A Crossover Randomized Prospective Pilot Study Evaluating a Central Venous Catheter Team in Reducing Catheter-Related Bloodstream Infections in Pediatric Oncology Patients

Background: Treatment for most children with cancer includes the use of a central venous catheter (CVC). CVCs provide reliable venous access for delivery of chemotherapy and supportive care. This advantage is mitigated by an increased risk of bloodstream infections (BSIs). Despite the ubiquitous use of CVCs, few prospective studies have been conducted to address infection prevention strategies in pediatric oncology patients. Design: Prospective, crossover pilot study of a CVC team intervention versus standard care. Setting: Two inpatient oncology units in a metropolitan children’s hospital. Patients: A total of 41 patients/135 admissions for the experimental unit (EU) and 41/129 admissions for the control unit (CU). Methods: Patients received a CVC blood draw bundle procedure by a CVC registered nurse (RN) team member (experimental intervention: EU) for 6 months and by the assigned bedside RN (standard care: CU) for 6 months. Feasibility of implementing a CVC RN team; a significant difference in CVC-related BSIs between the team intervention versus standard care and risk factors associated in the development of CVC-related BSIs were determined. Results: There were 7 CVC-related BSIs/1238 catheter days in the EU group (5.7/1000 catheter days) versus 3 CVC-related BSIs/1419 catheter days in the CU group (2.1/1000 catheter days; P = .97). Selected risk factors were not significantly associated with the development of a CVC-related BSI. Conclusions: A CVC team in the care of pediatric oncology patients is feasible; however, a larger cohort will be required to adequately determine the effectiveness of the team reducing CVC-related BSIs.

Reduction of catheter-associated bloodstream infections through procedures in newborn babies admitted in a university hospital intensive care unit in Brazil

INTRODUCTION

Catheter-associated bloodstream infection (CA-BSI) is the most common nosocomial infection in neonatal intensive care units. There is evidence that care bundles to reduce CA-BSI are effective in the adult literature. The aim of this study was to reduce CA-BSI in a Brazilian neonatal intensive care unit by means of a care bundle including few strategies or procedures of prevention and control of these infections.

METHODS

An intervention designed to reduce CA-BSI with five evidence-based procedures was conducted.

RESULTS

A total of sixty-seven (26.7%) CA-BSIs were observed. There were 46 (32%) episodes of culture-proven sepsis in group preintervention (24.1 per 1,000 catheter days [CVC days]). Neonates in the group after implementation of the intervention had 21 (19.6%) episodes of CA-BSI (14.9 per 1,000 CVC days). The incidence of CA-BSI decreased significantly after the intervention from the group preintervention and postintervention (32% to 19.6%, 24.1 per 1,000 CVC days to 14.9 per 1,000 CVC days, p=0.04). In the multiple logistic regression analysis, the use of more than 3 antibiotics and length of stay >8 days were independent risk factors for BSI.

CONCLUSIONS

A stepwise introduction of evidence-based intervention and intensive and continuous education of all healthcare workers are effective in reducing CA-BSI.

Subjective global nutritional assessment in critically ill children

BACKGROUND

Underweight children admitted to the pediatric intensive care unit (PICU) have a higher risk of mortality than normal-weight children. The authors hypothesized that subjective global nutrition assessment (SGNA) could identify malnutrition in the PICU and predict nutrition-associated morbidities.

METHODS

The authors prospectively evaluated the nutrition status of 150 children (aged 31 days to 5 years) admitted to the PICU with the use of SGNA and commonly used objective anthropometric and laboratory measurements. Each child was administered the SGNA by a dietitian while anthropometric measurements were performed by an independent assessor. To test interrater reproducibility, 76 children had SGNA performed by another dietitian. Occurrence of nutrition-associated complications was documented for 30 days after admission.

RESULTS

SGNA ratings of well nourished, moderately malnourished, or severely malnourished demonstrated moderate to strong correlation with several standard anthropometric measurements (P < .05). The laboratory markers did not demonstrate any correlation with SGNA. Interrater agreement showed moderate reliability (κ = 0.671). Length of stay, pediatric logistic organ dysfunction, and Pediatric Risk of Mortality III were not significantly different across the groups and did not correlate with SGNA.

