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Costs of ambulatory pediatric healthcare-associated infections: Central-line–associated bloodstream infection (CLABSIs), catheter-associated urinary tract infection (CAUTIs), and surgical site infections (SSIs). Infect Control Hosp Epidemiol 2020; 41:1292-1297. [DOI: 10.1017/ice.2020.305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AbstractObjective:Ambulatory healthcare-associated infections (HAIs) occur frequently in children and are associated with morbidity. Less is known about ambulatory HAI costs. This study estimated additional costs associated with pediatric ambulatory central-line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSIs) following ambulatory surgery.Design:Retrospective case-control study.Setting:Four academic medical centers.Patients:Children aged 0–22 years seen between 2010 and 2015 and at risk for HAI as identified by electronic queries.Methods:Chart review adjudicated HAIs. Charges were obtained for patients with HAIs and matched controls 30 days before HAI, on the day of, and 30 days after HAI. Charges were converted to costs and 2015 USD. Mixed-effects linear regression was used to estimate the difference-in-differences of HAI case versus control costs in 2 models: unrecorded charge values considered missing and a sensitivity analysis with unrecorded charge considered $0.Results:Our search identified 177 patients with ambulatory CLABSIs, 53 with ambulatory CAUTIs, and 26 with SSIs following ambulatory surgery who were matched with 382, 110, and 75 controls, respectively. Additional cost associated with an ambulatory CLABSI was $5,684 (95% confidence interval [CI], $1,005–$10,362) and $6,502 (95% CI, $2,261–$10,744) in the 2 models; cost associated with a CAUTI was $6,660 (95% CI, $1,055, $12,145) and $2,661 (95% CI, −$431 to $5,753); cost associated with an SSI following ambulatory surgery at 1 institution only was $6,370 (95% CI, $4,022–$8,719).Conclusions:Ambulatory HAI in pediatric patients are associated with significant additional costs. Further work is needed to reduce ambulatory HAIs.
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Spaulding AB, Watson D, Dreyfus J, Heaton P, Grapentine S, Bendel-Stenzel E, Kharbanda AB. Epidemiology of Bloodstream Infections in Hospitalized Children in the United States, 2009-2016. Clin Infect Dis 2020; 69:995-1002. [PMID: 30534940 DOI: 10.1093/cid/ciy1030] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 12/03/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Bloodstream infections (BSIs) cause significant morbidity and mortality in children. Recent pediatric epidemiological data may inform prevention strategies and empiric antimicrobial therapy selection. METHODS We conducted a retrospective cohort study from 2009 through 2016 utilizing demographic and microbiologic data on inpatients aged <19 years using the Premier Healthcare Database. BSIs were positive blood cultures without known contaminants. Hospitalization rate was the number of BSI-positive encounters per 1000 admissions. Community-acquired infections (CAIs) were cultures positive ≤2 days of admission among nonneonates. BSI patients were compared to documented positive BSI patients (non-BSI); differences were analyzed using χ2 test, t test, and Cochran-Armitage test for time trends. RESULTS Among 1 809 751 encounters from 162 US hospitals, 5340 (0.30%) were BSI positive; CAIs were most common (50%). BSI patients were more often aged 1-5 years and had complex chronic conditions or central lines compared to non-BSI patients. The BSI hospitalization rate declined nonsignificantly over time (3.13 in 2009 to 2.98 in 2016, P = .08). Among pathogens, Escherichia coli (0.80 to 1.26), methicillin-sensitive Staphylococcus aureus (0.83 to 1.98), and group A Streptococcus (0.16 to 0.37) significantly increased for nonneonates, while Streptococcus pneumoniae (1.07 to 0.26) and Enterococcus spp. (0.60 to 0.17) declined. Regional differences were greatest for E. coli and highest in the New England and South Atlantic regions. CONCLUSIONS Trends in pediatric BSI hospitalization rates varied by pathogen and regionally. Overall the BSI hospitalization rate did not significantly decline, indicating a continued need to improve pediatric BSI assessment and prevention.
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Affiliation(s)
| | - David Watson
- Center for Acute Care Outcomes, Children's Minnesota Research Institute
| | | | | | | | - Ellen Bendel-Stenzel
- Center for Acute Care Outcomes, Children's Minnesota Research Institute
- Minnesota Neonatal Physicians
- Midwest Fetal Care Center
| | - Anupam B Kharbanda
- Pediatric Emergency Medicine, Chief of Critical Care Services, Children's Minnesota
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Chehab O, Morsi RZ, Kanj A, Rachwan RJ, Pahuja M, Mansour S, Tabaja H, Ahmad U, Zein SE, Raad M, Saker A, Alvarez P, Briasoulis A. Incidence and clinical outcomes of nosocomial infections in patients presenting with STEMI complicated by cardiogenic shock in the United States. Heart Lung 2020; 49:716-723. [PMID: 32866743 DOI: 10.1016/j.hrtlng.2020.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 07/31/2020] [Accepted: 08/17/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This study addresses the incidence, trends, and impact of nosocomial infections (NI) on the outcomes of patients admitted with ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock (STEMI-CS) using the United States National Inpatient Sample (NIS) database. METHODS We analyzed data from 105,184 STEMI-CS patients using the NIS database from the years 2005-2014. NI was defined as infections of more than or equal to three days, comprising of central line-associated bloodstream infection (CLABSI), urinary tract infection (UTI), hospital-acquired pneumonia (HAP), Clostridium difficile infection (CDI), bacteremia, and skin related infections. Outcomes of the impact of NI on STEMI-CS included in-hospital mortality, length of hospital stay (LOS) and costs. Significant associations of NI in patients admitted with STEMI-CS were also identified. RESULTS Overall, 19.1% (20,137) of patients admitted with STEMI-CS developed NI. Trends of NI have decreased from 2005-2014. The most common NI were UTI (9.2%), followed by HAP (6.8%), CLABSI (1.5%), bacteremia (1.5%), skin related infections (1.5%), and CDI (1.3%). The strongest association of developing a NI was increasing LOS (7-9 days; OR: 1.99; 95% CI: 1.75-2.26; >9 days; OR: 4.51; 95% CI: 4.04-5.04 compared to 4-6 days as reference). Increased mortality risk among patients with NI was significant, especially those with sepsis-associated NI compared to those without sepsis (OR: 2.95; 95% CI: 2.72-3.20). Patients with NI were found to be associated with significantly longer LOS and higher costs, irrespective of percutaneous mechanical circulatory support placement. CONCLUSIONS NI were common among patients with STEMI-CS. Those who developed NI were at a greater risk of in-hospital mortality, increased LOS and costs.
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Affiliation(s)
- Omar Chehab
- Department of Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA.
| | - Rami Z Morsi
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Amjad Kanj
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rayan Jo Rachwan
- Department of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Mohit Pahuja
- Department of Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Shareef Mansour
- Division of Cardiovascular Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Hussam Tabaja
- Department of Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Usman Ahmad
- Department of Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Said El Zein
- Department of Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Mohammad Raad
- Division of Cardiology, Department of Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ali Saker
- Department of Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Paulino Alvarez
- Division of Cardiovascular Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Alexandros Briasoulis
- Division of Cardiovascular Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
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Benenson S, Cohen MJ, Schwartz C, Revva M, Moses AE, Levin PD. Is it financially beneficial for hospitals to prevent nosocomial infections? BMC Health Serv Res 2020; 20:653. [PMID: 32664922 PMCID: PMC7358996 DOI: 10.1186/s12913-020-05428-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 06/12/2020] [Indexed: 12/05/2022] Open
Abstract
Background Financial incentives represent a potential mechanism to encourage infection prevention by hospitals. In order to characterize the place of financial incentives, we investigated resource utilization and cost associated with hospital-acquired infections (HAI) and assessed the relative financial burden for hospital and insurer according to reimbursement policies. Methods We conducted a prospective matched case-control study over 18 months in a tertiary university medical center. Patients with central-line associated blood-stream infections (CLABSI), Clostridium difficile infection (CDI) or surgical site infections (SSI) were each matched to three control patients. Resource utilization, costs and reimbursement (per diem for CLABSI and CDI, diagnosis related group (DRG) reimbursement for SSI) were compared between patients and controls, from both the hospital and insurer perspective. Results HAIs were associated with increased resource consumption (more blood tests, imaging, antibiotic days, hospital days etc.). Direct costs were higher for cases vs. controls (CLABSI: $6400 vs. $2376 (p < 0.001), CDI: $1357 vs $733 (p = 0.047) and SSI: $6761 vs. $5860 (p < 0.001)). However as admissions were longer following CLABSI and CDI, costs per-day were non-significantly different (USD/day, cases vs. controls: CLABSI, 601 vs. 719, (p = 0.63); CDI, 101 vs. 93 (p = 0.5)). For CLABSI and CDI, reimbursement was per-diem and thus the financial burden ($14,608 and $5430 respectively) rested on the insurer, not the hospital. For SSI, as reimbursement was per procedure, costs rested primarily on the hospital rather than the insurer. Conclusion Nosocomial infections are associated with both increased resource utilization and increased length of stay. Reimbursement strategy (per diem vs DRG) is the principal parameter affecting financial incentives to prevent hospital acquired infections and depends on the payer perspective. In the Israeli health care system, financial incentives are unlikely to represent a significant consideration in the prevention of CLABSI and CDI.
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Affiliation(s)
- Shmuel Benenson
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, POB 12000, 9112001, Jerusalem, Israel
| | - Matan J Cohen
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, POB 12000, 9112001, Jerusalem, Israel. .,Clalit Health Services, Jerusalem district, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel.
| | - Carmela Schwartz
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, POB 12000, 9112001, Jerusalem, Israel
| | - Michael Revva
- Finance Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Allon E Moses
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, POB 12000, 9112001, Jerusalem, Israel
| | - Phillip D Levin
- Critical Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
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Jitrungruengnij N, Anugulruengkitt S, Rattananupong T, Prinyawat M, Jantarabenjakul W, Wacharachaisurapol N, Chatsuwan T, Janewongwirot P, Suchartlikitwong P, Tawan M, Kanchanabutr P, Pancharoen C, Puthanakit T. Efficacy of chlorhexidine patches on central line-associated bloodstream infections in children. Pediatr Int 2020; 62:789-796. [PMID: 32065485 DOI: 10.1111/ped.14200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 01/17/2020] [Accepted: 02/12/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSIs) are important hospital-acquired infections. Chlorhexidine-impregnated dressings (also known as chlorhexidine patches, CHG patches) are reported to decrease CLABSIs in adults. This study aims to determine the efficacy of CHG patches in reducing CLABSIs in children. METHODS An open-label randomized controlled trial was conducted in children aged 2 months to 18 years, requiring a short-term catheter. Patients were randomized into two groups, allocated to receive CHG patches or standard transparent dressings. Care of the catheter was in accordance with Asia Pacific Society of Infection Control (APSIC) recommendations. Central-line-associated bloodstream infections were defined using National Healthcare Safety Network surveillance criteria. RESULTS From April 2017 to April 2018, 192 children were enrolled. There were 108 CHG patch catheters and 101 standard dressing catheters, contributing to 3,113 catheter days. The median duration of catheter dwelling was 13 days, with an interquartile range (IQR) of 8-20 days. Half were placed at the jugular vein and 22% at the femoral vein. There were 23 CLABSI events. Incidence rates for CHG patches and standard dressings were 7.98 (95% confidence interval (CI), 4.25-13.65) and 6.74 (95% CI, 3.23-12.39) per 1,000 catheter days, respectively (incidence rate ratio 1.18; 95% CI, 0.52-2.70). The CLABSI pathogens were 15 Gram-negative bacteria, six Gram-positive bacteria, and two Candida organisms. Catheter colonization of CHG patches and standard dressings were 2.02 (95% CI, 0.42-5.91) and 3.07 (95% CI, 1.00-7.16) per 1,000 catheter days, respectively. Only local adverse effects occurred in 6.8% of the participants. CONCLUSIONS In our setting, there was no difference in CLABSI rates when the chlorhexidine patch dressings were compared with the standard transparent dressings. Strengthening of CLABSI prevention bundles is mandatory.
