1
|
Heath M, Bernstein SJ, Paje D, McLaughlin E, Horowitz JK, McKenzie A, Leyden T, Flanders SA, Chopra V. Improving Appropriate Use of Peripherally Inserted Central Catheters Through a Statewide Collaborative Hospital Initiative: A Cost-Effectiveness Analysis. Jt Comm J Qual Patient Saf 2024; 50:591-600. [PMID: 38762387 DOI: 10.1016/j.jcjq.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 03/29/2024] [Accepted: 04/03/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Quality improvement (QI) programs require significant financial investment. The authors evaluated the cost-effectiveness of a physician-led, performance-incentivized, QI intervention that increased appropriate peripherally inserted central catheter (PICC) use. METHODS The authors used an economic evaluation from a health care sector perspective. Implementation costs included incentive payments to hospitals and costs for data abstractors and the coordinating center. Effectiveness was calculated from propensity score-matched observations across two time periods for complications (venous thromboembolism [VTE], central line-associated bloodstream infection [CLABSI], and catheter occlusion): preintervention period (January 2015 through December 2016) and intervention period (January 2017 through December 2021). Cost-effectiveness was presented as the cost-offset per averted complication, reflecting the health care costs avoided due to having lower complication rates. RESULTS Across 35 hospitals, this study sampled 17,418 PICCs placed preintervention and 26,004 placed during the intervention period. PICC complications decreased significantly following the intervention. CLABSIs decreased from 2.1% to 1.5%, VTEs from 3.2% to 2.3%, and catheter occlusions from 10.8% to 7.0% (all p < 0.01). Estimated number of complications prevented included 871 CLABSIs, 2,535 VTEs, and 8,743 catheter occlusions. Project implementation costs were $31.8 million, and the cost-offset related to avoided complications was $64.4 million. Each participating hospital averaged $932,073 in cost-offset over seven years, and the average cost-offset per complication averted was $2,614 (95% CI [confidence interval] $2,314-$3,003). CONCLUSION A large-scale, multihospital QI initiative to improve appropriate PICC use yielded substantial return on investment from cost-offset of prevented complications.
Collapse
|
2
|
Xu D, Hu C, Xiong J, Huang H, Wang S, Ding X, Zhou J, Deng J, Guo C, Li M, You T, Cheng W, Li B, Tang X, Li X, Li H, Li J, Ma J, Xiao M, Fu X, Li H, Peng Z, Hu B, Hu F. Effect of Infusion Set Replacement Intervals on Central Line-Associated Bloodstream Infection in the Intensive Care Unit: Study Protocol of the INSPIRATION Study. Infect Dis Ther 2024; 13:941-951. [PMID: 38483776 PMCID: PMC11058178 DOI: 10.1007/s40121-024-00953-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 02/26/2024] [Indexed: 04/30/2024] Open
Abstract
INTRODUCTION The replacement intervals for infusion sets may differ among healthcare institutions, which may have an impact on the occurrence of central line-associated bloodstream infections (CLABSI). Nevertheless, there exists a limited amount of high-quality evidence available to assist clinicians in determining the most suitable replacement intervals for infusion sets. Therefore, the objective of this trial is to compare the efficacy of 24-h and 96-h replacement intervals for infusion sets on CLABSI among critically ill adults who have central venous access devices. METHODS This is a multicenter, parallel-group randomized controlled trial that will investigate the effect of infusion set replacement intervals on CLABSI in adult patients admitted to intensive care units (ICUs). The study will enroll 1240 participants who meet the inclusion criteria, which includes being 18 years or older, expected to stay in the ICU for longer than 96 h, and in need of central venous access. Participants will be randomly assigned to either a control group receiving a 96-h replacement interval or a treatment group receiving a 24-h replacement interval. PLANNED OUTCOME The primary outcome of this trial is the rate of CLABSI within 28 days after randomization. CONCLUSION This is the first randomized controlled trial to investigate the effects of infusion set replacement at 24-h and 96-h intervals on CLABSI in ICU patients. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT05359601.
Collapse
Affiliation(s)
- Dandan Xu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Chang Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Jie Xiong
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Haiyan Huang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shasha Wang
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China
| | - Xinbo Ding
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Junying Zhou
- Department of Laboratory Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Juan Deng
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Chunling Guo
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Miqi Li
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Ting You
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Wei Cheng
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Bo Li
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiaoqin Tang
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China
| | - Xiaohong Li
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China
| | - Hongmei Li
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China
| | - Jin Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Jing Ma
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Meng Xiao
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Xing Fu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Huilin Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Zhiyong Peng
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China.
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, 430071, Hubei, China.
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China.
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, 430071, Hubei, China.
| | - Fen Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China.
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, 430071, Hubei, China.
| |
Collapse
|
3
|
Okhovatian S, Shakeri A, Huyer LD, Radisic M. Elastomeric Polyesters in Cardiovascular Tissue Engineering and Organs-on-a-Chip. Biomacromolecules 2023; 24:4511-4531. [PMID: 37639715 PMCID: PMC10915885 DOI: 10.1021/acs.biomac.3c00387] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Cardiovascular tissue constructs provide unique design requirements due to their functional responses to substrate mechanical properties and cyclic stretching behavior of cardiac tissue that requires the use of durable elastic materials. Given the diversity of polyester synthesis approaches, an opportunity exists to develop a new class of biocompatible, elastic, and immunomodulatory cardiovascular polymers. Furthermore, elastomeric polyester materials have the capability to provide tailored biomechanical synergy with native tissue and hence reduce inflammatory response in vivo and better support tissue maturation in vitro. In this review, we highlight underlying chemistry and design strategies of polyester elastomers optimized for cardiac tissue scaffolds. The major advantages of these materials such as their tunable elasticity, desirable biodegradation, and potential for incorporation of bioactive compounds are further expanded. Unique fabrication methods using polyester materials such as micromolding, 3D stamping, electrospinning, laser ablation, and 3D printing are discussed. Moreover, applications of these biomaterials in cardiovascular organ-on-a-chip devices and patches are analyzed. Finally, we outline unaddressed challenges in the field that need further study to enable the impactful translation of soft polyesters to clinical applications.
Collapse
Affiliation(s)
- Sargol Okhovatian
- Institute of Biomaterials Engineering; University of Toronto; Toronto; Ontario, M5S 3G9; Canada
- Toronto General Research Institute, Toronto; Ontario, M5G 2C4; Canada
| | - Amid Shakeri
- Institute of Biomaterials Engineering; University of Toronto; Toronto; Ontario, M5S 3G9; Canada
- Toronto General Research Institute, Toronto; Ontario, M5G 2C4; Canada
| | - Locke Davenport Huyer
- Department of Applied Oral Sciences, Faculty of Dentistry, Dalhousie University, Halifax, Nova Scotia B3H 4R2, Canada
- School of Biomedical Engineering, Faculties of Medicine and Engineering, Dalhousie University, Halifax, Nova Scotia B3H 4R2, Canada
- Department of Microbiology & Immunology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia B3H 4R2, Canada
| | - Milica Radisic
- Institute of Biomaterials Engineering; University of Toronto; Toronto; Ontario, M5S 3G9; Canada
- Toronto General Research Institute, Toronto; Ontario, M5G 2C4; Canada
- Department of Chemical Engineering and Applied Chemistry; University of Toronto; Toronto; Ontario, M5S 3E5; Canada
| |
Collapse
|
4
|
Benenson S, Ben-Yosef Y, Schwartz C, Cohen MJ, Oster Y. Sources of primary bloodstream infections in internal medicine patients - a cohort study. Eur J Intern Med 2023; 113:69-74. [PMID: 37117089 DOI: 10.1016/j.ejim.2023.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/20/2023] [Accepted: 04/22/2023] [Indexed: 04/30/2023]
Abstract
PURPOSE To describe the sources of bloodstream infections (BSIs) in internal-medicine patients, on admission and during hospitalization, and to determine the proportion of BSIs in which no secondary cause could be defined (i.e., primary-BSI). METHODS We analyzed all BSIs at the internal-medicine wards of the two campuses of the Hadassah Hebrew-University Medical Center, during 2017-2018. We defined the BSI source of each event (secondary, Central-line associated BSI (CLABSI) or primary non-CLABSI) and compared BSIs present on admission (POA) to hospital acquired (HA). RESULTS There were 595 patient-unique BSI events, 316 (53.1%) POA-BSI and 279 (46.9%) HA-BSI. Overall, 309 (51.9%) were secondary, 194 (32.6%) primary non-CLABSI and 92 (15.5%) CLABSI. Primary non-CLABSI in the POA-BSI group was 20.6% vs. 46.2% in the HA-BSI group (p = 0.001). The length of hospital stay (LOS) of the HA-BSI group was longer than in the POA-BSI group (mean LOS, 19 days vs. 13.6 days, p = 0.01) and mortality rate was higher (48.7% vs. 19%, p = 0.001). Staphylococcus aureus was more common in primary non-CLABSI than in CLABSI and secondary BSI (29.5%, 12.8% and 16.2%, respectively). CONCLUSIONS The proportion of primary non-CLABSI among HA-BSI events is very high (46.2%). The absence of any plausible source for these BSIs, and the fact that in our hospital more than 90% of patients in medicine wards have peripheral lines, suggests that these may be a possible source for primary non-CLABSIs. Measures to prevent peripheral-line associated BSI (PLABSI), like those implemented successfully for the prevention of CLABSI, should be considered.