Preventive strategies for central line-associated bloodstream infections in pediatric hematopoietic stem cell transplant recipients

BACKGROUND

Few studies have described preventive strategies for central line-associated bloodstream infections (CLABSIs) in pediatric hematopoietic stem cell transplantation (HSCT) recipients.

METHODS

We performed a pilot intervention study in our pediatric HSCT population in 2006-2008 and compared CLABSI rates before and after implementation of preventive strategies (ie, training staff and caregivers in procedures for dressing changes and drawing blood) in the inpatient, outpatient, and non-health care (ie, home) settings. We also studied the pathogens associated with hospital-onset versus community-onset CLABSIs.

RESULTS

During the study period, 90 children (median age, 10 years) underwent HSCT. Fifty-nine children (66%) developed a CLABSI; 18 in the hospital, 27 in the community, and 14 in both settings. After implementation of central line (CL) maintenance care strategies, the overall CLABSI rate declined from 10.03 to 3.00 CLABSIs per 1,000 CL-days (rate ratio, 0.3; 95% confidence interval, 0.2-0.5, P < .0001) and rates declined for both hospital- and community-onset CLABSIs. Gram negative pathogens caused more community-onset (45/65, 69%) than hospital-onset (22/46, 48%) CLABSIs (odds ratio, 2.5; 95% confidence interval, 1.1-5.4; P = .02).

CONCLUSIONS

Standardization of care practices for CL maintenance was associated with a reduction of CLABSIs in our pediatric HSCT population. A multicenter study is needed to confirm these observations.

"Targeting to zero" in pediatric oncology: a review of central venous catheter-related bloodstream infections

Reducing or eliminating hospital acquired infections is a national quality of care priority. The majority of the 12,400 children diagnosed with cancer each year require long-term intravenous access to receive intensive and complex therapies. These children are at high risk for infection by nature of their disease and treatment, which often involves use of a central venous catheter (CVC). Throughout the nation, nurses assume frontline responsibility for safe, quality CVC care to minimize the risk of potentially life-threatening infections. Substantial financial and human costs are associated with CVC-related bloodstream infections, including prolonged hospital lengths of stay and increased care required to treat these infections. The purpose of this review of the literature is to summarize existing adult and pediatric data on CVC-related bloodstream infections and explore nursing models of CVC care that may improve pediatric oncology patient outcomes.

A multicenter collaborative approach to reducing pediatric codes outside the ICU

OBJECTIVES

The Child Health Corporation of America formed a multicenter collaborative to decrease the rate of pediatric codes outside the ICU by 50%, double the days between these events, and improve the patient safety culture scores by 5 percentage points.

METHODS

A multidisciplinary pediatric advisory panel developed a comprehensive change package of process improvement strategies and measures for tracking progress. Learning sessions, conference calls, and data submission facilitated collaborative group learning and implementation. Twenty Child Health Corporation of America hospitals participated in this 12-month improvement project. Each hospital identified at least 1 noncritical care target unit in which to implement selected elements of the change package. Strategies to improve prevention, detection, and correction of the deteriorating patient ranged from relatively simple, foundational changes to more complex, advanced changes. Each hospital selected a broad range of change package elements for implementation using rapid-cycle methodologies. The primary outcome measure was reduction in codes per 1000 patient days. Secondary outcomes were days between codes and change in patient safety culture scores.

RESULTS

Code rate for the collaborative did not decrease significantly (3% decrease). Twelve hospitals reported additional data after the collaborative and saw significant improvement in code rates (24% decrease). Patient safety culture scores improved by 4.5% to 8.5%.

CONCLUSIONS

A complex process, such as patient deterioration, requires sufficient time and effort to achieve improved outcomes and create a deeply embedded culture of patient safety. The collaborative model can accelerate improvements achieved by individual institutions.

Impact of a multidimensional infection control strategy on central line-associated bloodstream infection rates in pediatric intensive care units of five developing countries: findings of the International Nosocomial Infection Control Consortium (INICC)

PURPOSE

To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control strategy including a practice bundle to reduce the rates of central line-associated bloodstream infection (CLAB) in patients hospitalized in pediatric intensive care units (PICUs) of hospitals, which are members of the INICC, from nine cities of five developing countries: Colombia, India, Mexico, Philippines, and Turkey.