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Affiliation(s)
- Nattapong Jitrungruengnij
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Suvaporn Anugulruengkitt
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thanapoom Rattananupong
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Mayuree Prinyawat
- Infection Control Unit, Department of Nursing, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Watsamon Jantarabenjakul
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Thai Red Cross Emerging Infectious Diseases Clinical Center (TRC-EID), King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Noppadol Wacharachaisurapol
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Tanittha Chatsuwan
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pakpoom Janewongwirot
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pintip Suchartlikitwong
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Monta Tawan
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Chitsanu Pancharoen
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thanyawee Puthanakit
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Impact of rapid diagnostics with antimicrobial stewardship support for children with positive blood cultures: A quasi-experimental study with time trend analysis. Infect Control Hosp Epidemiol 2020; 41:883-890. [PMID: 32571440 DOI: 10.1017/ice.2020.191] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Evaluate the clinical impact of the implementation of VERIGENE gram-positive blood culture testing (BC-GP) coupled with antimicrobial stewardship result notification for children with positive blood cultures. DESIGN Quasi-experimental study. SETTING Quaternary children's hospital. PATIENTS Hospitalized children aged 0-21 years with positive blood culture events 1 year before and 1 year after implementation of BC-GP testing. METHODS The primary outcome was time to optimal antibiotic therapy for positive blood cultures, defined as receiving definitive therapy without unnecessary antibiotics (pathogens) or no antibiotics (contaminants). Secondary outcomes were time to effective therapy, time to definitive therapy, and time to stopping vancomycin, length of stay, and 30-day mortality. Time-to-therapy outcomes before and after the intervention were compared using Cox regression models and interrupted time series analyses, adjusting for patient characteristics and trends over time. Gram-negative events were included as a nonequivalent dependent variable. RESULTS We included 264 preintervention events (191 gram-positive, 73 gram-negative) and 257 postintervention events (168 gram-positive, 89 gram-negative). The median age was 2.9 years (interquartile range, 0.3-10.1), and 418 pediatric patients (80.2%) had ≥1 complex chronic condition. For gram-positive isolates, implementation of BC-GP testing was associated with an immediate reduction in time to optimal therapy and time to stopping vancomycin for both analyses. BC-GP testing was associated with decreased time to definitive therapy in interrupted time series analysis but not Cox modeling. No such changes were observed for gram-negative isolates. No changes in time to effective therapy, length of stay, or mortality were associated with BC-GP. CONCLUSIONS The implementation of BC-GP testing coupled with antimicrobial stewardship result notification was associated with decreased time to optimal therapy and time to stopping vancomycin for hospitalized children with gram-positive blood culture isolates.
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Sarı N, Okur N, Çakmakcı S, Aksu T, İlhan İE. Antibiotic Lock Therapy with Linezolid for the Treatment of Persistent Catheter-Related Infection in Children with Cancer. J PEDIAT INF DIS-GER 2020. [DOI: 10.1055/s-0040-1712922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Abstract
Objective Central venous catheter (CVC) colonization is a common problem in the pediatric oncology department. Initial colonization of CVC by coagulase-negative staphylococci (CoNS), Staphylococcus aureus, and enterococci is followed by the growth of intraluminal biofilm formation, and results in antibiotic therapy failure. The removal of the old CVC and insertion of new CVC is a difficult and expensive procedure in small children with cancer. The present article aimed to study our treatment results of antibiotic lock therapy (ALT) with linezolid in pediatric cancer patients.
Methods This study was planned as retrospective presentation of case series with eight pediatric cancer patients treated with 11 courses of systemic and linezolid lock therapy. Demographic information, clinical findings, laboratory data, blood culture results, complications, and outcome were collected for each patient retrospectively and descriptive statistical methods were used.
Results Prior to treatment, peripheral and CVC blood culture results showed Staphylococcus epidermidis in seven patients and Staphylococcus hominis in four patients. All pathogens were susceptible to vancomycin and teicoplanin; first-line treatment was vancomycin in six and teicoplanin in five patients. After first-line treatment, peripheral blood cultures of all patients were negative, whereas blood cultures from CVC remained positive. During second-line therapy with linezolid, microbiological eradication was achieved on the fourth day of treatment in each patient. Median catheter survival time for all patients was 14 (range: 8–30) months. No side effects were observed during the treatment and no resistant organisms were documented.
Conclusion Although multicentric prospective controlled trials will be required to provide more generalizable results, we suggest that systemic antibiotics combined with linezolid lock therapy used in pediatric cancer patients may be an effective option in treating catheter-related bloodstream infection (CRBSI) and prolonging CVC survival when CoNS are identified.
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Affiliation(s)
- Neriman Sarı
- Department of Pediatric Hematology and Oncology, Ankara City Hospital, Ankara, Turkey
| | - Nurettin Okur
- Department of Pediatric Hematology and Oncology, Diyarbakır Maternity and Children's Training and Research Hospital, Diyarbakır, Turkey
| | - Selma Çakmakcı
- Department of Pediatric Hematology and Oncology, Ankara City Hospital, Ankara, Turkey
| | - Tekin Aksu
- Department of Pediatric Hematology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - İnci Ergürhan İlhan
- Department of Pediatric Hematology and Oncology, Health Science University, Ankara City Hospital, Ankara, Turkey
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Central venous catheter bundle adherence: Kamishibai card (K-card) rounding for central-line-associated bloodstream infection (CLABSI) prevention. Infect Control Hosp Epidemiol 2020; 41:1058-1063. [PMID: 32493532 DOI: 10.1017/ice.2020.235] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To institute facility-wide Kamishibai card (K-card) rounding for central venous catheter (CVC) maintenance bundle education and adherence and to evaluate its impact on bundle reliability and central-line-associated bloodstream infection (CLABSI) rates. DESIGN Quality improvement project. SETTING Inpatient units at a large, academic freestanding children's hospital. PARTICIPANTS Data for inpatients with a CVC in place for ≥1 day between November 1, 2017 and October 31, 2018 were included. INTERVENTION A K-card was developed based on 7 core elements in our CVC maintenance bundle. During monthly audits, auditors used the K-cards to ask bedside nurses standardized questions and to conduct medical record documentation reviews in real time. Adherence to every bundle element was required for the audit to be considered "adherent." We recorded bundle reliability prospectively, and we compared reliability and CLABSI rates at baseline and 1 year after the intervention. RESULTS During the study period, 2,321 K-card audits were performed for 1,051 unique patients. Overall maintenance bundle reliability increased significantly from 43% at baseline to 78% at 12 months after implementation (P < .001). The hospital-wide CLABSI rate decreased from 1.35 during the 12-month baseline period to 1.17 during the 12-month intervention period, but the change was not statistically significant (incidence rate ratio [IRR], 0.87; 95% confidence interval [CI], 0.60-1.24; P = .41). CONCLUSIONS Hospital-wide CVC K-card rounding facilitated standardized data collection, discussion of reliability, and real-time feedback to nurses. Maintenance bundle reliability increased after implementation, accompanied by a nonsignificant decrease in the CLABSI rate.
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The business case for quality improvement. J Perinatol 2020; 40:972-979. [PMID: 32231258 DOI: 10.1038/s41372-020-0660-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 11/09/2022]
Abstract
Value in healthcare can be defined as providing the optimal outcome per health dollar spent. Improving the value of healthcare for patients and healthcare organizations requires an understanding and evaluation of the costs and benefits. Investing in quality improvement (QI) work can bring about financial results for healthcare organizations over time, have beneficial organizational effects, and improve outcomes for patients. This article continues a series of QI educational papers in the Journal of Perinatology, and reviews financial and economic measures used to create the business case for QI. Ultimately, the business case for QI is better defined as a business strategy for success.
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Wolf J, Milstone AM. Vascular Access in Children to Prevent and Treat Infectious Diseases. Pediatrics 2020; 145:S290-S291. [PMID: 32482742 DOI: 10.1542/peds.2019-3474l] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Joshua Wolf
- St Jude Children's Research Hospital, Memphis, Tennessee; .,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Aaron M Milstone
- Division of Infectious Diseases, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland; and.,Department of Hospital Epidemiology and Infection Control, The Johns Hopkins Hospital, Baltimore, Maryland
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Cost-effectiveness Analysis of Feeding Guidelines for Infants Following Intestinal Surgery. J Pediatr Gastroenterol Nutr 2020; 70:657-663. [PMID: 31977952 DOI: 10.1097/mpg.0000000000002642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The aim of the study was to determine the cost-effectiveness of postoperative feeding guidelines to reduce complications in infants with intestinal surgery compared to standard feeding practices. METHODS Using outcomes from a cohort study, Markov models from health care and societal perspectives simulated costs per hospitalization among infants fed via guidelines versus standard practice. Short-term outcomes included intestinal failure-associated liver disease, necrotizing enterocolitis after feeding, sepsis, and mortality. Effectiveness was measured as length of stay. The incremental cost-effectiveness ratios (ICER) compared cost over length of stay. Univariate and multivariate probabilistic sensitivity analyses with 10,000 Monte Carlo Simulations were performed. A second decision tree model captured the cost per quality-adjusted life years (QALYs) using utilities associated with long-term outcomes (liver cirrhosis and transplantation). RESULTS In the hospital perspective, standard feeding had a cost of $31,258,902 and 8296 hospital days, and the feeding guidelines had a cost of $29,295,553 and 8096 hospital days. The ICER was $-9832 per hospital stay with guideline use. More than 90% of the ICERs were in the dominant quadrant. Results were similar for the societal perspective. Long-term costs and utilities in the guideline group were $2830 and 0.91, respectively, versus $4030 and 0.90, resulting in an ICER of $-91,756/QALY. CONCLUSION In our models, feeding guideline use resulted in cost savings and reduction in hospital stay in the short-term and cost savings and an increase in QALYs in the long-term. Using a systematic approach to feed surgical infants appears to reduce costly complications, but further data from a larger cohort are needed.