Collapse
Affiliation(s)
- Shmuel Benenson
- Faculty of Medicine, Hebrew University of Jerusalem, Israel; Department of Clinical Microbiology and Infectious Diseases, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | | | - Carmela Schwartz
- Faculty of Medicine, Hebrew University of Jerusalem, Israel; Department of Clinical Microbiology and Infectious Diseases, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Matan J Cohen
- Faculty of Medicine, Hebrew University of Jerusalem, Israel; Clalit Health Services, Jerusalem District, Affiliated With The Hebrew University, 1 Ygal Alon St, Bet Shemesh, Jerusalem, Israel.
| | - Yonatan Oster
- Faculty of Medicine, Hebrew University of Jerusalem, Israel; Department of Clinical Microbiology and Infectious Diseases, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| |
Collapse
|
5
|
King B, Patel RM. Using Quality Improvement to Improve Value and Reduce Waste. Clin Perinatol 2023; 50:489-506. [PMID: 37201993 DOI: 10.1016/j.clp.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Value is defined as health outcomes achieved per dollar spent. Addressing value in quality improvement (QI) efforts can help optimize patient outcomes while reducing unnecessary spending. In this article, we discuss how QI focused on reducing morbidities frequently reduces costs, and how proper cost accounting can help demonstrate improvements in value. We provide examples of high-yield opportunities for value improvement in neonatology and review the literature associated with these topics. Opportunities include reducing neonatal intensive care admissions for low-acuity infants, sepsis evaluations in low-risk infants, unnecessary total parental nutrition use, and utilization of laboratory and imaging.
Collapse
Affiliation(s)
- Brian King
- Department of Pediatrics, University of Pittsburg School of Medicine.
| | - Ravi M Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive, NE, Atlanta, GA 30322, USA
| |
Collapse
|
6
|
Kotwal S, Cass A, Coggan S, Gray NA, Jan S, McDonald S, Polkinghorne KR, Rogers K, Talaulikar G, Di Tanna GL, Gallagher M. Multifaceted intervention to reduce haemodialysis catheter related bloodstream infections: REDUCCTION stepped wedge, cluster randomised trial. BMJ 2022; 377:e069634. [PMID: 35414532 PMCID: PMC9002320 DOI: 10.1136/bmj-2021-069634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To identify whether multifaceted interventions, or care bundles, reduce catheter related bloodstream infections (CRBSIs) from central venous catheters used for haemodialysis. DESIGN Stepped wedge, cluster randomised design. SETTING 37 renal services across Australia. PARTICIPANTS All adults (age ≥18 years) under the care of a renal service who required insertion of a new haemodialysis catheter. INTERVENTIONS After a baseline observational phase, a service-wide, multifaceted intervention bundle that included elements of catheter care (insertion, maintenance, and removal) was implemented at one of three randomly assigned time points (12 at the first time point, 12 at the second, and 13 at the third) between 20 December 2016 and 31 March 2020. MAIN OUTCOMES MEASURE The primary endpoint was the rate of CRBSI in the baseline phase compared with intervention phase at the renal service level using the intention-to-treat principle. RESULTS 1.14 million haemodialysis catheter days of use were monitored across 6364 patients. Patient characteristics were similar across baseline and intervention phases. 315 CRBSIs occurred (158 in the baseline phase and 157 in the intervention phase), with a rate of 0.21 per 1000 days of catheter use in the baseline phase and 0.29 per 1000 days in the intervention phase, giving an incidence rate ratio of 1.37 (95% confidence interval 0.85 to 2.21; P=0.20). This translates to one in 10 patients who undergo dialysis for a year with a catheter experiencing an episode of CRBSI. CONCLUSIONS Among patients who require a haemodialysis catheter, the implementation of a multifaceted intervention did not reduce the rate of CRBSI. Multifaceted interventions to prevent CRBSI might not be effective in clinical practice settings. TRIAL REGISTRATION Australia New Zealand Clinical Trials Registry ACTRN12616000830493.
Collapse
Affiliation(s)
- Sradha Kotwal
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Prince of Wales Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Sarah Coggan
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Nicholas A Gray
- Sunshine Coast University Hospital, Birtinya, QLD, Australia
- Department of Health and Behavioural Science,University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Stephen Jan
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Stephen McDonald
- ANZDATA Registry, South Australia Health and Medical Research Institute, Adelaide, SA, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Renal Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Kevan R Polkinghorne
- Department of Epidemiology and Preventive Medicine, Monash University, VIC, Australia
- Departments of Nephrology and Medicine, Monash Medical Centre, Monash University, VIC, Australia
| | - Kris Rogers
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
- School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Gian Luca Di Tanna
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Martin Gallagher
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, NSW, Sydney, Australia
| |
Collapse
|
7
|
Central line-associated bloodstream infections, multidrug-resistant bacteraemias and infection control interventions: a six-year time-series analysis in a tertiary-care hospital in Greece. J Hosp Infect 2022; 123:27-33. [PMID: 35149172 DOI: 10.1016/j.jhin.2022.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/27/2022] [Accepted: 01/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSI) are serious healthcare-associated infections with substantial morbidity and hospital costs. AIM To investigate the association between the incidence of CLABSI, the implementation of specific infection control measures, and the incidence of multidrug-resistant (MDR) bacteraemias in a tertiary-care hospital in Greece from 2013-2018. METHODS Analysis was applied for the following monthly calculated indices: 1.CLABSI rate, 2.use of hand hygiene disinfectants, 3.isolation rate of patients with MDR bacteria, 4.incidence of bacteraemias [total resistant Gram-negative: carbapenem-resistant (CR) Acinetobacter baumanii, Pseudomonas aeruginosa, Klebsiella pneumoniae and/or Gram-positive: meticillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci]. FINDINGS Total bacteraemias from CR-Gram-negative pathogens statistically correlated with increased CLABSI rate in total Hospital Departments (IRR: 1.17, 95% CI: 1.05-1.31, p-value: 0.006) and Adults ICU (IRR: 1.37, 95%CI: 1.07-1.75, p-value: 0.013). In Adults ICU, every increase in the incidence of each resistant Gram-negative pathogen significantly correlated with decreased CLABSI rate (CR-A. baumanii: IRR: 0.59, 95%CI: 0.39-0.90, p-value=0.015; CR-K. pneumoniae: IRR: 0.48, 95%CI: 0.25-0.94, p-value=0.031; CR-P. aeruginosa: IRR: 0.54, 95%CI: 0.33-0.89, p-value=0.015). The use of hand disinfectants correlated with decreased CLABSI rate 1-3 months before the application of this intervention, in total Hospital Departments (IRR: 0.80, 95%CI: 0.69-0.93, p-value: 0.005), and for scrub disinfectants the current month in Adults ICU (IRR: 0.34, 95%CI: 0.11-1.03, p-value: 0.057). Isolation of patients with MDR pathogens was not associated with CLABSI incidence. CONCLUSION Hand hygiene was associated with a significant reduction of CLABSI incidence in our hospital. Time-series analysis is an important tool to evaluate infection control interventions.