METHODS

CLAB rates were determined by means of a prospective surveillance study conducted on 1,986 patients hospitalized in nine PICUs, over a period of 12,774 bed-days. The study was divided into two phases. During Phase 1 (baseline period), active surveillance was performed without the implementation of the multi-faceted approach. CLAB rates obtained in Phase 1 were compared with CLAB rates obtained in Phase 2 (intervention period), after implementation of the INICC multidimensional infection control program.

RESULTS

During Phase 1, 1,029 central line (CL) days were recorded, and during Phase 2, after implementing the CL care bundle and interventions, we recorded 3,861 CL days. The CLAB rate was 10.7 per 1,000 CL days in Phase 1, and in Phase 2, the CLAB rate decreased to 5.2 per 1,000 CL days (relative risk [RR] 0.48, 95% confidence interval [CI] 0.29-0.94, P = 0.02), showing a reduction of 52% in the CLAB rate.

CONCLUSIONS

This study shows that the implementation of a multidimensional infection control strategy was associated with a significant reduction in the CLAB rates in the PICUs of developing countries.

Quality improvement interventions to prevent healthcare-associated infections in neonates and children

PURPOSE OF REVIEW

Healthcare-associated infections cause substantial harm to hospitalized neonates and children. Efforts that prevent these infections are a major focus of current patient safety initiatives. This review focuses on the reports of quality improvement interventions to prevent central line-associated bloodstream infections (CLABSIs) in neonates and children.

RECENT FINDINGS

Single-center and multicenter collaborative studies have examined the effect of quality improvement interventions to reliably implement central line insertion and maintenance bundles on CLABSI rates in neonatal and pediatric intensive care units. Quality improvement interventions were associated with reductions in CLABSI rates in neonates and children by a half or more, although many of the studies have important methodologic limitations. Studies that utilized improvement science methodologies demonstrated larger improvement effects, but required a sizable investment of institutional support and personnel time.

SUMMARY

Quality improvement interventions to reduce CLABSI are an important component of patient safety initiatives. Future studies of quality improvement interventions to reduce HAI among hospitalized neonates and children will benefit from further investigation of methods to enhance reliable implementation of evidence-based practices, factors that enable multicenter collaboratives to be more successful, and better understanding of the causes of heterogeneity in the results at different centers.

Trend of healthcare-associated infections in children: annual prevalence surveys in a research hospital in Italy, 2007-2010

BACKGROUND

Annual prevalence surveys of healthcare-associated infections (HAIs) between 2007 and 2010 were conducted in the largest tertiary care children's hospital in Italy. During this period, actions to improve HAI prevention were implemented, including strengthened isolation measures; adoption of care bundles for invasive procedures; hand hygiene promotion using the World Health Organization multimodal strategy; and promotion of appropriate antimicrobial use.

AIM

To determine the impact of these measures on HAI rates.

METHODS

A total of 1506 patients were surveyed. Information on patient demographics, mechanical ventilation, central line and urinary catheterization in the preceding 48 h, and surgery in the previous 30 days were abstracted from medical charts. The type and date of onset of HAIs, and microbiological data were recorded. Univariate and multivariate logistic analysis were used to evaluate changes in HAI rates over time, and the influence of ward type and patient characteristics.

FINDINGS

There were significant (P < 0.001) reductions in the prevalence of patients developing HAI (from 7.6% to 4.3%) and in the prevalence of total HAIs (from 8.6 to 4.3 per 100 patients). Factors independently associated with increased HAI risk were hospitalization in intensive care ward, length of stay >30 days, presence of invasive device, and age 6-11 years.

CONCLUSION

This HAI prevention strategy was influential in decreasing infections among hospitalized children. Repeated prevalence surveys are an effective tool for monitoring HAI frequency, increasing awareness among the healthcare personnel, and contributing to the establishment of effective infection control.

Hospital-acquired viral infection increases mortality in children with severe viral respiratory infection

OBJECTIVE

To investigate the association of method of acquisition (hospital-acquired vs. community-acquired) and mortality in children with severe viral respiratory infection.

DESIGN

Retrospective cohort study.

SETTING

: Pediatric intensive care unit at an urban academic tertiary care children's hospital.

PATIENTS

All patients aged <18 yrs admitted to our pediatric intensive care unit with laboratory-confirmed respiratory syncytial virus, influenza, parainfluenza, or adenovirus infection between October 2002 and September 2008.