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Batra S, Rahman S, Rana MS, Matta S, Darbari A. Epidemiology and healthcare utilization of inpatient admissions in children with pediatric intestinal pseudo-obstruction. Neurogastroenterol Motil 2020; 32:e13781. [PMID: 31885159 DOI: 10.1111/nmo.13781] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 11/18/2019] [Accepted: 11/22/2019] [Indexed: 12/05/2022]
Abstract
BACKGROUND Pediatric intestinal pseudo-obstruction is a rare disorder affecting gastrointestinal motility leading to chronic symptoms and hospitalizations. There is limited understanding of the epidemiology and healthcare burden. METHODS We analyzed data from Kids' Inpatient Database from 2016, which includes inpatient discharge records from US hospitals. ICD-10 codes were used to identify patients 0-18 years with pediatric intestinal pseudo-obstruction and comorbid conditions. Multivariable logistic regression and Wilcoxon rank-sum test were used. RESULTS In 2016, there were 1671 inpatient discharges from US hospitals for patients 0-18 years of age with this diagnosis. The incidence of inpatient admission was 29/100 000 patients. After controlling for age, race, income status, and insurance, males vs females (adjusted odds ratio, aOR: 1.10; 95% CI: 0.94-1.28; P = .241) and caucasians vs other races (aOR: 1.55; 95% CI: 1.27-1.88; P < .001) were more likely to be admitted. Inpatient admissions incurred significant healthcare burden; median (inter quartile range IQR) cost of hospitalization of US$ 52 079 (US$ 23 530-120 961) and a median (IQR) length of stay of 6 days (3-14 days). Gastrostomy (32%) and ileostomy (12.6%) status appeared to incur lower healthcare burden. Parenteral nutrition, malnutrition, and central line/bloodstream infections resulted in higher healthcare burden. CONCLUSIONS Pediatric intestinal pseudo-obstruction is a rare diagnosis with a high incidence of inpatient admissions and healthcare burden. An aggressive multidisciplinary management is crucial in reducing inpatient admissions in this cohort.
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Affiliation(s)
- Suruchi Batra
- Division of Pediatric Gastroenterology, Children's National Hospital, Washington, DC, USA
| | - Sheikh Rahman
- Division of Pediatric Gastroenterology, Children's National Hospital, Washington, DC, USA
| | - Md Sohel Rana
- Joseph E. Robert Jr. Center for Surgical Care, Children's National Hospital, Washington, DC, USA
| | - Sravan Matta
- Division of Pediatric Gastroenterology, Children's National Hospital, Washington, DC, USA
| | - Anil Darbari
- Division of Pediatric Gastroenterology, Children's National Hospital, Washington, DC, USA
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Snyder AN, Burjonrappa S. Central line associated blood stream infections in gastroschisis patients: A nationwide database analysis of risks, outcomes, and disparities. J Pediatr Surg 2020; 55:286-291. [PMID: 31708200 DOI: 10.1016/j.jpedsurg.2019.10.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 10/26/2019] [Indexed: 01/27/2023]
Abstract
PURPOSE The aim of this study was to determine the risk of central line associated blood-stream infections (CLABSI) in neonatal gastroschisis patients, risk factors, outcomes, and financial implications. METHODS The 2016 Healthcare Cost and Utilization Project (HCUP)'s kid's inpatient database (KID), a national database of pediatric inpatient admissions across the United States, was used to obtain a large sample of gastroschisis admissions. Incidence of CLABSI in the gastroschisis patient population was compared to the incidence of CLABSI in the database. To further study the factors influencing CLABSI in gastroschisis, demographic and clinical features of patients were analyzed. Categorical variables were analyzed using Fisher's exact test or Pearson's chi-squared test. Odds ratios (OR) with 95% confidence intervals (CI) for variables found to have significance (p < 0.05) were calculated. FINDINGS Incidence of CLABSI in this database for pediatric inpatients was 4449 out of 298,862 central line insertions [1.48%] and was 81 out of 2032 [3.9%] (OR 2.83, 95% CI 2.26-3.54, p < 0.001) in the gastroschisis cohort. African American neonates had a significantly higher risk of CLABSI with gastroschisis. Prematurity and low birth-weight in gastroschisis were protective from CLABSI, along with patients from suburban areas or admitted in the Southern USA. Average costs were greater in gastroschisis patients with CLABSI, increasing from $281,779 to $421,970 (p = 0.008). The average length of stay increased from 31 days to 38 days with a CLABSI (p < 0.001). CONCLUSIONS In gastroschisis patients, CLABSI incidence is high and adds great morbidity and expense. For uncertain reasons, premature and low birth weight babies appear to be protected. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Alana N Snyder
- University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Blvd, Tampa, FL 33612, USA
| | - Sathyaprasad Burjonrappa
- University of South Florida Morsani College of Medicine, Tampa General Hospital, 1 Tampa General Circle, Tampa, FL 33606, USA.
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Baier C, Linke L, Eder M, Schwab F, Chaberny IF, Vonberg RP, Ebadi E. Incidence, risk factors and healthcare costs of central line-associated nosocomial bloodstream infections in hematologic and oncologic patients. PLoS One 2020; 15:e0227772. [PMID: 31978169 PMCID: PMC6980604 DOI: 10.1371/journal.pone.0227772] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 12/27/2019] [Indexed: 12/28/2022] Open
Abstract
Non-implanted central vascular catheters (CVC) are frequently required for therapy in hospitalized patients with hematological malignancies or solid tumors. However, CVCs may represent a source for bloodstream infections (central line-associated bloodstream infections, CLABSI) and, thus, may increase morbidity and mortality of these patients. A retrospective cohort study over 3 years was performed. Risk factors were determined and evaluated by a multivariable logistic regression analysis. Healthcare costs of CLABSI were analyzed in a matched case-control study. In total 610 patients got included with a CLABSI incidence of 10.6 cases per 1,000 CVC days. The use of more than one CVC per case, CVC insertion for conditioning for stem cell transplantation, acute myeloid leukemia, leukocytopenia (≤ 1000/μL), carbapenem therapy and pulmonary diseases were independent risk factors for CLABSI. Hospital costs directly attributed to the onset of CLABSI were 8,810 € per case. CLABSI had a significant impact on the overall healthcare costs. Knowledge about risk factors and infection control measures for CLABSI prevention is crucial for best clinical practice.
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Affiliation(s)
- Claas Baier
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - Lena Linke
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Frank Schwab
- Institute of Hygiene and Environmental Medicine, Charité - University Medicine, Berlin, Germany
| | - Iris Freya Chaberny
- Institute of Hygiene, Hospital Epidemiology and Environmental Medicine, Leipzig University Hospital, Leipzig, Germany
| | - Ralf-Peter Vonberg
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - Ella Ebadi
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
- * E-mail:
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Pathogens causing central-line-associated bloodstream infections in acute-care hospitals-United States, 2011-2017. Infect Control Hosp Epidemiol 2020; 41:313-319. [PMID: 31915083 DOI: 10.1017/ice.2019.303] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To describe pathogen distribution and rates for central-line-associated bloodstream infections (CLABSIs) from different acute-care locations during 2011-2017 to inform prevention efforts. METHODS CLABSI data from the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) were analyzed. Percentages and pooled mean incidence density rates were calculated for a variety of pathogens and stratified by acute-care location groups (adult intensive care units [ICUs], pediatric ICUs [PICUs], adult wards, pediatric wards, and oncology wards). RESULTS From 2011 to 2017, 136,264 CLABSIs were reported to the NHSN by adult and pediatric acute-care locations; adult ICUs and wards reported the most CLABSIs: 59,461 (44%) and 40,763 (30%), respectively. In 2017, the most common pathogens were Candida spp/yeast in adult ICUs (27%) and Enterobacteriaceae in adult wards, pediatric wards, oncology wards, and PICUs (23%-31%). Most pathogen-specific CLABSI rates decreased over time, excepting Candida spp/yeast in adult ICUs and Enterobacteriaceae in oncology wards, which increased, and Staphylococcus aureus rates in pediatric locations, which did not change. CONCLUSIONS The pathogens associated with CLABSIs differ across acute-care location groups. Learning how pathogen-targeted prevention efforts could augment current prevention strategies, such as strategies aimed at preventing Candida spp/yeast and Enterobacteriaceae CLABSIs, might further reduce national rates.
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Length of stay, cost, and mortality of healthcare-acquired bloodstream infections in children and neonates: A systematic review and meta-analysis. Infect Control Hosp Epidemiol 2020; 41:342-354. [PMID: 31898557 DOI: 10.1017/ice.2019.353] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To estimate the attributable mortality, length of stay (LOS), and healthcare cost of pediatric and neonatal healthcare-acquired bloodstream infections (HA-BSIs). DESIGN A systematic review and meta-analysis. METHODS A systematic search (January 2000-September 2018) was conducted in PubMed, Cochrane, and CINAHL databases. Reference lists of selected articles were screened to identify additional studies. Case-control or cohort studies were eligible for inclusion when full text was available in English and data for at least 1 of the following criteria were provided: attributable or excess LOS, healthcare cost, or mortality rate due to HA-BSI. Study quality was evaluated using the Critical Appraisal Skills Programme Tool (CASP). Study selection and quality assessment were conducted by 2 independent researchers, and a third researcher was consulted to resolve any disagreements. Fixed- or random-effect models, as appropriate, were used to synthesize data. Heterogeneity and publication bias were evaluated. RESULTS In total, 21 studies were included in the systematic review and 13 studies were included in the meta-analysis. Attributable mean LOS ranged between 4 and 27.8 days; healthcare cost ranged between $1,642.16 and $160,804 (2019 USD) per patient with HA-BSI; and mortality rate ranged between 1.43% and 24%. The pooled mean attributable hospital LOS was 16.91 days (95% confidence interval [CI], 13.70-20.11) and the pooled attributable mortality rate was 8% (95% CI, 6-9). A meta-analysis was not conducted for cost due to lack of eligible studies. CONCLUSIONS Pediatric HA-BSIs have a significant impact on mortality, LOS, and healthcare cost, further highlighting the need for implementation of HA-BSI prevention strategies.
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A 1-year survey of catheter-related infections in a pediatric university hospital: A prospective study. Arch Pediatr 2019; 27:79-86. [PMID: 31791827 DOI: 10.1016/j.arcped.2019.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 10/10/2019] [Accepted: 11/11/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Central venous catheters (CVCs) provide a great comfort for hospitalized children. However, CVCs increase the risk of severe infection. As there are few data regarding pediatric epidemiology of catheter-related infections (CRIs), the main objective of this study was to measure the incidence rate of CRIs in our pediatric university hospital. We also sought to characterize the CRIs and to identify risk factors. MATERIALS AND METHODS We conducted an epidemiological prospective monocentric study including all CVCs, except Port-a-Caths and arterial catheters, inserted in children from birth to 18 years of age between April 2015 and March 2016 in the pediatric University Hospital of Nantes. Our main focus was the incidence rate of CRIs, defined according to French guidelines, while distinguishing between bloodstream infections (CRBIs) and non-bloodstream infections (CRIWBs). The incidence rate was also described for each pediatric ward. We analyzed the association between infection and potential risk factors using univariate and multivariate analysis by Cox regression. RESULTS We included 793 CVCs with 60 CRBIs and four CRIWBs. The incidence rate was 4.6/1000 catheter-days, with the highest incidence rate occurring in the neonatal intensive care unit (13.7/1000 catheter-days). Coagulase-negative staphylococci were responsible for 77.5% of the CRIs. Factors independently associated with a higher risk of infection in neonates were invasive ventilation and low gestational age. CONCLUSIONS The incidence of CRIs in children hospitalized in our institution appears to be higher than the typical rate of CRIs reported in the literature. This was particularly true for neonates. These results should lead us to reinforce preventive measures and antibiotic stewardship but they also raise the difficulty of diagnosing with certainty CRIs in neonates.