Collapse
|
8
|
McCleskey SG, Shek L, Grein J, Gotanda H, Anderson L, Shekelle PG, Keeler E, Morton S, Nuckols TK. Economic evaluation of quality improvement interventions to prevent catheter-associated urinary tract infections in the hospital setting: a systematic review. BMJ Qual Saf 2021; 31:308-321. [PMID: 34824163 DOI: 10.1136/bmjqs-2021-013839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 11/05/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Hospitals have implemented diverse quality improvement (QI) interventions to reduce rates of catheter-associated urinary tract infections (CAUTIs). The economic value of these QI interventions is uncertain. OBJECTIVE To systematically review economic evaluations of QI interventions designed to prevent CAUTI in acute care hospitals. METHODS A search of Ovid MEDLINE, Econlit, Centre for Reviews & Dissemination, New York Academy of Medicine's Grey Literature Report, WorldCat, IDWeek conference abstracts and prior systematic reviews was conducted from January 2000 to October 2020.We included English-language studies of any design that evaluated organisational or structural changes to prevent CAUTI in acute care hospitals, and reported programme and infection-related costs.Dual reviewers assessed study design, effectiveness, costs and study quality. For each eligible study, we performed a cost-consequences analysis from the hospital perspective, estimating the incidence rate ratio (IRR) and incremental net cost/savings per hospital over 3 years. Unadjusted weighted regression analyses tested predictors of these measures, weighted by catheter days per study. RESULTS Fifteen unique economic evaluations were eligible, encompassing 74 hospitals. Across 12 studies amenable to standardisation, QI interventions were associated with a 43% decline in infections (mean IRR 0.57, 95% CI 0.44 to 0.70) and wide ranges of net costs (mean US$52 000, 95% CI -$288 000 to $392 000), relative to usual care. CONCLUSIONS QI interventions were associated with large declines in infection rates and net costs to hospitals that varied greatly but that, on average, were not significantly different from zero over 3 years. Future research should examine specific practices associated with cost-savings and clinical effectiveness, and examine whether or not more comprehensive interventions offer hospitals and patients the best value.
Collapse
Affiliation(s)
- Sara G McCleskey
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA .,Health Policy & Management, UCLA, Los Angeles, California, USA
| | - Lili Shek
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jonathan Grein
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Hiroshi Gotanda
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Laura Anderson
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.,Center for Observational Research, Amgen, Thousand Oaks, California, USA
| | - Paul G Shekelle
- Department of Medicine, West Los Angeles Vet Administration, Los Angeles, California, USA.,RAND Corporation, Santa Monica, California, USA
| | | | - Sally Morton
- Knowledge Enterprise, Arizona State University, Tempe, Arizona, USA
| | - Teryl K Nuckols
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.,RAND Corporation, Santa Monica, California, USA
| |
Collapse
|
9
|
Soop M. Extending infusion set replacement intervals to preserve resources and reduce waste. Lancet 2021; 397:1420-1421. [PMID: 33865481 DOI: 10.1016/s0140-6736(21)00791-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/31/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Mattias Soop
- Department of Surgery, Ersta Hospital, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden.
| |
Collapse
|
10
|
Benichou N, Lebbah S, Hajage D, Martin-Lefèvre L, Pons B, Boulet E, Boyer A, Chevrel G, Lerolle N, Carpentier D, de Prost N, Lautrette A, Bretagnol A, Mayaux J, Nseir S, Megarbane B, Thirion M, Forel JM, Maizel J, Yonis H, Markowicz P, Thiery G, Schortgen F, Tubach F, Ricard JD, Dreyfuss D, Gaudry S. Vascular access for renal replacement therapy among 459 critically ill patients: a pragmatic analysis of the randomized AKIKI trial. Ann Intensive Care 2021; 11:56. [PMID: 33830370 PMCID: PMC8032839 DOI: 10.1186/s13613-021-00843-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/24/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Vascular access for renal replacement therapy (RRT) is routine question in the intensive care unit. Randomized trials comparing jugular and femoral sites have shown similar rate of nosocomial events and catheter dysfunction. However, recent prospective observational data on RRT catheters use are scarce. We aimed to assess the site of RRT catheter, the reasons for catheter replacement, and the complications according to site in a large population of critically ill patients with acute kidney injury. PATIENTS AND METHODS We performed an ancillary study of the AKIKI study, a pragmatic randomized controlled trial, in which patients with severe acute kidney injury (KDIGO 3 classification) with invasive mechanical ventilation, catecholamine infusion or both were randomly assigned to either an early or a delayed RRT initiation strategy. The present study involved all patients who underwent at least one RRT session. Number of RRT catheters, insertion sites, factors potentially associated with the choice of insertion site, duration of catheter use, reason for catheter replacement, and complications were prospectively collected. RESULTS Among the 619 patients included in AKIKI, 462 received RRT and 459 were finally included, with 598 RRT catheters. Femoral site was chosen preferentially (n = 319, 53%), followed by jugular (n = 256, 43%) and subclavian (n = 23, 4%). In multivariate analysis, continuous RRT modality was significantly associated with femoral site (OR = 2.33 (95% CI (1.34-4.07), p = 0.003) and higher weight with jugular site [88.9 vs 83.2 kg, OR = 0.99 (95% CI 0.98-1.00), p = 0.03]. Investigator site was also significantly associated with the choice of insertion site (p = 0.03). Cumulative incidence of catheter replacement did not differ between jugular and femoral site [sHR 0.90 (95% CI 0.64-1.25), p = 0.67]. Catheter dysfunction was the main reason for replacement (n = 47), followed by suspected infection (n = 29) which was actually seldom proven (n = 4). No mechanical complication (pneumothorax or hemothorax) occurred. CONCLUSION Femoral site was preferentially used in this prospective study of RRT catheters in 31 French intensive care units. The choice of insertion site depended on investigating center habits, weight, RRT modality. A high incidence of catheter infection suspicion led to undue replacement.
Collapse
Affiliation(s)
- Nicolas Benichou
- AP-HP, Hôpital Européen Georges Pompidou, Service de Néphrologie, 75015, Paris, France.,Université de Paris, Paris, France.,French National Institute of Health and Medical Research (INSERM), UMR_S1155, Remodeling and Repair of Renal Tissue, Hôpital Tenon, Sorbonne Université, 75020, Paris, France
| | - Saïd Lebbah
- Département de Biostatistiques, Santé Publique Et Information Médicale, AP-HP, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - David Hajage
- Département de Biostatistiques, Santé Publique Et Information Médicale, AP-HP, Hôpital Pitié-Salpêtrière, 75013, Paris, France.,INSERM, ECEVE, U1123, CIC 1421, F-75013, Paris, France.,Faculté de Médecine Sorbonne, Sorbonne Université, Université, Paris, France
| | | | - Bertrand Pons
- Service de Réanimation, CHU de Pointe À Pitre-Abymes, CHU de La Guadeloupe, Pointe-à-Pitre, France
| | - Eric Boulet
- Réanimation Polyvalente, CH René Dubos, 95301, Pontoise, France
| | - Alexandre Boyer
- Réanimation Médicale CHU Bordeaux, Hôpital Pellegrin, 33000, Bordeaux, France
| | - Guillaume Chevrel
- Service de Réanimation, Centre Hospitalier Sud Francilien, Corbeil Essonne, France
| | - Nicolas Lerolle
- Département de Réanimation Médicale Et Médecine Hyperbare, CHU Angers, Université D'Angers, Angers, France
| | | | - Nicolas de Prost
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, DHU A-TVB, Service de Réanimation Médicale, Créteil, France.,CARMAS Research Group and UPEC-Université Paris-Est Créteil Val de Marne, Créteil, France
| | - Alexandre Lautrette
- Réanimation Médicale, Hôpital Gabriel Montpied, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Anne Bretagnol
- Réanimation Médico-Chirurgicale, Hôpital de La Source, Centre Hospitalier Régional D'Orléans, BP 6709, 45067, Orléans Cedex, France
| | - Julien Mayaux
- Service de Pneumologie Et Réanimation Médicale, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Saad Nseir
- Centre de Réanimation, CHU de Lille, Faculté de Médecine, Université de Lille, 59000, Lille, France
| | - Bruno Megarbane
- Réanimation Médicale Et Toxicologique, Hôpital Lariboisière, INSERM U1144, Université Paris-Diderot, Paris, France
| | - Marina Thirion
- Réanimation Polyvalente, CH Victor Dupouy, 95107, Argenteuil Cedex, France
| | - Jean-Marie Forel
- Service de Réanimation Des Détresses Respiratoires Aiguës Et Infections Sévères, Hôpital Nord Marseille, 13015, Marseille, France
| | - Julien Maizel
- Service de Réanimation Médicale INSERM U1088, Centre Hospitalier Universitaire de Picardie, Amiens, France
| | - Hodane Yonis
- Réanimation Médicale, Hôpital de La Croix Rousse, 69004, Lyon, France
| | | | - Guillaume Thiery
- Service de Réanimation, CHU de Pointe À Pitre-Abymes, CHU de La Guadeloupe, Pointe-à-Pitre, France
| | - Frederique Schortgen
- Centre Hospitalier Inter-Communal, Service de Réanimation Polyvalente Adulte, Créteil, France
| | - Florence Tubach
- Département de Biostatistiques, Santé Publique Et Information Médicale, AP-HP, Hôpital Pitié-Salpêtrière, 75013, Paris, France.,INSERM, ECEVE, U1123, CIC 1421, F-75013, Paris, France.,Univ Pierre Et Marie Curie, Sorbonne Universités, 75013, Paris, France
| | - Jean-Damien Ricard
- Univ Paris Diderot, Sorbonne Paris Cité, IAME, UMRS 1137, 75018, Paris, France.,AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, 92700, Colombes, France
| | - Didier Dreyfuss
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, 92700, Colombes, France.,Université de Paris, Paris, France.,French National Institute of Health and Medical Research (INSERM), UMR_S1155, Remodeling and Repair of Renal Tissue, Hôpital Tenon, Sorbonne Université, 75020, Paris, France
| | - Stéphane Gaudry
- French National Institute of Health and Medical Research (INSERM), UMR_S1155, Remodeling and Repair of Renal Tissue, Hôpital Tenon, Sorbonne Université, 75020, Paris, France. .,AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Avicenne, 93008, Bobigny, France. .,Service de Réanimation Médico-Chirurgicale, Hôpital Avicenne, 125 Rue de Stalingrad, 93000, Bobigny, France.