INTERVENTIONS

We stratified patients by method of viral acquisition and identified those patients with chronic medical conditions associated with an increased risk of complications from viral illness.

MEASUREMENTS AND MAIN RESULTS

There were 289 patients admitted to the pediatric intensive care unit with laboratory-confirmed viral respiratory infection during the period of study. Fifty-three patients (18%) had hospital-acquired infection and 117 patients (40%) had chronic medical conditions associated with an increased risk of complications from viral illness. Hospital-acquired infection was associated with increased mortality and length of stay (all p < .001). Adjusting for age, chronic medical conditions, severity of illness index, and catheter-associated bloodstream infections, patients with hospital-acquired infection had a 5.8 (95% confidence interval 2.1-15.6) times greater odds (p = .001) of mortality.

CONCLUSIONS

Our results suggest that in children with severe viral respiratory infection, hospital acquisition of infection is associated with increased mortality even after adjusting for chronic medical conditions that predispose to an increased risk of complications from viral illness.

Moving CLABSI prevention beyond the intensive care unit: risk factors in pediatric oncology patients

BACKGROUND AND OBJECTIVE

Central line-associated bloodstream infections (CLABSIs) frequently complicate the use of central venous catheters (CVCs) among pediatric patients with cancer. Our objectives were to describe the microbiology and identify risk factors for hospital-onset CLABSI in this patient population.

DESIGN

Retrospective case-control study.

SETTING

Oncology and stem cell transplant units of a freestanding, 396-bed quaternary care pediatric hospital.

PARTICIPANTS

Case subjects ([Formula: see text]) were patients with a diagnosis of malignancy and/or stem cell transplant recipients with CLABSI occurring during admission. Controls ([Formula: see text]) were identified using risk set sampling of hospitalizations among patients with a CVC, matched on date of admission.

METHODS

Multivariate conditional logistic regression was used to identify independent predictors of CLABSI.

RESULTS

The majority of CLABSI isolates were gram-positive bacteria (58%). The most frequently isolated organism was Enterococcus faecium, and 6 of 9 isolates were resistant to vancomycin. In multivariate analyses, independent risk factors for CLABSI included platelet transfusion within the prior week (odds ratio [OR], 10.90 [95% confidence interval (CI), 3.02-39.38]; [Formula: see text]) and CVC placement within the previous month (<1 week vs ≥1 month: OR, 11.71 [95% CI, 1.98-69.20]; [Formula: see text]; ≥1 week and <1 month vs ≥1 month: OR, 7.37 [95% CI, 1.85-29.36]; [Formula: see text]).

CONCLUSIONS

Adjunctive measures to prevent CLABSI among pediatric oncology patients may be most beneficial in the month following CVC insertion and in patients requiring frequent platelet transfusions. Vancomycin-resistant enterococci may be an emerging cause of CLABSI in hospitalized pediatric oncology patients and are unlikely to be treated by typical empiric antimicrobial regimens.

Epidemiology of central line-associated bloodstream infections in the pediatric intensive care unit

OBJECTIVE

Describe central line-associated bloodstream infection (CLA-BSI) epidemiology in pediatric intensive care units (PICUs).

DESIGN

Descriptive study (29 PICUs); cohort study (18 PICUs).

SETTING

PICUs in a national improvement collaborative.

PATIENTS/PARTICIPANTS

Patients admitted October 2006 to December 2007 with 1 or more central lines.

METHODS

CLA-BSIs were prospectively identified using the National Healthcare Safety Network definition and then readjudicated using the revised 2008 definition. Risk factors for CLA-BSI were examined using age-adjusted, time-varying Cox proportional hazards models.

RESULTS

In the descriptive study, the CLA-BSI incidence was 3.1/1,000 central line-days; readjudication with the revised definition resulted in a 17% decrease. In the cohort study, the readjudicated incidence was 2.0/1,000 central line-days. Ninety-nine percent of patients were CLA-BSI-free through day 7, after which the daily risk of CLA-BSI doubled to 0.27% per day. Compared with patients with respiratory diagnoses (most prevalent category), CLA-BSI risk was higher in patients with gastrointestinal diagnoses (hazard ratio [HR], 2.7 [95% confidence interval {CI}, 1.43-5.16]; P < .002 ) and oncologic diagnoses (HR, 2.6 [CI, 1.06-6.45]; P = .037). Among all patients, including those with more than 1 central line, CLA-BSI risk was lower among patients with a central line inserted in the jugular vein (HR, 0.43 [CI, 0.30-0.95]; [P < .03).