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Novel risk factors for central-line associated bloodstream infections in critically ill children. Infect Control Hosp Epidemiol 2019; 41:67-72. [PMID: 31685049 DOI: 10.1017/ice.2019.302] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Central-line-associated bloodstream infections (CLABSI) cause morbidity and mortality in critically ill children. We examined novel and/or modifiable risk factors for CLABSI to identify new potential targets for infection prevention strategies. METHODS This single-center retrospective matched case-control study of pediatric intensive care unit (PICU) patients was conducted in a 60-bed PICU from April 1, 2013, to December 31, 2017. Case patients were in the PICU, had a central venous catheter (CVC), and developed a CLABSI. Control patients were in the PICU for ≥2 days, had a CVC for ≥3 days, and did not develop a CLABSI. Cases and controls were matched 1:4 on age, number of complex chronic conditions, and hospital length of stay. RESULTS Overall, 72 CLABSIs were matched to 281 controls. Univariate analysis revealed 14 risk factors, and 4 remained significant in multivariable analysis: total number of central line accesses in the 3 days preceding CLABSI (80+ accesses: OR, 4.8; P = .01), acute behavioral health needs (OR, 3.2; P = .02), CVC duration >7 days (8-14 days: OR, 4.2; P = .01; 15-29 days: OR, 9.8; P < .01; 30-59 days: OR, 17.3; P < .01; 60-89 days: OR, 39.8; P < .01; 90+ days: OR, 4.9; P = .01), and hematologic/immunologic disease (OR, 1.5; P = .05). CONCLUSIONS Novel risk factors for CLABSI in PICU patients include acute behavioral health needs and >80 CVC accesses in the 3 days before CLABSI. Interventions focused on these factors may reduce CLABSIs in this high-risk population.
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Impact of Peptide Nucleic Acid Fluorescence in Situ Hybridization Testing for Coagulase-Negative Staphylococci in a Pediatric Setting. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2019. [DOI: 10.1097/ipc.0000000000000772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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70
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Styslinger E, Nguyen H, Hess O, Srivastava T, Heipel D, Patrick A, Malik M, Doll M, Godbout E, Stevens MP, Cooper K, Hemphill R, Bearman G. Central line-associated bloodstream infections and completion of the central line insertion checklist: A descriptive analysis comparing a dedicated procedure team to other providers. Am J Infect Control 2019; 47:1400-1402. [PMID: 31324488 DOI: 10.1016/j.ajic.2019.05.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/29/2019] [Accepted: 05/30/2019] [Indexed: 12/18/2022]
Abstract
A primary strategy of central line-associated bloodstream infection (CLABSI) prevention is standardized, aseptic insertion of central lines. We compared hospital-wide CLABSI rate pre- and post-implementation of a dedicated procedure team as well as central line checklist completion and patient-specific variables between the procedure team and other providers. No significant differences were found. Further CLABSI prevention should focus on central line maintenance.
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Affiliation(s)
- Emily Styslinger
- Virginia Commonwealth University School of Medicine, Richmond, VA.
| | - Huong Nguyen
- The Division of Infectious Diseases, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Olivia Hess
- Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Tara Srivastava
- Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Diane Heipel
- The Division of Infectious Diseases, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Amie Patrick
- The Division of Infectious Diseases, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Manpreet Malik
- Virginia Commonwealth University School of Medicine, Richmond, VA; The Division of Infectious Diseases, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Michelle Doll
- Virginia Commonwealth University School of Medicine, Richmond, VA; The Division of Infectious Diseases, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Emily Godbout
- Children's Hospital of Richmond at Virginia Commonwealth University Hospital, Richmond, VA
| | - Michael P Stevens
- Virginia Commonwealth University School of Medicine, Richmond, VA; The Division of Infectious Diseases, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Kaila Cooper
- The Division of Infectious Diseases, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Robin Hemphill
- The Division of Infectious Diseases, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Gonzalo Bearman
- Virginia Commonwealth University School of Medicine, Richmond, VA; The Division of Infectious Diseases, Virginia Commonwealth University Medical Center, Richmond, VA
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Increased Use of Noninvasive Ventilation Associated With Decreased Use of Invasive Devices in Children With Bronchiolitis. Crit Care Explor 2019; 1:e0026. [PMID: 32166268 PMCID: PMC7063953 DOI: 10.1097/cce.0000000000000026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To assess how a change in practice to more frequent use of high-flow nasal cannula for the treatment of bronchiolitis would affect the use of invasive devices in children.
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Effect of a Systemwide Approach to a Reduction in Central Line-Associated Bloodstream Infections. J Nurs Care Qual 2019; 35:40-44. [PMID: 31145184 DOI: 10.1097/ncq.0000000000000410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Unit-based initiatives were deployed independently creating silos in practice variability across the system with little impact on reduction of central line-associated bloodstream infections (CLABSI). PROBLEM The goal was to decrease CLABSI systemwide by establishing standardized evidence-based practice (EBP) procedures to advance nursing practice. APPROACH A new innovative method, the Ferrari Method for Practice Standardization, enhanced the quality infrastructure by merging EBP and lean methodology to translate nursing innovations into practice. Leveraging a culture of shared decision making to support autonomy, as well as collaborating interprofessionally, allowed the organization to standardize and sustain CLABSI prevention. OUTCOMES The Ferrari Method for Practice Standardization successfully reduced CLABSI rates by 48% over a 1-year improvement cycle. Eight standardized EBP clinical procedures were developed and implemented across the organization. CONCLUSION The implementation of the Ferrari Method for Practice Standardization swiftly moves new knowledge into clinical practice to improve outcomes. Using standardized improvement methodology, it eases the interprofessional approval processes, maximizes autonomy, and focuses on quality care.
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Santos WMD, Secoli SR. Economic burden of inpatients infected with Klebsiella pneumoniae carbapenemase. EINSTEIN-SAO PAULO 2019; 17:eGS4444. [PMID: 31116310 PMCID: PMC6533035 DOI: 10.31744/einstein_journal/2019gs4444] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 11/23/2018] [Indexed: 12/28/2022] Open
Abstract
Objective: To estimate the direct medical costs of drug therapy of Klebsiella pneumoniae carbapenemase (KPC) infection patients in hospital-based context. Methods: A cost-of-illness study conducted with a prospective cohort design with hospitalized adults infected by KPC. Data collection was performed using an instrument composed of sociodemographic data, clinical and prescription medication. Estimates of the direct costs associated to each treatment were derived from the payer's perspective, in the case of federal public hospitals from Brazil, and included only drug costs. These costs were based on the average price available at the Brazilian Price Database Health. No discount rate was used for the cost of drugs. The costs are calculate in American Dollar (US$). Results: A total of 120 inpatients participated of this study. The total drug cost of these inpatients was US$ 367,680.85. The systemic antimicrobial group was responsible for 59.5% of total costs. The direct drug cost per patients infected by KPC was conservatively estimated at nearly US$ 4,100.00, and about of 60% of costs occurred during the period of infection. Conclusion: The findings of our study indicate a thoughtful economic hazard posed by KPC that all healthcare sectors have to face. The increasing worldwide incidence of these bacteria represents a growing burden that most health systems are unable to deal with. There is an imperative need to develop protocols and new antimicrobials to treatment of KPC, aiming to rearrange resources to increase the effectiveness of healthcare services.
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Tweddell S, Loomba RS, Cooper DS, Benscoter AL. Health care‐associated infections are associated with increased length of stay and cost but not mortality in children undergoing cardiac surgery. CONGENIT HEART DIS 2019; 14:785-790. [DOI: 10.1111/chd.12779] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/16/2019] [Accepted: 04/10/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Sarah Tweddell
- Division of Cardiology, Department of Pediatrics Cincinnati Children’s Hospital Medical Center Cincinnati Ohio
| | - Rohit S. Loomba
- Division of Cardiology, Department of Pediatrics Cincinnati Children’s Hospital Medical Center Cincinnati Ohio
| | - David S. Cooper
- Division of Cardiology, Department of Pediatrics Cincinnati Children’s Hospital Medical Center Cincinnati Ohio
| | - Alexis L. Benscoter
- Division of Cardiology, Department of Pediatrics Cincinnati Children’s Hospital Medical Center Cincinnati Ohio
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Impact of Healthcare-Associated Infections on Length of Stay: A Study in 68 Hospitals in China. BIOMED RESEARCH INTERNATIONAL 2019; 2019:2590563. [PMID: 31119159 PMCID: PMC6500696 DOI: 10.1155/2019/2590563] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 04/11/2019] [Indexed: 12/21/2022]
Abstract
Healthcare-associated infections (HAIs) not only bring additional medical cost to the patients but also prolong the length of stay (LOS). 2119 HAI case-patients and 2119 matched control-patients were identified in 68 hospitals in 14 primary sampling provinces of 7 major regions of China. The HAI caused an increase in stay of 10.4 days. The LOS due to HAI increased from 9.7 to 10.9 days in different levels of hospitals. There was no statistically significant difference in the increased LOS between different hospital levels. The increased LOS due to HAI in different regions was 8.2 to 12.6 days. Comparing between regions, we found that the increased LOS due to HAI in South China is longer than other regions except the Northeast. The gastrointestinal infection (GI) caused the shortest extra LOS of 6.7 days while the BSI caused the longest extra LOS of 12.8 days. The increased LOS for GI was significantly shorter than that of other sites. Among 2119 case-patients, the non-multidrug-resistant pathogens were detected in 365 cases. The average increased LOS due to these bacterial infections was 12.2 days. E. coli infection caused significantly shorter LOS. The studied MDROs, namely, MRSA, VRE, ESBLs-E. coli, ESBLs-KP, CR-E. coli, CR-KP, CR-AB, and CR-PA were detected in 381 cases (18.0%). The average increased LOS due to these MDRO infections was 14 days. Comparing between different MDRO infections, we found that the increased LOS due to HAI caused by CR-PA (26.5 days) is longer than other MDRO infections (shorter than 19.8 days).
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Russell TA, Fritschel E, Do J, Donovan M, Keckeisen M, Agopian VG, Farmer DG, Wang T, Rubin Z, Busuttil RW, Kaldas FM. Minimizing central line-associated bloodstream infections in a high-acuity liver transplant intensive care unit. Am J Infect Control 2019; 47:305-312. [PMID: 30333081 DOI: 10.1016/j.ajic.2018.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 08/05/2018] [Accepted: 08/05/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Increases in liver transplant patient perioperative acuity have resulted in frail immunosuppressed patients at elevated risk for nosocomial infections. Avoiding central line-associated bloodstream infections (CLABSIs) is paramount to facilitate transplantation and post-transplant recovery. In 2015, our liver transplant intensive care unit (ICU) CLABSIs accounted for more than 25% of all CLABSI at our institution. We therefore undertook a multidisciplinary collaborative among clinical epidemiology, nursing, transplant surgery, and critical care to eliminate CLABSI events. METHODS From 2014-2016, using Lean methodology and plan-do-study-act (PDSA) cycles, 14 interventions were implemented in the liver transplant ICU. Interventions were aimed at infection prevention, care standardization, and team-based monitoring. Implementation used quality improvement methodology including audit and feedback, education, standardization, multidisciplinary stakeholder involvement, and PDSA cycles. Process measures were monitored and audited. CLABSI rates per 1,000 central venous catheter (CVC) days were tracked by clinical epidemiology. RESULTS During the intervention, 901 CVC catheter audits were completed. Improvements were seen on all process measures, and complete compliance increased from 25%-67%. CLABSI infection rates dropped from 4.2 to 1.8 in 1,000 CVC days, with an average of less than 1 CLABSI per month. This marked a 61.2% annual reduction, which correlated with an estimated $935,000 annual savings. CONCLUSION Concerted ongoing multidisciplinary collaboratives are essential to minimize CLABSI and optimize value and quality in a challenging, high-acuity patient population.
