Systematic review of emergency department central venous and arterial catheter infection

[Early source control of infection in patients seen in the emergency department: a systematic review]

OBJECTIVE

The term source (or focus) control encompasses all those physical measures that can be used to reduce the inoculum and modify those factors in the infectious medium that promote microbial growth or foreign antimicrobial defenses of the host. The main objective of this systematic review (SR) is to know and compare whether early detection and control of the focus (in less than 6 hours) in adult patients treated in the ED for severe infection or sepsis, compared to not controlling the focus or delayed focus control (more than 12 hours) is more effective and safer (improves clinical evolution, mortality, complications, hospital stay or need for ICU admission).

METHODS

A systematic review is carried out following the PRISMA regulations in the databases of PubMed, Web of Science, EMBASE, Lilacs, Cochrane, Epistemonikos, Tripdatabase and ClinicalTrials.gov from January 2000 to December 31, 2023 without language restrictions and using a combination of MESH terms: "Source Control", "Early" "Infection OR Bacterial Infection OR Sepsis", "Emergencies OR Emergency OR Emergency Department" and "Adults". Observational cohort studies were included. No meta-analysis techniques were performed, but results were compared narratively.

RESULTS

A total of 1,658 articles were identified, of which 2 that met the inclusion criteria and were classified as high quality were finally analyzed. The included studies represent a total of 2,404 patients with 678 cases in which an intervention was performed to control the focus (28.20%). In the first study, 28-day mortality was lower in patients who underwent an intervention to control the focus (12.3% vs. 22.5%; P <0.001), with an adjusted HR of 0.538 (95% CI: 0.389-0.744; P<0.001). In the second, it was demonstrated that the time elapsed from when the patient was evaluated for the first time and was hemodynamically stabilized, until the start of surgery was associated with his survival at 60 days with an OR of 0.31 (95% CI: 0.19-0.45; P <0.0001). In fact, for each hour of delay an adjusted OR of 0.29 (95% CI: 0.16-0.47; P<0.0001) is established. So if the intervention is performed before 2 hours at 60 days, 98% of the patients are still alive, if it is performed between 2-4 hours it is reduced to 78%, if it is between 4-6 hours it drops to 55%, but if it is done for more than 6 hours there will be no survivors at 60 days.

CONCLUSIONS

This review shows that source control carried out after the evaluation of patients attending the ED reduces short-term mortality (30-60 days) and that it would be advisable to implement any required source control intervention as soon as possible, ideally early (within 6 hours).

Quality Improvement Initiative to Reduce Intravenous Line-related Infiltration and Phlebitis Incidence in Pediatric Emergency Room

Aim and objective

To reduce the incidence of infiltration and phlebitis by 50% over 2 months among children admitted to the emergency room (ER) of a tertiary care hospital.

Materials and methods

The study was conducted in the pediatric ER of a tertiary care hospital in North India. All children aged >28 days, receiving intravenous (IV) medication and/or fluids, were enrolled between June (2017) and September (2017). Existing practices of IV line insertion and maintenance were observed and recorded. The visual infusion phlebitis score and infiltration assessment scale were to grade the extent of two. The intervention classified as “IV line insertion and maintenance bundle” included the introduction of low-cost mobile sterile compartment trays, audit and feedback, organizational change, introduction of infection control nurse and quality improvement (QI) team formations were implement in different Plan-Do-Study-Act (PDSA) cycles. Reduction in the “incidence of phlebitis and infiltration” was outcome measures while “scores on checklist of IV line insertion and IV line maintenance and administration of drugs” were process measures.

Result

The process measures, for IV line insertion, maintenance and administration of drugs through IV line, revealed an increase in scores on the checklist. There was a significant decrease in the incidence of infiltration and phlebitis from 82.9 and 96.1% to 45 and 55%, respectively, postimplementation of all PDSA cycles.

Conclusion

Multifaceted QI IV line insertion and maintenance bundle reduced the incidence of infiltration and phlebitis. These interventions when integrated into daily work bundles along with continuous education and motivation help in sustaining the goal and attaining long-term success.

How to cite this article

Singh N, Kalyan G, Kaur S, Jayashree M, Ghai S. Quality Improvement Initiative to Reduce Intravenous Line-related Infiltration and Phlebitis Incidence in Pediatric Emergency Room. Indian J Crit Care Med 2021;25(5):557–565.

Central line associated blood stream infections in gastroschisis patients: A nationwide database analysis of risks, outcomes, and disparities

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.