CONCLUSIONS

The 2008 CLA-BSI definition change decreased the measured incidence. The daily CLA-BSI risk was very low in patients during the first 7 days of catheterization but doubled thereafter. The risk of CLA-BSI was lower in patients with lines inserted in the jugular vein and higher in patients with gastrointestinal and oncologic diagnoses. These patients are target populations for additional study and intervention.

Using Statistical Process Control to Identify Early Growth Failure Among Infants With Hypoplastic Left Heart Syndrome

Although interventions to improve outcomes for children with congenital heart disease may be designed and tested, the rarity of any one specific defect presents a barrier to using traditional statistical methods to measure the effects of these interventions. The purpose of this report is to describe the innovative statistical approach taken by the Joint Council on Congenital Heart Disease (JCCHD) National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) to measure outcomes for infants with hypoplastic left heart syndrome—a relatively rare disease. We report our experience with the application of statistical process control methods to generate measures capable of identifying statistically significant change in the incidence of early growth failure—a clinically important outcome in this relatively small patient population.

Moving CLABSI prevention beyond the intensive care unit: risk factors in pediatric oncology patients

BACKGROUND AND OBJECTIVE

Central line-associated bloodstream infections (CLABSIs) frequently complicate the use of central venous catheters (CVCs) among pediatric patients with cancer. Our objectives were to describe the microbiology and identify risk factors for hospital-onset CLABSI in this patient population.

DESIGN

Retrospective case-control study.

SETTING

Oncology and stem cell transplant units of a freestanding, 396-bed quaternary care pediatric hospital.

PARTICIPANTS

Case subjects ([Formula: see text]) were patients with a diagnosis of malignancy and/or stem cell transplant recipients with CLABSI occurring during admission. Controls ([Formula: see text]) were identified using risk set sampling of hospitalizations among patients with a CVC, matched on date of admission.

METHODS

Multivariate conditional logistic regression was used to identify independent predictors of CLABSI.

RESULTS

The majority of CLABSI isolates were gram-positive bacteria (58%). The most frequently isolated organism was Enterococcus faecium, and 6 of 9 isolates were resistant to vancomycin. In multivariate analyses, independent risk factors for CLABSI included platelet transfusion within the prior week (odds ratio [OR], 10.90 [95% confidence interval (CI), 3.02-39.38]; [Formula: see text]) and CVC placement within the previous month (<1 week vs ≥1 month: OR, 11.71 [95% CI, 1.98-69.20]; [Formula: see text]; ≥1 week and <1 month vs ≥1 month: OR, 7.37 [95% CI, 1.85-29.36]; [Formula: see text]).

CONCLUSIONS

Adjunctive measures to prevent CLABSI among pediatric oncology patients may be most beneficial in the month following CVC insertion and in patients requiring frequent platelet transfusions. Vancomycin-resistant enterococci may be an emerging cause of CLABSI in hospitalized pediatric oncology patients and are unlikely to be treated by typical empiric antimicrobial regimens.

Impact of sepsis on neurodevelopmental outcome in a Swiss National Cohort of extremely premature infants

OBJECTIVE

Neonatal sepsis causes high mortality and morbidity in preterm infants, but less is known regarding the long-term outcome after sepsis. This study aimed to determine the impact of sepsis on neurodevelopment at 2 years' corrected age in extremely preterm infants.

PATIENTS AND METHODS

This was a multicenter Swiss cohort study on infants born between 2000 and 2007 at 24(0/7) to 27(6/7) weeks' gestational age. Neurodevelopmental outcome was assessed with the Bayley Scales of Infant Development-II. Neurodevelopmental impairment (NDI) was defined as a Mental or Psychomotor Developmental Index lower than 70, cerebral palsy (CP), or visual or auditory impairment.