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Burstein DS, Shamszad P, Dai D, Almond CS, Price JF, Lin KY, O’Connor MJ, Shaddy RE, Mascio CE, Rossano JW. Significant mortality, morbidity and resource utilization associated with advanced heart failure in congenital heart disease in children and young adults. Am Heart J 2019; 209:9-19. [PMID: 30639612 DOI: 10.1016/j.ahj.2018.11.010] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 11/27/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Children with congenital heart disease (CHD) are at risk for advanced heart failure (AHF). We sought to define the mortality and resource utilization in CHD-related AHF in children and young adults. METHODS All hospitalizations in the Pediatric Health Information System database involving patients ≤21 years old with a CHD diagnosis and heart failure requiring at least 7 days of continuous inotropic support between 2004 and 2015 were included. Hospitalizations including CHD surgery were excluded. RESULTS Of 465,482 CHD hospitalizations, AHF was present in 2,712 (0.6%) [58% infant, 55% male, 30% single ventricle]. AHF therapies frequently used included extracorporeal membrane oxygenation (ECMO) (15%) and cardiac transplant (16%). Ventricular assist device (VAD) support was rare (3%), although VAD use significantly increased from 2004 to 2015 (P < .0010). Hospital mortality in CHD with AHF was 26%, with higher mortality associated with single ventricle heart disease (OR 1.64, 95% CI 1.23-2.19; P = .0009), infancy (OR 1.71, 95% CI 1.17-2.5; P = .0057), non-white race (OR 1.28, 95% CI 1.04-1.59; p=0.0234), and chronic complex comorbidities (OR 1.76, 95% CI 1.34-2.30; P < .0001). Over the 11-year study period, despite the significant increase in CHD-related AHF hospitalizations (P < .0001), hospital mortality improved (P = .0011). Median hospital costs were $252,000, a 6-fold increase above those without AHF, and was primarily driven by hospital length of stay (P < .0001). CONCLUSION AHF in children with CHD in uncommon but increasing and is associated with significant morbidity, mortality and resource utilization. Approximately 1 in 5 children do not survive to hospital discharge. Many risk factors for mortality may not be modifiable, and further study is needed to identify modifiable risk factors and improve care for this complex population.
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Watson D, Spaulding AB, Dreyfus J. Risk-Set Matching to Assess the Impact of Hospital-Acquired Bloodstream Infections. Am J Epidemiol 2019; 188:461-466. [PMID: 30475949 DOI: 10.1093/aje/kwy252] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/05/2018] [Indexed: 11/14/2022] Open
Abstract
Hospital-acquired bloodstream infections have a definite impact on patient encounters and cause increased length of stay, costs, and mortality. However, methods for estimating these effects are potentially biased, especially if the time of infection is not incorporated into the estimation strategy. We focused on matching patient encounters in which a hospital-acquired infection occurred to comparable encounters in which an infection did not occur. This matching strategy is susceptible to a selection bias because inpatients that stay longer in the hospital are more likely to acquire an infection and thus also are more likely to have longer and more costly stays. Instead, we have proposed risk-set matching, which matches infected encounters to similar encounters still at risk for infection at the corresponding time of infection. Matching on the one-dimensional propensity score can create comparable pairs for a large number of characteristics; an analogous propensity score is described for risk-set matching. We have presented dramatically different estimates using these 2 approaches with data from a pediatric cohort from the Premier Healthcare Database, United States, 2009-2016. The results suggest that estimates that did not incorporate time of infection exaggerated the impact of hospital-acquired infections with regard to attributed length of stay and costs.
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Affiliation(s)
- David Watson
- Children’s Minnesota Research Institute, Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Alicen B Spaulding
- Children’s Minnesota Research Institute, Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Jill Dreyfus
- Premier Applied Sciences, Premier, Inc., Charlotte, North Carolina
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Gauntt J, Vaidyanathan P, Basu S. Utilizing serum bicarbonate instead of venous pH to transition from intravenous to subcutaneous insulin shortens the duration of insulin infusion in pediatric diabetic ketoacidosis. J Pediatr Endocrinol Metab 2019; 32:11-17. [PMID: 30530908 DOI: 10.1515/jpem-2018-0394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 11/02/2018] [Indexed: 11/15/2022]
Abstract
Background Standard therapy of diabetic ketoacidosis (DKA) in pediatrics involves intravenous (IV) infusion of regular insulin until correction of acidosis, followed by transition to subcutaneous (SC) insulin. It is unclear what laboratory marker best indicates correction of acidosis. We hypothesized that an institutional protocol change to determine correction of acidosis based on serum bicarbonate level instead of venous pH would shorten the duration of insulin infusion and decrease the number of pediatric intensive care unit (PICU) therapies without an increase in adverse events. Methods We conducted a retrospective (pre/post) analysis of records for patients admitted with DKA to the PICU of a large tertiary care children's hospital before and after a transition-criteria protocol change. Outcomes were compared between patients in the pH transition group (transition when venous pH≥7.3) and the bicarbonate transition group (transition when serum bicarbonate ≥15 mmol/L). Results We evaluated 274 patient records (n=142 pH transition group, n=132 bicarbonate transition group). Duration of insulin infusion was shorter in the bicarbonate transition group (18.5 vs. 15.4 h, p=0.008). PICU length of stay was 3.2 h shorter in the bicarbonate transition group (26.0 vs. 22.8 h, p=0.04). There was no difference in the number of adverse events between the groups. Conclusions Transitioning patients from IV to SC insulin based on serum bicarbonate instead of venous pH led to a shorter duration of insulin infusion with a reduction in the number of PICU therapies without an increase in the number of adverse events.
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Affiliation(s)
- Jennifer Gauntt
- Division of Cardiology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA, Phone: +614-722-0596
| | - Priya Vaidyanathan
- Division of Endocrinology and Diabetes, Children's National Health System, Washington, DC, USA
| | - Sonali Basu
- Division of Critical Care Medicine, Children's National Health System, Washington, DC, USA
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81
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Karagiannidou S, Zaoutis T, Maniadakis N, Papaevangelou V, Kourlaba G. Attributable length of stay and cost for pediatric and neonatal central line-associated bloodstream infections in Greece. J Infect Public Health 2019; 12:372-379. [PMID: 30616938 DOI: 10.1016/j.jiph.2018.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Central line-associated bloodstream infections (CLABSIs) are the most frequent pediatric hospital-acquired infections and are associated with significant morbidity and healthcare costs. The aim of our study was to determine the attributable length of stay (LOS) and cost for CLABSIs in pediatric patients in Greece, for which there is currently a paucity of data. METHODS A retrospective matched-cohort study was performed in two tertiary pediatric hospitals. Inpatients with a central line in neonatal and pediatric intensive care units, hematology/oncology units, and a bone marrow transplantation unit between June 2012 and June 2015 were eligible. Patients with confirmed CLABSI were enrolled on the day of the event and were matched (1:1) to patients without CLABSI (non-CLABSIs) by hospital, unit, and LOS prior to study enrollment (188 children enrolled, 94 CLABSIs). The primary outcome measure was the attributable LOS and cost. Baseline demographic and clinical characteristics were recorded. Attributable outcomes were calculated as the differences in estimates of outcomes between CLABSIs and non-CLABSIs, after adjustment for propensity score and potential confounders. RESULTS There were no differences between the two groups regarding their baseline characteristics. After adjustment for age, gender, matching characteristics, central line management after study enrollment, and propensity score, the mean LOS and cost were 57.5days and €31,302 in CLABSIs versus 36.6days and €17,788 in non-CLABSIs. Overall, a CLABSI was associated with a mean (95% CI) adjusted attributable LOS and cost of 21days (7.3-34.8) and €13,727 (5,758-21,695), respectively. No significant difference was detected in LOS and cost by hospitalization unit. CONCLUSIONS CLABSIs were found to impose a significant economic burden in Greece, a finding that highlights the importance of implementing CLABSI prevention strategies.
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Affiliation(s)
- Sofia Karagiannidou
- Center for Clinical Epidemiology and Outcomes Research (CLEO), Non-Profit Civil Partnership, Athens, Greece.
| | - Theoklis Zaoutis
- Center for Clinical Epidemiology and Outcomes Research (CLEO), Non-Profit Civil Partnership, Athens, Greece; Division of Infectious Diseases, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nikolaos Maniadakis
- Department of Health Services Management, National School of Public Health, Athens, Greece
| | - Vassiliki Papaevangelou
- Third Department of Pediatrics, National and Kapodistrian University of Athens, School of Medicine, University General Hospital ATTIKON, Athens, Greece
| | - Georgia Kourlaba
- Center for Clinical Epidemiology and Outcomes Research (CLEO), Non-Profit Civil Partnership, Athens, Greece
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Cho HJ, Cho HK. Central line-associated bloodstream infections in neonates. KOREAN JOURNAL OF PEDIATRICS 2018; 62:79-84. [PMID: 30590002 PMCID: PMC6434225 DOI: 10.3345/kjp.2018.07003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 12/19/2018] [Indexed: 12/11/2022]
Abstract
Newborn infants, including premature infants, are high-risk patients susceptible to various microorganisms. Catheter-related bloodstream infections are the most common type of nosocomial infections in this population. Regular education and training of medical staffs are most important as a preventive strategy for central line-associated bloodstream infections (CLABSIs). Bundle approaches and the use of checklists during the insertion and maintenance of central catheters are effective measures to reduce the incidence of CLABSIs. Chlorhexidine, commonly used as a skin disinfectant before catheter insertion and dressing replacement, is not approved for infants <2 months of age, but is usually used in many neonatal intensive care units due to the lack of alternatives. Chlorhexidine-impregnated dressing and bathing, recommended for adults, cannot be applied to newborns. Appropriate replacement intervals for dressing and administration sets are similar to those recommended for adults. Umbilical catheters should not be used longer than 5 days for the umbilical arterial catheter and 14 days for the umbilical venous catheter. It is most important to regularly educate, train and give feedback to the medical staffs about the various preventive measures required at each stage from before insertion to removal of the catheter. Continuous efforts are needed to develop effective and safe infection control strategies for neonates and young infants.