Vascular Access Complications: An Emergency Medicine Approach

Millions of central venous and arterial catheters are placed across the United States annually as mechanisms of obtaining advanced hemodynamic monitoring and facilitating acute resuscitation. Although presumably life saving or sustaining in many circumstances, current literature identifies the preprocedural and postprocedural complications of infection, thrombosis, embolism, and iatrogenic injury as resulting in patient morbidity and mortality. Today, through the application of aseptic technique, performance of operator training, and the utilization of ultrasound, emergency physicians may limit vascular access complications and improve patient outcomes.

[Anaesthesia procedures and invasive vascular access in severely injured patients at trauma room admission in Germany : An online survey]

BACKGROUND

The continuous monitoring of vital parameters and subsequent therapy belong to the core duties of anaesthetists during acute trauma resuscitation in the trauma room. Important procedures may include placement of arterial lines and central venous catheters (CVCs). Knowledge of indication, performance and localization of invasive catheterisation of trauma care in Germany is scarce.

METHODS

After approval of the German Society of Anaesthesiology and Intensive Care Medicine we conducted an online survey about arterial and central venous catheterisation of severely injured patients with consideration of common practice used by anaesthetists in German trauma rooms. Data are presented in a descriptive manner.

RESULTS

Of 843 hospitals invited for the survey, 72 (8.5%) had complete and valid data and were thus included in the analysis. Of these, 47% were supra-regional (level 1) trauma centres, 38% regional trauma centres and 15% local trauma centres. The annual mean injury severity score (ISS) of admitted patients to these hospitals was 21 ± 10. In the trauma room, the responding hospitals place CVCs (49%) and arterial lines (59%) only in haemodynamically unstable patients, whereas 24% (CVC) and 39% (arterial line) do when pathological laboratory tests were confirmed. Standard operating procedures (SOPs) merely exist for placement of either arterial lines (25%) or CVCs (22%) in multiple trauma resuscitation. The decision to perform CVC or arterial line placement is usually (79%) at the discretion of the attending anaesthetist. The preferred anatomical access site for CVCs is the right internal jugular vein (46%) and for arterial lines the radial artery (without side preference) (57%), respectively. Of the responding hospitals, 49% prefer landmark-guided CVC-puncture (91% of arterial lines) instead of 43% using sonographic guidance (9% of arterial lines). Intravascular electrocardiography monitoring for CVC tip detection is used by 36%.

CONCLUSION

In Germany, medical indication and schedule of invasive vascular catheterisation of severely injured patients in the trauma room is rarely regulated by SOPs and often performed at the discretion of the attending trauma team. Sonographic assistance during vascular puncture and electrocardiography for CVC tip detection is not as common as in non-emergency anaesthesia. Further studies are required to explore the real necessity and safety of invasive vascular catheterisation in multiple trauma patients in order to improve trauma care.

A survey of the use of arterial catheters in anesthetized dogs and cats: 267 cases

OBJECTIVES

To describe the clinical practice of insertion of arterial catheters in anesthetized dogs and cats, to document complications of arterial catheterization, and to determine risk factors associated with the complications.

DESIGN

Prospective clinical study and retrospective evaluation of medical records.

SETTING

University teaching hospital.

ANIMALS

Dogs (n = 251) and 13 cats anesthetized for clinical procedures with arterial catheters inserted for blood pressure monitoring.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Details of the animal and catheter were collected at the time of anesthesia. On the following day, the catheter site was palpated and observed for abnormalities and the medical records of all animals were reviewed retrospectively for complications. Details of catheter placement were available for 216 catheters: 158 catheters in a dorsal pedal artery, 50 catheters in the median caudal (coccygeal) artery, 6 in the median artery, and 1 each in a cranial tibial and lingual artery. Blood pressure was obtained from 200 catheters, and 12 catheters failed before the end of anesthesia. Postoperative observational data obtained from 112 catheters described a palpable arterial pulse at 73 sites and no pulse at 21 sites. No risk factor for arterial occlusion was identified. No complications resulting from arterial catheterization were noted in the medical records.

CONCLUSIONS

Arterial catheterization resulted in loss of a peripheral pulse postoperatively in 21/94 (22.3%) of animals examined, although no evidence of tissue ischemia was noted in the medical records of any of the patients in this study. These results suggest that insertion of a catheter in the dorsal pedal or coccygeal arteries was not associated with a high risk for complications. However, the course of arterial occlusion postoperatively warrants further investigation.