RESULTS

Of 541 infants, 136 (25%) had proven sepsis, 169 (31%) had suspected sepsis, and 236 (44%) had no signs of infection. CP occurred in 14 of 136 (10%) infants with proven sepsis compared with 10 of 236 (4%) uninfected infants (odds ratio [OR]: 2.90 [95% confidence interval (CI): 1.22-6.89]; P = .016). NDI occurred in 46 of 134 (34%) infants with proven sepsis compared with 55 of 235 (23%) uninfected infants (OR: 1.85 [95% CI: 1.12-3.05]; P = .016). Multivariable analysis confirmed that proven sepsis independently increased the risk of CP (OR: 3.23 [95% CI: 1.23-8.48]; P = .017) and NDI (OR: 1.69 [95% CI: 0.96-2.98]; P = .067). In contrast, suspected sepsis was not associated with neurodevelopmental outcome (P > .05). The presence of bronchopulmonary dysplasia, pathologic brain ultrasonography, retinopathy, and sepsis predicted the risk of NDI (P < .0001).

CONCLUSIONS

Proven sepsis significantly contributes to NDI in extremely preterm infants, independent of other risk factors. Better strategies aimed at reducing the incidence of sepsis in this highly vulnerable population are needed.

Equipment and monitoring--what is in the future to improve safety?

There have been a number of recent developments in the practice of anesthesia and intensive care aimed at improving outcome in terms of reducing both morbidity and mortality, as well as other less-defined factors, such as quality of service provision. Significant advances have been made in airway devices such as pediatric tracheal tube designs, Microcuff(®) tracheal tubes, and new laryngoscopes. Noninvasive monitoring devices, including continuous hemoglobin analysis and near infrared spectrometry, are being increasingly used in pediatric anesthesia. Other, 'scaled-down' versions from adult anesthesia care, however, have not universally been shown to result in improved safety and outcomes in pediatric anesthesia.

Peripherally inserted central catheters

Peripherally inserted central catheters are increasingly used in the pediatric and adolescent population for long-term central access. This article reviews the indications, insertion techniques, and complications of peripherally inserted central catheter lines.

Central line-associated bloodstream infections: prevention and management

Approximately 80,000 central venous line-associated bloodstream infections (CLA-BSI) occur in the United States each year. CLA-BSI is most commonly caused by coagulase-negative staphylococci, Staphylococcus aureus, Candida spp, and aerobic gram-negative bacilli. These organisms commonly gain entrance in into the bloodstream via the catheter-skin interface (insertion site) or via the catheter hub. Use of strict aseptic technique for insertion is the key method for the prevention of CLA-BSI. Various methods can be used to reduce unacceptably high rates of CLA-BSI, including use of an antiseptic- or antibiotic-impregnated catheter, daily chlorhexidine baths/washes, and placement of a chlorhexidine-impregnated sponge over the insertion site.

Prevention of central line associated bloodstream infections in critical care units

PURPOSE OF REVIEW

Central line associated bloodstream infections (CLABSIs) are a common source of morbidity and mortality in neonatal and pediatric intensive care units. Successful preventive strategies have recently been reported which have resulted in significant reductions in CLABSIs and their associated adverse outcomes.

RECENT FINDINGS

Current surveillance data indicate a recent decline in reported CLABSI rates, likely secondary to changes in diagnostic criteria and improvements in central line care. Recent pilot randomized trials in the neonatal intensive care unit population have assessed the safety and efficacy of chlorhexidine gluconate for cutaneous antisepsis and silver alginate-impregnated dressings. No significant reductions in CLABSIs have been noted with the use of either. The greatest success has come with implementation of evidence-based catheter care bundles, which have been shown in individual units and collaborative critical care networks to significantly reduce CLABSI rates.

SUMMARY

CLABSIs remain a significant problem in neonatal and pediatric critical care units, but implementation of catheter care bundles can significantly reduce rates of these infections. The safety and efficacy of chlorhexidine gluconate, silver alginate, and antibiotic-coated catheters need to be assessed via large, multicenter trials. Creation of collaborative networks may facilitate this goal.

Use of quality-improvement methods to improve timeliness of analgesic delivery

OBJECTIVES

Despite its high prevalence, pain often is poorly managed in the emergency department. We used improvement science and quality-improvement methods to reduce delays associated with opioid delivery for children presenting to the emergency department with clinically apparent extremity fractures.