| |
Collapse
|
11
|
Wang Z, Wei X, Qin T, Chen S, Liao X, Guo W, Hu P, Wu Y, Li J, Liao Y, Wang S. Prognostic value of central venous-to-arterial carbon dioxide difference in patients with bloodstream infection. Int J Med Sci 2021; 18:929-935. [PMID: 33456350 PMCID: PMC7807196 DOI: 10.7150/ijms.51447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/17/2020] [Indexed: 11/18/2022] Open
Abstract
Background: Bloodstream infection (BSI) are prone to circulation disorders, which portend poor outcome. The central venous-to-arterial carbon dioxide difference (Pcv-aCO2) is a biomarker for circulation disorders, but the prognostic value of Pcv-aCO2 in BSI patients remains unclear. This study was to investigate the association of Pcv-aCO2 with adverse events in BSI patients. Methods: The patients with BSI between August 2014 and August 2017 were prospectively enrolled. Clinical characteristic and laboratory results were collected. We analyzed the association of the level of Pcv-aCO2 with clinical variables and 28-day mortality. Results: A total of 152 patients were enrolled. The Pcv-aCO2 was positively correlated with white blood cell count (r=0.241, p=0.003), procalcitonin (r=0.471, p<0.001), C-reactive protein (r=0.192, p=0.018), lactate (r=0.179, p=0.027), Sequential Organ Failure Assessment (r=0.318, p<0.001) and Acute Physiology And Chronic Health Evaluation II score (r=0.377, p<0.001), while that was negatively correlated with central venous oxygen saturation (r=-0.242, p<0.001) and platelet (r=-0.205, p=0.011). Kaplan-Meier curves demonstrated that patients with Pcv-aCO2 >6mmHg had a worse prognosis than those without (log rank=32.10, p<0.001). Multivariate analysis showed Level of Pcv-aCO2 was an independent risk factor for 28-day mortality (HR: 3.10, 95% CI: 1.43-6.74, p=0.004). The area under the receiver operating characteristic curve of Pcv-aCO2 for prediction of 28-day mortality in patients with BSI was 0.794. Pcv-aCO2>6 mmHg had 81.1% sensitivity and 78.8% specificity for predicting 28-day mortality. Conclusion: Pcv-aCO2 may be a simple and valuable biomarker to assessment of 28-day mortality in patients with BSI.
Collapse
Affiliation(s)
- Zhonghua Wang
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Xuebiao Wei
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Tiehe Qin
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Shenglong Chen
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Xiaolong Liao
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Weixin Guo
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Peihang Hu
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Yan Wu
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Jie Li
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Youwan Liao
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Shouhong Wang
- Department of Critical Care Medicine, Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| |
Collapse
|
12
|
A Retrospective Study of Infection in Patients Requiring Extracorporeal Membrane Oxygenation Support. Ann Thorac Surg 2020; 112:1168-1175. [PMID: 33359722 DOI: 10.1016/j.athoracsur.2020.12.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 12/02/2020] [Accepted: 12/08/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Healthcare-associated infections (HAIs) in critically ill patients are a serious public health problem. Extracorporeal membrane oxygenation (ECMO) has been used increasingly for patients with severe cardiac or respiratory failure, but it may increase HAI risk. The goal of our study was to characterize HAIs in ECMO patients at an ECMO referral center. METHODS This institutional review board-approved study identified all consecutive adult ECMO patients admitted to the cardiac surgery intensive care unit (CSICU) between January 1, 2015, and December 31, 2017. Demographic data, diagnosis, ECMO cannulation technique, and survival were collected. Urinary tract infection, pneumonia, and bacteremia incidence during ECMO and within 3 months of decannulation were collected. Outcomes of patients with HAIs were compared with noninfected patients, the CSICU infection incidence, and overall Extracorporeal Life Support Organization survival data. RESULTS There were 288 ECMO patients and 3396 CSICU admissions during this period. Survival was 72.3% for venoarterial ECMO, 85.3% for venovenous ECMO, and 57.1% for multimodality or veno-arteriovenous ECMO, with discharge survival of 60.2%, 72.0%, and 28.6%, respectively. Bacteremia incidence while cannulated was 6.8% for venoarterial ECMO and 9.3% for venovenous ECMO. Bacteremia occurred in 22 of 288 (7.6%) ECMO patients, compared with 48 of 3109 (1.5%) in non-ECMO CSICU patients, which was statistically significant (P < .002). Bacteremia and pneumonia were associated with decreased VA-ECMO survival, with prolonged overall requirements for ECMO support. CONCLUSIONS Nosocomial ECMO infections are significantly higher than in other CSICU patients. Infection risk remains significant even after decannulation. Infection is associated with increased mortality and longer duration of ECMO support. Further efforts are needed to determine HAI reduction strategies in this high-risk patient population.
Collapse
|
13
|
Mathur P, Khurana S, Kumar S, Gupta D, Aggrawal R, Soni KD, Goyal K, Sokhal N, Singh GP, Bindra A, Sagar S, Farooque K, Sharma V, Trikha V, Gupta A, Trikha A, Malhotra R. Device associated infections at a trauma surgical center of India: Trend over eight years. Indian J Med Microbiol 2020; 39:15-18. [PMID: 33610250 DOI: 10.1016/j.ijmmb.2020.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Device-associated infections (DAIs) are an important cause of excessive stay and mortality in ICUs. Trauma patients are predisposed to acquire such infections due to various factors. The prevalence of HAIs is underreported from developing nations due to a lack of systematic surveillance. This study reports the rates and outcomes of DAIs at a dedicated Trauma Center in trauma patients and compares the rates with a previous pilot observation. METHODS The study reports the finding of ongoing surveillance and the use of an indigenous software at a level-1 trauma center in India. Surveillance for ventilator-associated pneumonia, central line-associated bloodstream infections, and catheter-associated urinary tract infections was done based on standard definitions. The rates of HAIs and the profile of pathogens isolated from June 2010 to December 2018 were analyzed. RESULTS A total of 7485 patients were included in the analysis, amounting to 68,715 patient days. The rates of VAP, CLABSI, and CA-UTI were respectively 12, 9.8 1st 8.5/1000 device days. There was a significant correlation between device days and the propensity to develop infections. Of the 1449 isolates recovered from cases of DAIs, Acinetobacter sp (28.2%) was the most common isolate, followed by Candida sp. A high rate of multi-resistance was observed. CONCLUSION Automated surveillance was easy and useful for data entry and analysis. Surveillance data should be used for implementing preventive programs.