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Affiliation(s)
- Hye Jung Cho
- Department of Pediatrics, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Hye-Kyung Cho
- Department of Pediatrics, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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Interventions to reduce unnecessary central venous catheter use to prevent central-line–associated bloodstream infections in adults: A systematic review. Infect Control Hosp Epidemiol 2018; 39:1442-1448. [DOI: 10.1017/ice.2018.250] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
AbstractObjectiveTo identify, describe, and evaluate interventions to reduce unnecessary central venous catheter (CVC) use to prevent central-line–associated bloodstream infections (CLABSIs) in adults.DesignSystematic review.MethodsThe review has been registered in PROSPERO, an international prospective register of systematic reviews. We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and the Cumulative Index to Nursing and Allied Health (CINAHL) from inception until August 28, 2018, to collect experimental and observational studies. We included all studies that implemented interventions to reduce unnecessary CVC use, defined as interventions aimed at improving appropriateness, awareness of device presence, or prompt removal of devices.ResultsIn total, 1,892 unique citations were identified. Among them, 1 study (7.1%) was a randomized controlled trial, 9 studies (64.3%) were quasi-experimental studies, and 4 studies (28.6%) were cohort studies. Furthermore, 13 studies (92.9%) demonstrated a decrease in CVC use after intervention despite different reporting methods, and the reduction rate varied from 6.8% to 85%. Also, 7 studies (50.0%) that reported the incidence of CLABSI described a reduction in CLABSIs ranging from 24.4% to 100.0%. Data on secondary outcomes were limited, and results of the descriptive analysis showed 70%–84% compliance with these interventions, less catheter occlusion, shorter duration of hospitalization, and cost savings.ConclusionsInterventions to reduce unnecessary CVC use significantly decrease the rate of CLABSI. Healthcare providers should strongly consider implementing these interventions for prevention of CLABSI in adults.
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84
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Cai Y, Zhu M, Sun W, Cao X, Wu H. Study on the cost attributable to central venous catheter-related bloodstream infection and its influencing factors in a tertiary hospital in China. Health Qual Life Outcomes 2018; 16:198. [PMID: 30305105 PMCID: PMC6180575 DOI: 10.1186/s12955-018-1027-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 09/26/2018] [Indexed: 11/14/2022] Open
Abstract
Background Central venous catheters (CVC) have been widely used for patients with severe conditions. However, they increase the risk of catheter-related bloodstream infection (CRBSI), which is associated with high economic burden. Until now, no study has focused on the cost attributable to CRBSI in China, and data on its economic burden are unavailable. The aim of this study was to assess the cost attributable to CRBSI and its influencing factors. Methods A retrospective matched case-control study and multivariate analysis were conducted in a tertiary hospital, with 94 patients (age ≥ 18 years old) from January 2011 to November 2015. Patients with CRBSI were matched to those without CRBSI by age, principal diagnosis, and history of surgery. The difference in cost between the case group and control group during the hospitalization was calculated as the cost attributable to CRBSI, which included the total cost and five specific cost categories: drug, diagnostic imaging, laboratory testing, health care technical services, and medical material. The relation between the total cost attributable to CRBSI and its influencing factors such as demographic characteristics, diagnosis and treatment, and pathogenic microorganism, was analysed with a general linear model (GLM). Results The total cost attributable to CRBSI was $3528.6, and the costs of specific categories including drugs, diagnostic imaging, laboratory testing, health care technical services, and medical material, were $2556.4, $112.1, $321.7, $268.7, $276.5, respectively. GLM analysis indicated that the total cost was associated with the intensive care unit (ICU), pathogenic microorganism, age, and catheter number, according to the sequence of standardized estimate (β). ICU contributed the most to the model R-square. Conclusion Central venous catheter–related bloodstream infection represents a great economic burden for patients. More attentions should be paid to further prevent and control this infection in China.
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Affiliation(s)
- Yuanyi Cai
- Department of Health Service Management, School of Humanities and Social Sciences, China Medical University, No.77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning Province, 110122, People's Republic of China
| | - Min Zhu
- Department of Health Service Management, School of Humanities and Social Sciences, China Medical University, No.77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning Province, 110122, People's Republic of China
| | - Wei Sun
- Department of Social Medicine, School of Public Health, China Medical University, No.77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning Province, 110122, People's Republic of China
| | - Xiaohong Cao
- Department of Health Service Management, School of Humanities and Social Sciences, China Medical University, No.77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning Province, 110122, People's Republic of China
| | - Huazhang Wu
- Department of Health Service Management, School of Humanities and Social Sciences, China Medical University, No.77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning Province, 110122, People's Republic of China.
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85
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Analysis of Healthcare Institutional Costs of Pediatric Home Parenteral Nutrition Central Line Infections. J Pediatr Gastroenterol Nutr 2018; 67:e77-e81. [PMID: 29912033 DOI: 10.1097/mpg.0000000000002058] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although previous literature suggests home parenteral nutrition (HPN)-dependent children experience frequent complications like community-acquired central line-associated bloodstream infections (CLABSI), few studies have characterized the cost. OBJECTIVE The aim of this study was to evaluate institutional cost of community-acquired CLABSI in pediatric patients with HPN. METHODS This is a single-center retrospective review of institutional costs for patients with HPN with community-acquired CLABSI at a tertiary care children's hospital. Inclusion was age 18 years or less between October 2011 and April 2016. Exclusions were death during hospitalization and readmission within 2 days of discharge. Patient-level factors were compared between high-cost group and all others using Welch 2-sample t test and analysis of variance. Multivariable logistic regression was used to determine predictors of higher cost. RESULTS There were 176 CLABSI admissions among 68 patients during the study period (median 2 hospitalizations per patients). The mean cost and length of stay per hospital admission are $28,375 (2015 US dollars) and 8 days, and both were associated with intensive care unit admission (ICU), central venous catheter removal, private insurance, and age <2 years at admission. Nine percent of patients were classified as "super-utilizers" whose 54 hospitalizations accounted for 28% of total institutional costs. CONCLUSIONS Among pediatric patients with HPN, community-acquired CLABSI is associated with significant cost and length of stay. Healthcare utilization is disproportionately concentrated in a small number of patients. These study findings may help inform cost analysis for future CLABSI prevention strategies.
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Abstract
The relatively young field of pediatric critical care has seen a shift from an approach with little consideration for the complications and adverse effects resulting from the procedures and medications to a more cautious approach with careful concern for the associated risks. Many senior pediatric intensivists recall a time when nearly every patient had a central venous line and arterial line; and hospital acquired infections, pressure injuries, unplanned extubations, and venous thromboemboli were expected costs of aggressive care. In addition to the morbidity and mortality associated with many of the health care-acquired conditions (HACs) in children, the attributable cost due to these HACs contributes to the unsustainable health care financial crisis. The Centers for Medicare and Medicaid Services (CMS) often penalize hospitals for HACs, and also are beginning to reimburse in a bundled fashion such that complications become the institution's burden. In children, payors and patients' families are often saddling this burden of costs attributable to HACs. The direct attributable costs per event are staggering. Payors, families, patients, and health care teams now demand a circumspect approach to care: do no harm, but how?
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Affiliation(s)
- Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Elizabeth H Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, SC, USA
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87
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Emmanuel J, Torres A. The Impact of Automated Electronic Surveillance of Electronic Medical Records on Pediatric Inpatient Care. Cureus 2018; 10:e3395. [PMID: 30533330 PMCID: PMC6278995 DOI: 10.7759/cureus.3395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Purpose To assess the impact of the automated surveillance of the electronic medical record process on clinical interventions among hospitalized children at a tertiary care pediatric center. Methods A retrospective chart review of the alerts triggered for central line-associated blood stream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), neonatal sepsis, or clinical deterioration through elevated pediatric early warning scores (PEWS) by automated electronic surveillance of the hospital electronic medical record (EMR) over a five-month period among hospitalized children. Interventions instituted in response to the alerts were reviewed from the hospital EMR. Fisher’s exact test was performed to detect any significant difference in the proportion of interventions performed for alerts triggered between groups. Results A total of 244 alerts were collected (27 CAUTI, 55 CLABSI, 10 neonatal sepsis, and 152 PEWS alerts). A significant difference in the proportion of interventions instituted after neonatal sepsis and PEWS alerts (9/162, 5.6%) as compared to CLABSI and CAUTI alerts (20/82, 24.4%) was observed (p<0.001; Odds ratio (95% CI): 0.182 (0.079-0.422)). Neonatal sepsis triggered the least number of alerts (10/244, 4.1%) and proportionately fewer interventions than the other clinical alerts. Conclusions Alerts for potential device-associated infections resulted in more clinical intervention than less-specific alerts. Neonatal sepsis alerts resulted in minimal interventions undertaken in response to the alert. Identifying and focusing on alerts benefitting the patient can serve as a better allocation of time and resources. Future studies should explore which newer alerts and their accompanying interventions improve patient outcomes.
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Affiliation(s)
- Jais Emmanuel
- Pediatrics, University of Central Florida, Orlando, USA
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88
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Surveillance for central-line-associated bloodstream infections: Accuracy of different sampling strategies. Infect Control Hosp Epidemiol 2018; 39:1210-1215. [PMID: 30156182 DOI: 10.1017/ice.2018.187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Active daily surveillance of central-line days (CLDs) in the assessment of rates of central-line-associated bloodstream infections (CLABSIs) is time-consuming and burdensome for healthcare workers. Sampling of denominator data is a method that could reduce the time necessary to conduct active surveillance. OBJECTIVE To evaluate the accuracy of various sampling strategies in the estimation of CLABSI rates in adult and pediatric units in Greece. METHODS Daily denominator data were collected across Greece for 6 consecutive months in 33 units: 11 adult units, 4 pediatric intensive care units (PICUs), 12 neonatal intensive care units (NICUs), and 6 pediatric oncology units. Overall, 32 samples were evaluated using the following strategies: (1) 1 fixed day per week, (2) 2 fixed days per week, and (3) 1 fixed week per month. The CLDs for each month were estimated as follows: (number of sample CLDs/number of sampled days) × 30. The estimated CLDs were used to calculate CLABSI rates. The accuracy of the estimated CLABSI rates was assessed by calculating the percentage error (PE): [(observed CLABSI rates - estimated CLABSI rates)/observed CLABSI rates]. RESULTS Compared to other strategies, sampling over 2 fixed days per week provided the most accurate estimates of CLABSI rates for all types of units. Percentage of estimated CLABSI rates with PE ≤±5% using the strategy of 2 fixed days per week ranged between 74.6% and 88.7% in NICUs. This range was 79.4%-94.1% in pediatric onology units, 62.5%-91.7% in PICUs, and 80.3%-92.4% in adult units. Further evaluation with intraclass correlation coefficients and Bland-Altman plots indicated that the estimated CLABSI rates were reliable. CONCLUSION Sampling over 2 fixed days per week provides a valid alternative to daily collection of CLABSI denominator data. Adoption of such a monitoring method could be an important step toward better and less burdensome infection control and prevention.