METHODS

On the basis of a review of the literature, interviews with key stakeholders, expert consensus, and reviews of isolated examples of patients receiving timely analgesics, a multidisciplinary improvement team identified a set of operational factors, or key drivers, believed to be critical to the performance of appropriate initial pain management for children presenting to the emergency department with acute extremity injury. These key drivers focused the development of an intervention.

RESULTS

The intervention, termed the orthopedic evaluation process, addressed all 4 identified key drivers simultaneously by standardizing triage decisions, activating necessary health care providers, aligning the care delivery need with necessary resources, and allowing parallel-task completion between physicians and nursing staff. After implementation of this process, 95% of the patients with long-bone extremity fractures treated with intravenous opioids received a first dose within 45 minutes of arrival, compared with a preintervention baseline average of 20%.

CONCLUSIONS

By applying quality-improvement and process improvement methodology, we identified key drivers for the rapid delivery of systemic opioids to patients with clinically apparent extremity fractures and significantly improved the timeliness of analgesic delivery for this subgroup of patients.

Prevention of healthcare-associated infections in children: new strategies and success stories

PURPOSE OF REVIEW

Attention to patient safety has made hospital infection prevention and control strategies a subject of increasing focus from healthcare personnel, patients and families, accrediting organizations, and government. This review highlights recent literature and new successes in the prevention of healthcare-associated infections in children.

RECENT FINDINGS

Emerging evidence about risk factors for various healthcare-associated infections in children will help target available adjunctive preventive interventions. Multicenter pediatric collaborative efforts to emphasize best practices have resulted in decreases in infection rates, particularly for central line-associated bloodstream infections. A low prevalence of colonization or infection with multidrug-resistant organisms in hospitalized children, combined with a lack of compelling evidence of effectiveness for active surveillance and decolonization, have made decisions about routine screening challenging.

SUMMARY

A renewed interest in infection prevention by multiple stakeholders has energized our field and contributed to impressive successes in reducing rates of healthcare-associated infections. Nevertheless, important knowledge gaps remain and an emphasis on funding of high-quality, rigorous studies to answer unresolved questions will be critical to our efforts to further prevent infections for hospitalized children.

The harder you look, the more you find: Catheter-associated bloodstream infection surveillance variability

BACKGROUND

Catheter-related bloodstream infections are an important quality performance measure and remain a significant source of added morbidity, mortality, and medical costs.

OBJECTIVE

Our objectives were to assess variability in catheter-associated bloodstream infections (CA-BSI) surveillance practices, management, and attitudes/beliefs in pediatric intensive care units (PICUs) and to determine whether any correlation exists between surveillance variation and CA-BSI rates.

METHODS

We used a survey of 5 health care professions at multiple institutions.

RESULTS

One hundred forty-six respondents from 5 professions in 16 PICUs completed surveys with a response rate of 40%. All 10 (100%) infection control departments reported inclusion or exclusion of central line types inconsistent with the Centers for Disease Control and Prevention CA-BSI definition, 5 (50%) calculated line-days inconsistently, and only 5 (50%) used a strict, written policy for classifying BSIs. Infection control departments report substantial variation in methods, timing, and resources used to screen and adjudicate BSI cases. Greater than 80% of centers report having a formal, written policy about obtaining blood cultures, although less than 80% of these address obtaining samples from patients with central venous lines, and any such policies are reportedly followed less than half of the time. Substantial variation exists in blood culturing practices, such as temperature thresholds, preemptive antipyretics, and blood sampling (volumes, number, sites, frequencies). A surveillance aggressiveness score was devised to quantify practices likely to increase identification of bloodstream infections, and there was a significant correlation between the surveillance aggressiveness score and CA-BSI rates (r = 0.60, P = .034). In assessing attitudes and beliefs, there was much greater confidence in the validity of CA-BSI as an internal/historical benchmark than as an external/peer benchmark, and the factor most commonly believed to contribute to CA-BSI occurrences was patient risk factors, not central line maintenance or insertion practices.

CONCLUSION

There is substantial variation in reported CA-BSI surveillance practices among PICUs, and more aggressive surveillance correlates to higher CA-BSI rates, which has important implications in pay-for-performance and benchmarking applications. There is a compelling opportunity to improve standardized CA-BSI surveillance to enhance the validity of this metric for interinstitutional comparisons. Health care professionals' attitudes and beliefs about CA-BSI being driven by patient risk factors would benefit from recalibration that emphasized more important drivers-such as the quality of central line insertion and maintenance.