Collapse
Affiliation(s)
- Purva Mathur
- Department of Laboratory Medicine, JPNA Trauma Centre, AIIMS, New Delhi, India.
| | - Surbhi Khurana
- Department of Laboratory Medicine, JPNA Trauma Centre, AIIMS, New Delhi, India.
| | - Subodh Kumar
- Department of Surgery, JPNA Trauma Centre, AIIMS, New Delhi, India.
| | - Deepak Gupta
- Department of Neurosurgery, JPNA Trauma Centre, AIIMS, New Delhi, India.
| | - Richa Aggrawal
- Department of Critical and Intensive Care, JPNA Trauma Centre, AIIMS, New Delhi, India.
| | - Kapil Dev Soni
- Department of Critical and Intensive Care, JPNA Trauma Centre, AIIMS, New Delhi, India.
| | - Keshav Goyal
- Department of Neuroanaesthesia, JPNA Trauma Centre, AIIMS, New Delhi, India.
| | - Navdeep Sokhal
- Department of Neuroanaesthesia, JPNA Trauma Centre, AIIMS, New Delhi, India.
| | - Gyanendra Pal Singh
- Department of Neuroanaesthesia, JPNA Trauma Centre, AIIMS, New Delhi, India.
| | - Ashish Bindra
- Department of Neuroanaesthesia, JPNA Trauma Centre, AIIMS, New Delhi, India.
| | - Sushma Sagar
- Department of Surgery, JPNA Trauma Centre, AIIMS, New Delhi, India.
| | - Kamran Farooque
- Department of Orthopaedics, Chief, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India.
| | - Vijay Sharma
- Department of Orthopaedics, Chief, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India.
| | - Vivek Trikha
- Department of Orthopaedics, Chief, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India.
| | - Amit Gupta
- Department of Surgery, JPNA Trauma Centre, AIIMS, New Delhi, India.
| | - Anjan Trikha
- Anesthesiology, Pain Medicine and Critical Care, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India.
| | - Rajesh Malhotra
- Department of Orthopaedics, Chief, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India.
| |
Collapse
|
14
|
Wax DB. In Response. Anesth Analg 2020; 131:e161. [DOI: 10.1213/ane.0000000000004973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
15
|
Kotwal S, Coggan S, McDonald S, Talaulikar G, Cass A, Jan S, Polkinghorne KR, Gray NA, Gallagher M. REDUcing the burden of dialysis Catheter ComplicaTIOns: a National approach (REDUCCTION) - design and baseline results. KIDNEY360 2020; 1:746-754. [PMID: 35372959 PMCID: PMC8815740 DOI: 10.34067/kid.0001132020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/29/2020] [Indexed: 04/13/2023]
Abstract
Background Patients with hemodialysis central venous catheters (HD CVCs) are susceptible to health care-associated infections, particularly hemodialysis catheter-related bloodstream infection (HD-CRBSI), which is associated with high mortality and health care costs. There have been few systematic attempts to reduce this burden and clinical practice remains highly variable. This manuscript will summarize the challenges in preventing HD-CRBSI and describe the methodology of the REDUcing the burden of dialysis Catheter ComplicaTIOns: a National approach (REDUCCTION) trial. Methods The REDUCCTION trial is a stepped-wedge cluster randomized trial of a suite of clinical interventions aimed at reducing HD-CRBSI across Australia. It clusters the intervention at the renal-service level with implementation randomly timed across three tranches. The primary outcome is the effect of this intervention upon the rate of HD-CRBSI. Patients who receive an HD CVC at a participating renal service are eligible for inclusion. A customized data collection tool allows near-to-real-time reporting of the number of active catheters, total exposure to catheters over time, and rates of HD-CRBSI in each service. The interventions are centered around the insertion, maintenance, and removal of HD CVC, informed by the most current evidence at the time of design (mid-2018). Results A total of 37 renal services are participating in the trial. Data collection is ongoing with results expected in the last quarter of 2020. The baseline phase of the study has collected provisional data on 5385 catheters in 3615 participants, representing 603,506 days of HD CVC exposure. Conclusions The REDUCCTION trial systematically measures the use of HD CVCs at a national level in Australia, accurately determines the rate of HD-CRBSI, and tests the effect of a multifaceted, evidence-based intervention upon the rate of HD-CRBSI. These results will have global relevance in nephrology and other specialties commonly using CVCs.
Collapse
Affiliation(s)
- Sradha Kotwal
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Nephrology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Sarah Coggan
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | | | - Girish Talaulikar
- Renal Services, ACT Health, Canberra, Australian Capital Territory, Australia
- Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Kevan R. Polkinghorne
- Department of Epidemiology and Preventive Medicine, Monash University, Prahran, Victoria, Australia
- Departments of Nephrology and Medicine, Monash Medical Centre, Monash University, Clayton, Victoria, Australia
| | - Nicholas A. Gray
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia
- University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - Martin Gallagher
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
16
|
von Itzstein MS, Gupta A, Kernstine KH, Mara KC, Khanna S, Gerber DE. Increased reporting but decreased mortality associated with adverse events in patients undergoing lung cancer surgery: Competing forces in an era of heightened focus on care quality? PLoS One 2020; 15:e0231258. [PMID: 32271810 PMCID: PMC7145007 DOI: 10.1371/journal.pone.0231258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 03/19/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Advances in surgical techniques have improved clinical outcomes and decreased complications. At the same time, heightened attention to care quality has resulted in increased identification of hospital-acquired adverse events. We evaluated these divergent effects on the reported safety of lung cancer resection. METHODS AND MATERIALS We analyzed hospital-acquired adverse events in patients undergoing lung cancer resection using the National Hospital Discharge Survey (NHDS) database from 2001-2010. Demographics, diagnoses, and procedures data were abstracted using ICD-9 codes. We used the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI) to identify hospital-acquired adverse events. Weighted analyses were performed using t-tests and chi-square. RESULTS A total of 302,444 hospitalizations for lung cancer resection and were included in the analysis. Incidence of PSI increased over time (28% in 2001-2002 vs 34% in 2009-2010; P<0.001). Those with one or more PSI had increased in-hospital mortality (aOR = 11.1; 95% CI, 4.7-26.1; P<0.001) and prolonged hospitalization (12.5 vs 7.8 days; P<0.001). However, among those with PSI, in-hospital mortality decreased over time, from 17% in 2001-2002 to 2% in 2009-2010. CONCLUSIONS In a recent ten-year period, documented rates of adverse events associated with lung cancer resection increased. Despite this increase in safety events, we observed that mortality decreased. Because such metrics may be incorporated into hospital rankings and reimbursement considerations, adverse event coding consistency and content merit further evaluation.