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Kolaček S, Puntis JWL, Hojsak I. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Venous access. Clin Nutr 2018; 37:2379-2391. [PMID: 30055869 DOI: 10.1016/j.clnu.2018.06.952] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 12/15/2022]
Affiliation(s)
- S Kolaček
- Children's Hospital Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia.
| | | | - I Hojsak
- Children's Hospital Zagreb, Zagreb, Croatia
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90
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Parker SK, Hurst AL, Thurm C, Millard M, Jenkins TC, Child J, Dugan C. Anti-infective Acquisition Costs for a Stewardship Program: Getting to the Bottom Line. Clin Infect Dis 2018; 65:1632-1637. [PMID: 29020143 DOI: 10.1093/cid/cix631] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 07/18/2017] [Indexed: 01/12/2023] Open
Abstract
Background Though antimicrobial stewardship programs (ASPs) are in place for patient safety, financial justification is often required. In 2016, the Infectious Diseases Society of America (IDSA) recommended that anti-infective costs be measured by patient-level administration data normalized for patient census. Few publications use this methodology. Here, we aim to compare 3 methods of drug cost analysis during 3 phases of an ASP as an example of this recommendation's implementation. Methods At a freestanding pediatric hospital, we retrospectively assessed anti-infective cost using pharmacy purchasing data, patient-level administration data from the electronic medical record (EMR), and patient-level administration data from the Pediatric Hospital Information Systems (PHIS) database, all normalized to patient census. Costs pre-ASP, while planning the ASP, and post-ASP were then compared for each method. Results Significant differences in costs between the methods were observed. Pharmacy purchasing endorsed minimal financial benefit (decrease planning to post-ASP of $590 dollars per 1000 patient-days), while the EMR and PHIS data endorsed a decrease of $12785 and $21380 per 1000 patient-days, respectively, for a total yearly cost savings of $54656 for pharmacy purchasing data, $1184336 for EMR data, and $2117522 for PHIS data. Conclusions Pharmacy purchasing data underestimated cost savings compared with EMR and PHIS data, while EMR and PHIS data were comparable in magnitude of savings. At Children's Hospital Colorado, savings justified the full cost of the ASP. EMR patient-level administration data, normalized to patient census, offers a readily available and standardized measure of anti-infective costs over time.
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Affiliation(s)
- Sarah K Parker
- Department of Pediatrics, Division of Pediatric Infectious Diseases and Epidemiology, University of Colorado School of Medicine
| | - Amanda L Hurst
- Department of Pharmacy, Children's Hospital Colorado, Aurora
| | - Cary Thurm
- Children's Hospital Association, Lenexa, Kansas
| | - Matthew Millard
- Department of Pharmacy, Children's Hospital Colorado, Aurora
| | - Timothy C Jenkins
- Department of Medicine, Division of Infectious Diseases, University of Colorado Hospital, University of Colorado School of Medicine, Aurora.,Denver Health, Colorado
| | - Jason Child
- Department of Pharmacy, Children's Hospital Colorado, Aurora
| | - Casey Dugan
- Department of Pharmacy, Children's Hospital Colorado, Aurora
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We Will Not Compete on Safety: How Children's Hospitals Have Come Together to Hasten Harm Reduction. Jt Comm J Qual Patient Saf 2018; 44:377-388. [PMID: 30008350 DOI: 10.1016/j.jcjq.2018.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Launched in 2012, the Children's Hospitals' Solutions for Patient Safety (SPS) Network is a collaborative of children's hospitals in the United States and Canada working together to eliminate patient and employee/staff harm across all children's hospitals. METHODS The SPS Network, which has grown from 8 to 137 hospitals, has a foundation of leadership engagement, noncompetition, data-driven learning, attention to safety culture, family engagement, and transparency. The SPS Leadership Group, which consists of more than 150 leaders from participating hospitals, forms condition-specific teams to promote the reduction of hospital-acquired harm in a phased design that includes an ongoing focus on both process improvement and safety culture enhancements. Hospital leaders are engaged through monthly reports, executive webinars, in-person meetings, and biannual training opportunities for boards of trustees. SPS has developed extensive opportunities for learning collaboration, including in-person networkwide learning sessions, regional meetings, general and condition-specific webinars, communications, and a shared website. RESULTS Over time, the portfolio has expanded as SPS has achieved harm reduction targets for some conditions and begun work to reduce harm in other, previously unaddressed areas. In 2017 SPS reported a 9%-71% reduction in eight harm conditions by an initial cohort of 33 hospitals. SPS estimates that more than 9,000 children have been spared harm since 2012, with $148.5 million in health care spending avoided. CONCLUSION Participation in the SPS Network has been associated with improved safety in children's hospitals. Widespread participation in this or similar collaborations has the potential to dramatically decrease harm to patients, employees, and staff.
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Clinical Characteristics and Risk Factors of Long-term Central Venous Catheter-associated Bloodstream Infections in Children. Pediatr Infect Dis J 2018; 37:401-406. [PMID: 29194165 DOI: 10.1097/inf.0000000000001849] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSIs) account for significant morbidity and mortality in patients with long-term central venous catheters (CVCs). This study was performed to identify the characteristics and risk factors of CLABSIs among children with long-term CVCs. METHODS A retrospective review of children who had a long-term CVC in Seoul National University Children's Hospital between 2011 and 2015 was performed. Data on patient demographics, the isolated pathogens and the status of CVC placement were collected. Clinical variables were compared between subjects with and without CLABSIs to determine the risk factors for CLABSIs. RESULTS A total of 629 CVCs were inserted in 499 children during the 5-year period. The median age at insertion was 6.0 years (14 days-17.9 years), and hemato-oncologic disease was the most common underlying condition (n = 497, 79.0%). A total of 235 CLABSI episodes occurred in 155 children, with a rate of 0.93 per 1,000 catheter days. The most common pathogens were Klebsiella pneumoniae (n = 64, 27.2%), coagulase-negative staphylococci (n = 40, 17.0%) and Staphylococcus aureus (n = 28, 12.0%). In the univariate analysis, the gender, underlying disease, catheter characteristics and insertion technique did not increase the risk for CLABSI. In both the univariate and logistic regression analyses, patients with prior BSIs (odds ratio 1.66; 95% confidence interval: 1.090-2.531; P = 0.018) were more likely to have a CLABSI. CONCLUSIONS CLABSI prevention is of particular concern for children with a prior BSI. Furthermore, the antimicrobial resistance of major pathogens should be monitored to enable the empiric selection of appropriate antibiotics in patients with long-term CVCs.
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Hawes JA, Lee KS. Reduction in Central Line-Associated Bloodstream Infections in a NICU: Practical Lessons for Its Achievement and Sustainability. Neonatal Netw 2018; 37:105-115. [PMID: 29615158 DOI: 10.1891/0730-0832.37.2.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Central venous catheters are commonly used for the provision of parenteral nutrition and medications for critically ill neonates in the NICU. However, central line-associated bloodstream infections (CLABSIs) are a major complication associated with their use and remain an important cause of nosocomial sepsis in NICUs. Central line-associated bloodstream infection has shifted from being an expected routine complication of central line use to an adverse event now evaluated as a critical event with the goal of identifying root causes so future CLABSI events are prevented. Success has been achieved through multiple strategies including implementation and maintenance of care bundles, education strategies to promote consistent adherence to bundle components, and institutional and unit support. Although low CLABSI rates can be achieved, sustaining low CLABSI rates and achieving zero CLABSI remain an ongoing challenge. We describe our experience with lessons learned, with an emphasis on the areas of difficulty during implementation of the bundle elements and the strategies and tools we utilized to overcome them.
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Kieran EA, O'Sullivan A, Miletin J, Twomey AR, Knowles SJ, O'Donnell CPF. 2% chlorhexidine-70% isopropyl alcohol versus 10% povidone-iodine for insertion site cleaning before central line insertion in preterm infants: a randomised trial. Arch Dis Child Fetal Neonatal Ed 2018; 103:F101-F106. [PMID: 29074717 DOI: 10.1136/archdischild-2016-312193] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 09/19/2017] [Accepted: 09/28/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine whether 2% chlorhexidine gluconate-70% isopropyl alcohol (CHX-IA) is superior to 10% aqueous povidone-iodine (PI) in preventing catheter-related blood stream infection (CR-BSI) when used to clean insertion sites before placing central venous catheters (CVCs) in preterm infants. DESIGN Randomised controlled trial. SETTING Two neonatal intensive care units (NICUs). PATIENTS Infants <31 weeks' gestation who had a CVC inserted. INTERVENTIONS Insertion site was cleaned with CHX-IA or PI. Caregivers were not masked to group assignment. MAIN OUTCOME MEASURES Primary outcome was CR-BSI determined by one microbiologist who was masked to group assignment. Secondary outcomes included skin reactions to study solution and thyroid dysfunction. RESULTS We enrolled 304 infants (CHX-IA 148 vs PI 156) in whom 815 CVCs (CHX-IA 384 vs PI 431) were inserted and remained in situ for 3078 (CHX-IA 1465 vs PI 1613) days. We found no differences between the groups in the proportion of infants with CR-BSI (CHX-IA 7% vs PI 5%, p=0.631), the proportion of CVCs complicated by CR-BSI or the rate of CR-BSI per 1000 catheter days. Skin reaction rates were low (<1% CVC insertion episodes) and not different between the groups. More infants in the PI group had raised thyroid-stimulating hormone levels and were treated with thyroxine (CHX-IA 0% vs PI 5%, p=0.003). CONCLUSIONS We did not find a difference in the rate of CR-BSI between preterm infants treated with CHX-IA and PI, and more infants treated with PI had thyroid dysfunction. However, our study was not adequately powered to detect a difference in our primary outcome and a larger trial is required to confirm our findings. TRIAL REGISTRATION This study was registered with the EU clinical trials register before the first patient was enrolled (Eudract 2011-002962-19). (https://www.clinicaltrialsregister.eu).
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Affiliation(s)
- Emily A Kieran
- Department of Neonatology, The National Maternity Hospital, Dublin, Ireland.,National Children's Research Centre, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Anne O'Sullivan
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Jan Miletin
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Anne R Twomey
- Department of Neonatology, The National Maternity Hospital, Dublin, Ireland
| | - Susan J Knowles
- Department of Neonatology, The National Maternity Hospital, Dublin, Ireland
| | - Colm Patrick Finbarr O'Donnell
- Department of Neonatology, The National Maternity Hospital, Dublin, Ireland.,National Children's Research Centre, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
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95
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Fonseca G, Burgermaster M, Larson E, Seres DS. The Relationship Between Parenteral Nutrition and Central Line-Associated Bloodstream Infections: 2009-2014. JPEN J Parenter Enteral Nutr 2018; 42:171-175. [PMID: 29505142 PMCID: PMC5568511 DOI: 10.1177/0148607116688437] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 12/13/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Parenteral nutrition (PN) administered via central venous catheter has been identified as an independent risk factor for central line-associated bloodstream infections (CLABSIs). The aim of this study was to provide an updated description of the relationship between PN and CLABSI and assess temporal trends in CLABSI rates for individuals who received PN from 2009-2014, after the Centers for Medicare & Medicaid declared CLABSI a "never event." METHODS Using data obtained from all adult patient discharges between January 1, 2009, and December 31, 2014, from 2 affiliated hospitals in a large health system in New York City, univariate and multivariate analyses were performed to examine the relationship between PN and CLABSIs as well as temporal trends. RESULTS Among 38,674 patients with central lines, 3517 developed CLABSIs and 767 patients were prescribed PN. PN was an independent risk factor for developing CLABSI among our patients (odds ratio [OR], 2.65; 95% confidence interval [CI], 2.20-3.19). The incidence of CLABSI among patients who were prescribed PN was not significantly different across the years of this study, even after adjusting for severity of illness. CONCLUSION PN remains a significant risk factor for CLABSIs; further work is needed to identify effective strategies to reduce rates of CLABSI among patients receiving PN.