Preparing medical students for the continual improvement of health and health care: Abraham Flexner and the new "public interest"

In 1910, in his recommendations for reforming medical education, Abraham Flexner responded to what he deemed to be the "public interest." Now, 100 years later, to respond to the current needs of society, the education of physicians must once again change. In addition to understanding the biological basis of health and disease, and mastering technical skills for treating individual patients, physicians will need to learn to navigate in and continually improve complex systems in order to improve the health of the patients and communities they serve. Physicians should not be mere participants in, much less victims of, such systems. Instead, they ought to be prepared to help lead those systems toward ever-higher-quality care for all. A number of innovative programs already exist for students and residents to help integrate improvement skills into professional preparation, and that goal is enjoying increasing support from major professional organizations and accrediting bodies. These experiences have shown that medical schools and residency programs will need to both teach the scientific foundations of system performance and provide opportunities for trainees to participate in team-based improvement of the real-world health systems in which they work. This significant curricular change, to meet the social need of the 21st century, will require educators and learners to embrace new core values, in addition to those held by the profession for generations. These include patient-centeredness, transparency, and stewardship of limited societal resources for health care.

Impact of a program to prevent central line-associated bloodstream infection in the zero tolerance era

BACKGROUND

Central line-associated bloodstream infection (CLABSI) is one of the most important health care-associated infections in the critical care setting.

METHODS

A quasiexperimental study involving multiple interventions to reduce the incidence of CLABSI was conducted in a medical-surgical intensive care unit (ICU) and in 2 step-down units (SDUs). From March 2005 to March 2007 (phase 1 [P1]), some Centers for Disease Control and Prevention evidence-based practices were implemented. From April 2007 to April 2009 (P2), we intervened in these processes at the same time that performance monitoring was occurring at the bedside, and we implemented the Institute for Healthcare Improvement central line bundle for all ICU and SDU patients requiring central venous lines.

RESULTS

The mean incidence density of CLABSI per 1000 catheter-days in the ICU was 6.4 in phase 1 and 3.2 in phase 2, P < .001. The mean incidence density of CLABSI per 1000 catheter-days in the SDUs was 4.1 in phase 1 and 1.6 in phase 2, P = .005.

CONCLUSION

These results suggest that reducing CLABSI rates in an ICU setting is a complex process that involves multiple performance measures and interventions that can also be applied to SDU settings.

Crossing the quality chasm in neonatal-perinatal medicine

The "Quality Chasm" exists in neonatal intensive care. Despite years of clinical research in neonatology, therapies continue to be underused, overused, or misused. A key concept in crossing the quality chasm is system redesign. The unpredictability of human factors and the dynamic complexity of the neonatal ICU are not amenable to rigid reductionist control and redesign. Change is best accomplished in this complex adaptive system by use of simple rules: (1) general direction pointing, (2) prohibitions, (3) resource or permission providing. These rules create conditions for purposeful self-organizing behavior, allowing widespread natural experimentation, all focused on generating the desired outcome.

Can the costs of critical care be controlled?

PURPOSE OF REVIEW

Critical care medicine (CCM) is expensive. CCM costs have continued to rise since they were first calculated in the 1970s. By 2005, CCM costs in the US were estimated to be $81.7 billion accounting for 13.4% of hospital costs, 4.1% of the national health expenditures and 0.66% of the gross domestic product.

RECENT FINDINGS

This review first addresses the methodology and inherent limitations of calculating global CCM costs using the Russell equation and the challenges of defining critical care in the US when universal definitions of intensive care unit (ICU) bed types do not exist. Studies and concepts recently put forth to control CCM costs are then discussed. These include rationing ICU care, caring for patients in non-ICU locations, regionalizing care, changing the ICU workforce, imposing care protocols and bundles, and adjusting long-term ICU traditions. Many of these programs have benefits but may also have unintended expenses. Even documenting ICU costs themselves may be quite challenging as costs are frequently shifted between the ICU and its supporting clinical and hospital services.

SUMMARY

Cost containment is difficult to attain in critical care as the programs proposed to achieve cost control may be so pricey, that potential cost savings are offset. Some CCM cost saving methodologies may benefit patient care, whereas others may be detrimental to society. CCM cost containment may prove as illusory in the future as it has been in the past.