education through K-

Cards

o o o o o

New insert for

admission packet for

diapered patients

o o ^ ^ ^

Staff Inservice on diaper

changes

o O ^ ^ ^

Video-diaper change O O ^ ^ ^

Specialized Diaper

changers-service

X o X X X

Hem/Onc Process

Oct. 20, 2016

Leadership Meeting

Recommend Diaper

Protocol

Oct. 24, 2016

Staff Meeting

Project Update

Nov. 22, 2016

PDSA-Gain feedback-Reduce Barriers

May 11, 2017

Create Education

Video

May 22, 2017

Staff meeting.

Announce go-live

date and training

May 28, 2017

Diaper protocol roll-out

Ongoing

K-card Rounds to reinforce

Step 6:

See Countermeasures through

Staff &

Family

Education

H/O Diaper Protocol Video on U –Learn

Questions?