Collapse
Affiliation(s)
- Mitchell S. von Itzstein
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Arjun Gupta
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Kemp H. Kernstine
- Department of Cardiothoracic Surgery, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Kristin C. Mara
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States of America
| | - Sahil Khanna
- Division of Gastroenterology, Mayo Clinic, Rochester, MN, United States of America
| | - David E. Gerber
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States of America
- Department of Population & Data Sciences, UT Southwestern Medical Center, Dallas, TX, United States of America
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center Dallas, TX, United States of America
| |
Collapse
|
17
|
He H, Ma X, Su L, Wang L, Guo Y, Shan G, He HJ, Zhou X, Liu D, Long Y, Zhao Y, Zhang S. Effects of a national quality improvement program on ICUs in China: a controlled pre-post cohort study in 586 hospitals. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:73. [PMID: 32131872 PMCID: PMC7057512 DOI: 10.1186/s13054-020-2790-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 02/14/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Patient safety and critical care quality remain a challenging issue in the ICU. However, the effects of the national quality improvement (QI) program remain unknown in China. METHODS A national ICU QI program was implemented in a controlled cohort of 586 hospitals from 2016 to 2018. The effects of the QI program on critical care quality were comprehensively investigated. MAIN RESULTS A total of 81,461,554 patients were enrolled in 586 hospitals, and 1,587,724 patients were admitted to the ICU over 3 years. In 2018, there was a significantly higher number of ICU beds (2016 vs. 2018: 10668 vs. 13,661, P = 0.0132) but a lower doctor-to-bed ratio (2016 vs. 2018: 0.64 (0.50, 0.83) vs. 0.60 (0.45, 0.75), P = 0.0016) and nurse-to-bed ratio (2016 vs. 2018: 2.00 (1.64, 2.50) vs. 2.00 (1.50, 2.40), P = 0.031) than in 2016. Continuous and significant improvements in the ventilator-associated pneumonia (VAP) incidence rate, microbiology detection rate before antibiotic use and deep vein thrombosis (DVT) prophylaxis rate were associated with the implementation of the QI program (VAP incidence rate (per 1000 ventilator-days), 2016 vs. 2017 vs. 2018: 11.06 (4.23, 22.70) vs. 10.20 (4.25, 23.94) vs. 8.05 (3.13, 17.37), P = 0.0002; microbiology detection rate before antibiotic use (%), 2016 vs. 2017 vs. 2018: 83.91 (49.75, 97.87) vs. 84.14 (60.46, 97.24) vs. 90.00 (69.62, 100), P < 0.0001; DVT prophylaxis rate, 2016 vs. 2017 vs. 2018: 74.19 (33.47, 96.16) vs. 71.70 (38.05, 96.28) vs. 83.27 (47.36, 97.77), P = 0.0093). Moreover, the 6-h SSC bundle compliance rates in 2018 were significantly higher than those in 2016 (6-h SSC bundle compliance rate, 2016 vs. 2018: 64.93 (33.55, 93.06) vs. 76.19 (46.88, 96.67)). A significant change trend was not found in the ICU mortality rate from 2016 to 2018 (ICU mortality rate (%), 2016 vs. 2017 vs. 2018: 8.49 (4.42, 14.82) vs. 8.95 (4.89, 15.70) vs. 9.05 (5.12, 15.80), P = 0.1075). CONCLUSIONS The relationship between medical human resources and ICU overexpansion was mismatched during the past 3 years. The implementation of a national QI program improved ICU performance but did not reduce ICU mortality.
Collapse
Affiliation(s)
- Huaiwu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xudong Ma
- Department of Medical Administration, National Health Commission of the People's Republic of China, Beijing, 100044, China
| | - Longxiang Su
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Lu Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yanhong Guo
- Department of Medical Administration, National Health Commission of the People's Republic of China, Beijing, 100044, China
| | - Guangliang Shan
- Department of Epidemiology and Biostatistics, Institute of Basic Medicine Sciences, Chinese Academy of Medical Sciences (CAMS) & School of Basic Medicine, Peking Union Medical College, Beijing, 100730, China
| | - Hui Jing He
- Department of Epidemiology and Biostatistics, Institute of Basic Medicine Sciences, Chinese Academy of Medical Sciences (CAMS) & School of Basic Medicine, Peking Union Medical College, Beijing, 100730, China
| | - Xiang Zhou
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Shuyang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | | |
Collapse
|
18
|
Huang Z, Chen H, Liu Z. The 100 top-cited systematic reviews/meta-analyses in central venous catheter research: A PRISMA-compliant systematic literature review and bibliometric analysis. Intensive Crit Care Nurs 2020; 57:102803. [PMID: 32035805 DOI: 10.1016/j.iccn.2020.102803] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The central venous catheter is used extensively worldwide. The purpose of this bibliometric analysis was to identify the 100 top-cited systematic reviews/meta-analyses in the literature on central venous catheters and to capture the most important trends in this area of research. RESEARCH METHODOLOGY A search was performed in the Web of Science Core Collection on studies published prior to November 12th, 2019. The search terms included central venous catheter, systematic review and meta-analysis. Retrieved studies were ranked by citation number and selected by two of the authors. Information such as citation number, author, institution, country and year of publication was collected. RESULTS The 100 top-cited studies published between 1992 and 2017 were reviewed, with the largest proportion published in 2008 (n = 17). The number of citations ranged from 14 to 660. The country with the largest number of studies was the United States of America (n = 36). Critical Care Medicine published the greatest number of these studies (n = 13). The largest number of these studies were focused on central venous catheter-related infection (n = 56) and thrombosis (n = 19). CONCLUSION Developed countries were the most productive in the field of central venous catheters. Most meta-analyses focused on complications associated with central-venous catheters such as infection and thrombosis.
Collapse
Affiliation(s)
- Zhaojing Huang
- Center of Gerontology and Geriatrics, and National Clinical Research Center of Geriatrics, West China Hospital Sichuan University, PO Box 610041, No.37 Guo Xue Street, Chengdu, Sichuan Province, PR China
| | - Hongxiu Chen
- West China School of Nursing, West China Hospital, Sichuan University, PO Box 610041, No.37 Guo Xue Street, Chengdu, Sichuan Province, PR China.
| | - Zuoyan Liu
- Department of Rehabilitation Medical Center, West China Hospital, Sichuan University, PO Box 610041, No.37 Guo Xue Street, Chengdu, Sichuan Province, PR China.
| |
Collapse
|
19
|
Patel PK, Olmsted RN, Hung L, Popovich KJ, Meddings J, Jones K, Calfee DP, Fowler KE, Saint S, Chopra V. A Tiered Approach for Preventing Central Line-Associated Bloodstream Infection. Ann Intern Med 2019; 171:S16-S22. [PMID: 31569225 DOI: 10.7326/m18-3469] [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] [Indexed: 11/22/2022] Open
Affiliation(s)
- Payal K Patel
- University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., J.M., S.S., V.C.)
| | - Russell N Olmsted
- Integrated Clinical Services Team, Trinity Health, Livonia, Michigan (R.N.O.)
| | - Louella Hung
- Health Research & Educational Trust, American Hospital Association, Chicago, Illinois (L.H.)
| | | | - Jennifer Meddings
- University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., J.M., S.S., V.C.)
| | - Karen Jones
- University of Michigan Medical School, Ann Arbor, Michigan (K.J.)
| | | | - Karen E Fowler
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (K.E.F.)
| | - Sanjay Saint
- University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., J.M., S.S., V.C.)
| | - Vineet Chopra
- University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., J.M., S.S., V.C.)
| |
Collapse
|
20
|
Karampatakis T, Tsergouli K, Karantani E, Diamantopoulou A, Mouloudi E, Roilides E, Karyoti A. Comparison of semiquantitative and differential time to positivity methods for the diagnosis of central line-associated bloodstream infections in an intensive care unit. Access Microbiol 2019; 1:e000029. [PMID: 32974522 PMCID: PMC7470290 DOI: 10.1099/acmi.0.000029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 05/08/2019] [Indexed: 12/13/2022] Open
Abstract
Introduction Central line-associated bloodstream infections (CLABSIs) adversely affect patients’ hospitalization. Aim We compared semiquantitative roll plate (SQRP) and differential time to positivity (DTP) culture methods in diagnosing CLABSIs. Methodology A retrospective study was conducted in an intensive care unit (ICU) from January 2013 to August 2014. All ICU patients with suspected CLABSIs were included. Blood cultures were taken, while central venous catheter (CVC) tips were cultured using the roll-tip method. DTP was considered positive if CVC lumen blood cultures became positive at least 2 h prior to concurrently drawn peripheral blood cultures with an identical micro-organism. SQRP method was considered positive when ≥15 c.f.u. of a micro-organism identical to that of blood cultures grew. Measures of diagnostic accuracy were calculated. Results SQRP displayed high sensitivity (94.7 %), while DTP showed high specificity (82.5 %). SQRP combined with DTP displayed 100 % sensitivity and negative predictive value. Conclusion SQRP and DTP methods should be evaluated in combination.