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Affiliation(s)
- Gabriela Fonseca
- Mailman School of Public Health, Columbia University, New York, New York
| | - Marissa Burgermaster
- Department of Medicine, Columbia University Medical Center, New York, New York
- Department of Biomedical Informatics, Columbia University Medical Center, New York, New York
| | - Elaine Larson
- Mailman School of Public Health, Columbia University, New York, New York
- Schoolof Nursing, Columbia University, New York, New York
| | - David S Seres
- Department of Medicine, Columbia University Medical Center, New York, New York
- Institute of Human Nutrition, Columbia University Medical Center, New York, New York
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96
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Pediatric Adverse Event Rates Associated With Inexperience in Teaching Hospitals: A Multilevel Analysis. J Healthc Qual 2017; 40:69-78. [PMID: 29271800 DOI: 10.1097/jhq.0000000000000121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
High adverse event rates are a signal of potentially low-quality care that imposes burdens on patients, families, and hospitals. In this article, we examine the relationship between the distinct characteristics of teaching hospitals with adverse event rates among pediatric patients, controlling for patient complexity and severity using 2009-2011 Nationwide Inpatient Sample data from the Agency for Healthcare Research and Quality. We hypothesize that adverse event rates increase with the availability of more complex services and technologies (transplantation and pediatric open-heart surgery); increase as experience of providers decreases (July effect); and increase with residents per bed, a measure of both average provider inexperience and congestion. Using multilevel analysis, we find empirical evidence in support of our three hypotheses. We find that in environments where more learning occurs, more mistakes are made. Identifying high-performing hospitals with large residency programs and complex service lines that have made progress in patient safety and then studying how they have done so should become a priority. These findings should then be adapted within other hospitals through publicly funded mechanisms to improve the quality of care for all children.
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97
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Attributable Cost of Clostridium difficile Infection in Pediatric Patients. Infect Control Hosp Epidemiol 2017; 38:1472-1477. [PMID: 29173236 DOI: 10.1017/ice.2017.240] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The attributable cost of Clostridium difficile infection (CDI) in children is unknown. We sought to determine a national estimate of attributable cost and length of stay (LOS) of CDI occurring during hospitalization in children. DESIGN AND METHODS We analyzed discharge records of patients between 2 and 18 years of age from the Agency for Healthcare Research and Quality (AHRQ) Kids' Inpatient Database. We created a logistic regression model to predict CDI during hospitalization based on demographic and clinical characteristics. Predicted probabilities from the logistic regression model were then used as propensity scores to match 1:2 CDI to non-CDI cases. Charges were converted to costs and compared between patients with CDI and propensity-score-matched controls. In a sensitivity analysis, we adjusted for LOS as a confounder by including it in both the propensity score and a generalized linear model predicting cost. RESULTS We identified 8,527 pediatric hospitalizations (0.53%) with a diagnosis of CDI and 1,597,513 discharges without CDI. In our matched cohorts, the attributable cost of CDI occurring during a hospitalization ranged from $1,917 to $8,317, depending on whether model was adjusted for LOS. When not adjusting for LOS, CDI-associated hospitalizations cost 1.6 times more than non-CDI associated hospitalizations. Attributable LOS of CDI was approximately 4 days. CONCLUSIONS Clostridium difficile infection in hospitalized children is associated with an economic burden similar to adult estimates. This finding supports a continued focus on preventing CDI in children as a priority. Pediatric CDI cost analyses should account for LOS as an important confounder of cost. Infect Control Hosp Epidemiol 2017;38:1472-1477.
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98
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Roham M, Momeni M, Saberi M, Kheirkhah R, Jafarian A, Rahbar H. Epidemiologic analysis of central vein catheter infection in burn patients. IRANIAN JOURNAL OF MICROBIOLOGY 2017; 9:271-276. [PMID: 29296271 PMCID: PMC5748445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Currently, there are no well-defined guidelines or criteria for catheter-site care in burn patients, and there is little information about the epidemiology of central vein catheter (CVC) infection in such patients. This study aimed at addressing the epidemiological aspect of CVC infection in a sample of Iranian burn patients admitted to the largest referral burn center in Iran, Motahari Burn Center. MATERIALS AND METHODS A total of 191 burn patients were eligible for the study. Catheter related blood stream infection (CRBSI) was diagnosed according to suspected line infection, sepsis or blood culture growing bacteria, which could not have been associated with another site. RESULTS Of the 191 patients in this study, 45 males (23.68%) and 19 females (10%) had positive blood culture, confirming CV line infection. Patients who were burned by gas, gasoline ignition or burning Kerosene had the highest incidence of CV line infection. In contrast, patients burned by alcohol, pitch or thinner had the lower rate of CV line infection. Incidence of CV line infection was higher in patients with delay in presentation to the burn center (55.2%) when compared to those who presented without delay (22.8%). Pseudomonas aeruginosa was the most frequent colonizer of the wound culture (52.4%), the dominant strain of the first catheter tip culture (35%) and the dominant strain of the same day blood samples (53.8%). The mortality rate in patients diagnosed with CRBI was 21.9%. CONCLUSION One of the important factors related to CV line infection is delay inpresentation to the burn center. The rate of CV line infection was 20.64 in catheter days.
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Affiliation(s)
- Maryam Roham
- Burn Research Center, Iran University of Medical Sciences, Motahari Burn Hospital, Tehran, Iran
| | - Mahnoush Momeni
- Burn Research Center, Iran University of Medical Sciences, Motahari Burn Hospital, Tehran, Iran,Corresponding author: Dr. Mahnoush Momeni, Burn Research Center, Iran University of Medical Sciences, Motahari Burn Hospital, Tehran, Iran., Tel: ?,
| | - Mohsen Saberi
- Burn Research Center, Iran University of Medical Sciences, Motahari Burn Hospital, Tehran, Iran
| | - Rahil Kheirkhah
- Rowan University Graduate School of Biomedical Sciences, New Jersey, USA
| | - Ali Jafarian
- Burn Research Center, Iran University of Medical Sciences, Motahari Burn Hospital, Tehran, Iran
| | - Hossein Rahbar
- Burn Research Center, Iran University of Medical Sciences, Motahari Burn Hospital, Tehran, Iran
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99
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Ridyard CH, Plumpton CO, Gilbert RE, Hughes DA. Cost-Effectiveness of Pediatric Central Venous Catheters in the UK: A Secondary Publication from the CATCH Clinical Trial. Front Pharmacol 2017; 8:644. [PMID: 28974929 PMCID: PMC5610787 DOI: 10.3389/fphar.2017.00644] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 08/30/2017] [Indexed: 12/16/2022] Open
Abstract
Background: Antibiotic-impregnated central venous catheters (CVCs) reduce the risk of bloodstream infections (BSIs) in patients treated in pediatric intensive care units (PICUs). However, it is unclear if they are cost-effective from the perspective of the National Health Service (NHS) in the UK. Methods: Economic evaluation alongside the CATCH trial (ISRCTN34884569) to estimate the incremental cost effectiveness ratio (ICER) of antibiotic-impregnated (rifampicin and minocycline), heparin-bonded and standard polyurethane CVCs. The 6-month costs of CVCs and hospital admissions and visits were determined from administrative hospital data and case report forms. Results: BSIs were detected in 3.59% (18/502) of patients randomized to standard, 1.44% (7/486) to antibiotic and 3.42% (17/497) to heparin CVCs. Lengths of hospital stay did not differ between intervention groups. Total mean costs (95% confidence interval) were: £45,663 (£41,647-£50,009) for antibiotic, £42,065 (£38,322-£46,110) for heparin, and £44,503 (£40,619-£48,666) for standard CVCs. As heparin CVCs were not clinically effective at reducing BSI rate compared to standard CVCs, they were considered not to be cost-effective. The ICER for antibiotic vs. standard CVCs, of £54,057 per BSI avoided, was sensitive to the analytical time horizon. Conclusions: Substituting standard CVCs for antibiotic CVCs in PICUs will result in reduced occurrence of BSI but there is uncertainty as to whether this would be a cost-effective strategy for the NHS.
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Affiliation(s)
- Colin H Ridyard
- Centre for Health Economics and Medicines Evaluation, Bangor Institute for Health and Medical Research, Bangor UniversityBangor, United Kingdom
| | - Catrin O Plumpton
- Centre for Health Economics and Medicines Evaluation, Bangor Institute for Health and Medical Research, Bangor UniversityBangor, United Kingdom
| | - Ruth E Gilbert
- UCL Institute of Child Health, University College LondonLondon, United Kingdom
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor Institute for Health and Medical Research, Bangor UniversityBangor, United Kingdom
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100
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Lyren A, Brilli RJ, Zieker K, Marino M, Muething S, Sharek PJ. Children's Hospitals' Solutions for Patient Safety Collaborative Impact on Hospital-Acquired Harm. Pediatrics 2017; 140:peds.2016-3494. [PMID: 28814576 DOI: 10.1542/peds.2016-3494] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine if an improvement collaborative of 33 children's hospitals focused on reliable best practice implementation and culture of safety improvements can reduce hospital-acquired conditions (HACs) and serious safety events (SSEs). METHODS A 3-year prospective cohort study design with a 12-month historical control population was completed by the Children's Hospitals' Solutions for Patient Safety collaborative. Identification and dissemination of best practices related to 9 HACs and SSE reduction focused on key process and culture of safety improvements. Individual hospital improvement teams leveraged the resources of a large, structured children's hospital collaborative using electronic, virtual, and in-person interactions. RESULTS Thirty-three children's hospitals from across the United States volunteered to be part of the Children's Hospitals' Solutions for Patient Safety collaborative. Thirty-two met all the data submission eligibility requirements for the HAC improvement objective of this study, and 21 participated in the high-reliability culture work aimed at reducing SSEs. Significant harm reduction occurred in 8 of 9 common HACs (range 9%-71%; P < .005 for all). The mean monthly SSE rate decreased 32% (from 0.77 to 0.52; P < .001). The 12-month rolling average SSE rate decreased 50% (from 0.82 to 0.41; P < .001). CONCLUSIONS Participation in a structured collaborative dedicated to implementing HAC-related best-practice prevention bundles and culture of safety interventions designed to increase the use of high-reliability organization practices resulted in significant HAC and SSE reductions. Structured collaboration and rapid sharing of evidence-based practices and tools are effective approaches to decreasing hospital-acquired harm.
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Affiliation(s)
- Anne Lyren
- Departments of Pediatrics and Bioethics, University Hospitals Rainbow Babies & Children's Hospital, School of Medicine, Case Western Reserve University, Cleveland, Ohio;
| | - Richard J Brilli
- Department of Pediatrics, Nationwide Children's Hospital, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Karen Zieker
- Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Miguel Marino
- Departments of Family Medicine and Public Health and Preventive Medicine, Oregon Health & Science University, Portland, Oregon
| | - Stephen Muething
- Cincinnati Children's Medical Center, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Paul J Sharek
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, School of Medicine, Stanford University, Palo Alto, California
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