Collapse
Affiliation(s)
- Theodoros Karampatakis
- 1 Infectious Disease Unit, 3rd Department of Pediatrics, Medical Faculty, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece
- 2 Microbiology Department, Hippokration General Hospital, Thessaloniki, Greece
| | - Katerina Tsergouli
- 2 Microbiology Department, Hippokration General Hospital, Thessaloniki, Greece
| | - Ekaterini Karantani
- 2 Microbiology Department, Hippokration General Hospital, Thessaloniki, Greece
| | - Anna Diamantopoulou
- 2 Microbiology Department, Hippokration General Hospital, Thessaloniki, Greece
| | - Eleni Mouloudi
- 3 Intensive Care Unit, Hippokration General Hospital, Thessaloniki, Greece
| | - Emmanuel Roilides
- 1 Infectious Disease Unit, 3rd Department of Pediatrics, Medical Faculty, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece
- 4 Infection Control Committee, Hippokration General Hospital, Thessaloniki, Greece
| | - Angeliki Karyoti
- 2 Microbiology Department, Hippokration General Hospital, Thessaloniki, Greece
- 4 Infection Control Committee, Hippokration General Hospital, Thessaloniki, Greece
| |
Collapse
|
21
|
Menaker J, Galvagno S, Rabinowitz R, Penchev V, Hollis A, Kon Z, Deatrick K, Amoroso A, Herr D, Mazzeffi M. Epidemiology of blood stream infection in adult extracorporeal membrane oxygenation patients: A cohort study. Heart Lung 2019; 48:236-239. [DOI: 10.1016/j.hrtlng.2019.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/04/2019] [Accepted: 01/13/2019] [Indexed: 12/12/2022]
|
22
|
Watts RD, Li IW. Use of Checklists in Reviews of Health Economic Evaluations, 2010 to 2018. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:377-382. [PMID: 30832977 DOI: 10.1016/j.jval.2018.10.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 10/15/2018] [Accepted: 10/23/2018] [Indexed: 05/25/2023]
Abstract
OBJECTIVE It is useful for reviewers of economic evaluations to assess quality in a manner that is consistent and comprehensive. Checklists can allow this, but there are concerns about their reliability and how they are used in practice. We aimed to describe how checklists have been used in systematic reviews of health economic evaluations. METHODS Meta-review with snowball sampling. We compiled a list of checklists for health economic evaluations and searched for the checklists' use in systematic reviews from January 2010 to February 2018. We extracted data regarding checklists used, stated checklist function, subject area, number of reviewers, and issues expressed about checklists. RESULTS We found 346 systematic reviews since 2010 that used checklists to assess economic evaluations. The most common checklist in use was developed in 1996 by Drummond and Jefferson, and the most common stated use of a checklist was quality assessment. Checklists and their use varied within subject areas; 223 reviews had more than one reviewer who used the checklist. CONCLUSIONS Use of checklists is inconsistent. Eighteen individual checklists have been used since 2010, many of which have been used in ways different from those originally intended, often without justification. Different systematic reviews in the same subject areas would benefit from using one checklist exclusively, using checklists as intended, and having 2 reviewers complete the checklist. This would increase the likelihood that results are transparent and comparable over time.
Collapse
Affiliation(s)
- Rory D Watts
- School of Population and Global Health, The University of Western Australia, Crawley, Australia.
| | - Ian W Li
- School of Population and Global Health, The University of Western Australia, Crawley, Australia
| |
Collapse
|
23
|
Chung HC, Wang LS, Wu JL, Hsieh TC. Utilization of a central venous catheter insertion care bundle in Taiwan: A cross-sectional analysis of the National Health Insurance Research Database. Tzu Chi Med J 2019; 31:182-187. [PMID: 31258295 PMCID: PMC6559030 DOI: 10.4103/tcmj.tcmj_63_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objectives The objectives of this study are to explore medical care utilization associated with promoting the central venous catheter (CVC) care bundle plan using Taiwan's National Health Insurance Research Database (NHIRD). Materials and Methods We performed a cross-sectional, secondary analysis of the data from patients who were admitted to a medical center for the first time between July 1, 2010, and June 30, 2012, in the NHIRD. The control group was patients who were admitted at nine medical center hospitals that participated in the pilot plan, and the study group was patients who were admitted at other ten medical center hospitals that did not participate in the pilot plan, and the differences between groups were analyzed. Results After implementing the CVC care bundle, the average hospital stay decreased significantly (18.43 ± 12.96 vs. 15.49 ± 10.16, P < 0.05). In addition, the study group patients were clinically less likely to require antibiotics than the control group (odds ratio = 0.33, 95% confidence interval [CI] = [0.07, 1.71] vs. 0.62, 95% CI = [0.40, 0.96], P = 3768), and their medical expenses were lower (220, 618 ± 226, 419 vs. 208, 079 ± 193, 610, P > 05). Furthermore, the incidence rate of CVC-associated sepsis decreased from 12.59% to 5.66%. Conclusions By implementing the CVC care bundle in clinical practice in accordance with national policies, medical utilization decreased, thereby considerably improving medical resource usage. These results confirmed that implementing the CVC care bundle possibly decreased medical utilization in clinical practice.
Collapse
Affiliation(s)
- Hui-Chun Chung
- Department of Nursing, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan
| | - Lih-Shinn Wang
- Division of Infectious Disease, Department of Internal Medicine, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan
| | - Jung-Lun Wu
- Institute of Medical Sciences, College of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Tsung-Cheng Hsieh
- Institute of Medical Sciences, College of Medicine, Tzu Chi University, Hualien, Taiwan
| |
Collapse
|
24
|
Robinette ED, Brower L, Schaffzin JK, Whitlock P, Shah SS, Connelly B. Use of a Clinical Care Algorithm to Improve Care for Children With Hematogenous Osteomyelitis. Pediatrics 2019; 143:peds.2018-0387. [PMID: 30567715 DOI: 10.1542/peds.2018-0387] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Acute hematogenous osteomyelitis (AHO) causes significant morbidity in children. Quality improvement (QI) methods have been used to successfully improve care and decrease costs through standardization for numerous conditions, including pediatric AHO. We embarked on a QI initiative to standardize our approach to the inpatient management of AHO, with a global aim of reducing inpatient costs. METHODS We used existing literature and local consensus to develop a care algorithm for the inpatient management of AHO. We used the Model for Improvement as the framework for the project, which included process mapping, failure mode analysis, and key driver identification. We engaged with institutional providers to achieve at least 80% consensus regarding specific key drivers and tested various interventions to support uptake of the care algorithm. RESULTS Fifty-seven patients were included. There were 31 patients in the preintervention cohort and 26 in the postintervention cohort, of whom 19 were managed per the algorithm. Mean inpatient charges decreased from $45 718 in the preintervention cohort to $32 895 in the postintervention cohort; length of stay did not change. Adherence to recommended empirical antimicrobial agents trended upward. CONCLUSIONS A simple and low-cost QI project was used to safely decrease the cost of inpatient care for pediatric AHO at a tertiary care children's hospital. A robust local consensus process proved to be a key component in the uptake of standardization.
Collapse
Affiliation(s)
| | - Laura Brower
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Samir S Shah
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | |
Collapse
|
25
|
Okuda KI, Yoshii Y, Yamada S, Chiba A, Hironaka I, Hori S, Yanaga K, Mizunoe Y. Detection of bacterial DNA from central venous catheter removed from patients by next generation sequencing: a preliminary clinical study. Ann Clin Microbiol Antimicrob 2018; 17:44. [PMID: 30577829 PMCID: PMC6303997 DOI: 10.1186/s12941-018-0297-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/17/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Catheter-related infection (CRI) is one of the serious challenges in clinical practice. This preliminary clinical study aimed to examine whether next-generation sequencing (NGS) targeting 16S rDNA, which was PCR-amplified directly from the tip of a central venous catheter (CVC), can be used to identify causative pathogens in CRI, compared to the culture method. METHODS Hospitalized patients, from whom a CVC had just been removed, were prospectively enrolled and divided into the CRI-suspected and routine removal groups. DNA was extracted from the sonication fluid of CVC specimens derived from patients. For analysis of bacterial composition by NGS, the V3-V4 fragments of bacterial 16S rDNA were PCR-amplified, followed by index PCR and paired-end sequencing on an Illumina MiSeq device. Conventional culture methods were also performed in the CRI-suspected group. RESULTS Of CVCs collected from the 156 enrolled patients (114 men; mean age 65.6 years), a total of 14 specimens [nine out of 31 patients suspected with CRI and five out of 125 patients without infection symptoms (routine removal group)] were PCR-positive. In five patients with definite CRI, Staphylococcus was the most frequently detected genus by NGS (4/5 specimens), although no pathogens were detected by NGS in the one remaining specimen. The genera identified by NGS were consistent with those from conventional culture tests. There was high agreement between NGS and the culture method in the CRI-suspected group, with sensitivity and specificity values of 80.0% and 76.9%, respectively; meanwhile, the false-positive rate of NGS was as low as 4.0% in the routine removal group. Moreover, several genera, besides the genus identified by culture test, were detected in each patient with definite CRI and surgical site infection (SSI). Additionally, in one patient with SSI, Enterococcaceae were detected not only by NGS but also by abdominal abscess drainage culture. CONCLUSIONS NGS targeting 16S rDNA was able to analyze the bacterial composition of CVC specimens and detect causative pathogens in patients with CRI and was therefore suggested as a promising diagnostic tool for CRI.
Collapse
Affiliation(s)
- Ken-Ichi Okuda
- Department of Bacteriology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan. .,Jikei Center for Biofilm Science and Technology, The Jikei University School of Medicine, Tokyo, Japan.
| | - Yutaka Yoshii
- Department of Bacteriology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.,Jikei Center for Biofilm Science and Technology, The Jikei University School of Medicine, Tokyo, Japan.,Division of Respiratory Diseases, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Satomi Yamada
- Department of Bacteriology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Akio Chiba
- Department of Bacteriology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.,Jikei Center for Biofilm Science and Technology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ippei Hironaka
- Department of Bacteriology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Seiji Hori
- Jikei Center for Biofilm Science and Technology, The Jikei University School of Medicine, Tokyo, Japan.,Department of Infectious Disease and Control, The Jikei University School of Medicine, Tokyo, Japan
| | - Katsuhiko Yanaga
- Jikei Center for Biofilm Science and Technology, The Jikei University School of Medicine, Tokyo, Japan.,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshimitsu Mizunoe
- Department of Bacteriology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.,Jikei Center for Biofilm Science and Technology, The Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|
26
|
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.
Collapse
|
27
|
A state of the art review on optimal practices to prevent, recognize, and manage complications associated with intravascular devices in the critically ill. Intensive Care Med 2018; 44:742-759. [PMID: 29754308 DOI: 10.1007/s00134-018-5212-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/05/2018] [Indexed: 12/14/2022]
Abstract
Intravascular catheters are inserted into almost all critically ill patients. This review provides up-to-date insight into available knowledge on epidemiology and diagnosis of complications of central vein and arterial catheters in ICU. It discusses the optimal therapy of catheter-related infections and thrombosis. Prevention of complications is a multidisciplinary task that combines both improvement of the process of care and introduction of new technologies. We emphasize the main component of the prevention strategies that should be used in critical care and propose areas of future investigation in this field.
Collapse
|
28
|
Nuckols TK, Keeler E, Anderson LJ, Green J, Morton SC, Doyle BJ, Shetty K, Arifkhanova A, Booth M, Shanman R, Shekelle P. Economic Evaluation of Quality Improvement Interventions Designed to Improve Glycemic Control in Diabetes: A Systematic Review and Weighted Regression Analysis. Diabetes Care 2018; 41:985-993. [PMID: 29678865 PMCID: PMC5911791 DOI: 10.2337/dc17-1495] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/13/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Quality improvement (QI) interventions can improve glycemic control, but little is known about their value. We systematically reviewed economic evaluations of QI interventions for glycemic control among adults with type 1 or type 2 diabetes. RESEARCH DESIGN AND METHODS We used English-language studies from high-income countries that evaluated organizational changes and reported program and utilization-related costs, chosen from PubMed, EconLit, Centre for Reviews and Dissemination, New York Academy of Medicine's Grey Literature Report, and WorldCat (January 2004 to August 2016). We extracted data regarding intervention, study design, change in HbA1c, time horizon, perspective, incremental net cost (studies lasting ≤3 years), incremental cost-effectiveness ratio (ICER) (studies lasting ≥20 years), and study quality. Weighted least-squares regression analysis was used to estimate mean changes in HbA1c and incremental net cost. RESULTS Of 3,646 records, 46 unique studies were eligible. Across 19 randomized controlled trials (RCTs), HbA1c declined by 0.26% (95% CI 0.17-0.35) or 3 mmol/mol (2 to 4) relative to usual care. In 8 RCTs lasting ≤3 years, incremental net costs were $116 (95% CI -$612 to $843) per patient annually. Long-term ICERs were $100,000-$115,000/quality-adjusted life year (QALY) in 3 RCTs, $50,000-$99,999/QALY in 1 RCT, $0-$49,999/QALY in 4 RCTs, and dominant in 1 RCT. Results were more favorable in non-RCTs. Our limitations include the fact that the studies had diverse designs and involved moderate risk of bias. CONCLUSIONS Diverse multifaceted QI interventions that lower HbA1c appear to be a fair-to-good value relative to usual care, depending on society's willingness to pay for improvements in health.
Collapse
Affiliation(s)
- Teryl K Nuckols
- Cedars-Sinai Medical Center, Los Angeles, CA
- RAND Corp., Santa Monica, CA
| | | | - Laura J Anderson
- Cedars-Sinai Medical Center, Los Angeles, CA
- Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA
| | - Jonas Green
- Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Brian J Doyle
- VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | | | | | | | | | - Paul Shekelle
- RAND Corp., Santa Monica, CA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA
| |
Collapse
|
29
|
Anderson LJ, Shekelle P, Keeler E, Uscher-Pines L, Shanman R, Morton S, Aliyev G, Nuckols TK. The Cost of Interventions to Increase Influenza Vaccination: A Systematic Review. Am J Prev Med 2018; 54:299-315. [PMID: 29362167 PMCID: PMC5788040 DOI: 10.1016/j.amepre.2017.11.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 10/28/2017] [Accepted: 11/20/2017] [Indexed: 12/15/2022]
Abstract
CONTEXT Influenza vaccination rates remain below Healthy People 2020 goals. This project sought to systematically review economic evaluations of healthcare-based quality improvement interventions for improving influenza vaccination uptake among general populations and healthcare workers. EVIDENCE ACQUISITION The databases MEDLINE, Econlit, Centre for Reviews & Dissemination, Greylit, and Worldcat were searched in July 2016 for papers published from January 2004 to July 2016. Eligible studies evaluated efforts by bodies within the healthcare system to encourage influenza vaccination by means of an organizational or structural change. For each study, program costs per enrollee and per additional enrollee vaccinated were derived (excluding vaccine costs, standardized to 2017 U.S. dollars). Complete economic evaluations were examined when available. EVIDENCE SYNTHESIS Of 2,350 records, 18 articles were eligible and described 29 unique interventions. Most interventions improved vaccine uptake. Among 23 interventions in general populations, the median program cost was $3.27 (interquartile range, $0.82-$11.53) per enrollee and $50.78 (interquartile range, $27.85-$124.84) per additional enrollee vaccinated. Among ten complete economic evaluations in general populations, three studies reported net cost savings, four reported costs <$50,000 per quality-adjusted life year, and three reported costs <$60,000 per life saved. Among six interventions in healthcare workers, the median program cost was $8.09 (interquartile range, $5.03-$10.31) per worker enrolled and $125.24 (interquartile range, $96.06-$171.38) per additional worker vaccinated (there were no complete economic analyses). CONCLUSIONS Quality improvement interventions for influenza vaccination involve per-enrollee costs that are similar to the cost of the vaccine itself ($11.78-$36.08/dose). Based on limited available evidence in general populations, quality improvement interventions may be cost saving to cost effective for the health system.
Collapse
Affiliation(s)
- Laura J Anderson
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California; Department of Epidemiology, UCLA Jonathan and Karin Fielding School of Public Health, University of California-Los Angeles, Los Angeles, California.
| | - Paul Shekelle
- Evidence-based Synthesis Program, West Los Angeles VA Medical Center, Los Angeles, California; Rand Health, RAND Corporation, Santa Monica, California
| | - Emmett Keeler
- Rand Health, RAND Corporation, Santa Monica, California
| | | | | | - Sally Morton
- Department of Statistics, Virginia Polytechnic Institute and State University, Blacksburg, Virginia
| | - Gursel Aliyev
- Rand Health, RAND Corporation, Santa Monica, California
| | - Teryl K Nuckols
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California; Rand Health, RAND Corporation, Santa Monica, California
| |
Collapse
|