Short-term and long-term impact of the central line workshop on resident clinical performance during simulated central line placement

INTRODUCTION

The Central Line Workshop (CLW) was introduced at our institution to better train residents in safe placement of the central venous catheter (CVC). This study sought to determine if immediate performance improvements from the CLW are sustained 3 months after the training for residents with various levels of experience.

METHODS

Twenty-six emergency medicine residents completed the CLW, which includes online modules and experiential sessions in anatomy, ultrasound, sterile technique, and procedural task training. Demonstration of the synthesis of these skills including placement of both internal jugular and subclavian CVCs was assessed using a task trainer. Each resident was also tested approximately 3 months before and 3 months after the CLW. Residents were assessed using a validated CVC proficiency scale.

RESULTS

Residents' CVC proficiency scores (percentage of items performed correctly during the assessment station) improved after CLW (0.6 vs. 0.93, P < 0.05). At 3 months after CLW testing, there was apparent skill decay from the CLW but overall improvement compared with baseline testing (0.6 vs. 0.8, P < 0.05). There was no significant difference in procedure time after CLW training. The postgraduate year 1 group showed the greatest improvement of CVC skill after CLW training.

CONCLUSIONS

Resident CVC placement performance improved immediately after the CLW. Although performance 3 months after the CLW revealed evidence of skill decay, it was improved when compared with initial baseline assessment. Novice learners had the greatest benefit from the CLW.

Simulation-based training for emergency medicine residents in sterile technique during central venous catheterization: impact on performance, policy, and outcomes

OBJECTIVES

Central line-associated bloodstream infection (CLABSI) is a preventable nosocomial infection. Simulation-based training in sterile technique during central venous catheter (CVC) placement for emergency medicine (EM) residents, and its effect on changing the medical intensive care unit (MICU) practice of routine replacement of CVCs placed under sterile technique in the emergency department (ED), has not been evaluated.

METHODS

Emergency medicine residents received simulation-based sterile technique training during CVC placement between May 2008 and September 2010. Between June 2008 and January 2011, the authors reviewed records of patients who had CVCs placed in the ED under sterile technique by EM residents and were admitted to the MICU (group 1) and CVCs placed in the MICU under sterile technique by internal medicine (IM) residents (group 2). IM residents completed similar simulation-based training before May 2008. Changes in EM residents' sterile technique performance scores were compared, as well as CLABSI rates in both groups. EM residents' CVC procedural skills were not assessed.

RESULTS

Seventy-six EM residents completed simulation-based training with significant improvement in performance (median scores 13 out of 24 before training, 24 out of 24 after training; p < 0.001). CLABSI rates per 1,000 catheter-days were 1.02 in group 1 and 1.02 in group 2 (p = 0.99). Both groups had similar demographics, acuity, and mortality (p > 0.5).

CONCLUSIONS

Routine replacement of CVCs placed in the ED under sterile technique after simulation-based training would appear to be unnecessary. These findings demonstrate patient-centered outcomes that are comparable for CVCs in ED-admitted MICU patients, regardless of whether the CVC was placed in the ED or MICU.

Infection prevention in the emergency department

Infection prevention remains a major challenge in emergency care. Acutely ill and injured patients seeking evaluation and treatment in the emergency department (ED) not only have the potential to spread communicable infectious diseases to health care personnel and other patients, but are vulnerable to acquiring new infections associated with the care they receive. This article will evaluate these risks and review the existing literature for infection prevention practices in the ED, ranging from hand hygiene, standard and transmission-based precautions, health care personnel vaccination, and environmental controls to strategies for preventing health care-associated infections. We will conclude by examining what can be done to optimize infection prevention in the ED and identify gaps in knowledge where further research is needed. Successful implementation of evidence-based practices coupled with innovation of novel approaches and technologies tailored specifically to the complex and dynamic environment of the ED are the keys to raising the standard for infection prevention and patient safety in emergency care.

Common infection control practices in the emergency department: a literature review

BACKGROUND

Health care-associated infections (HAIs) are a major health concern, despite being largely avoidable. The emergency department (ED) is an essential component of the health care system and subject to workflow challenges, which may hinder ED personnel adherence to guideline-based infection prevention practices.

METHODS

The purpose of this review was to examine published literature regarding adherence rates among ED personnel to selected infection control practices, including hand hygiene (HH) and aseptic technique during the placement of central venous catheters and urinary catheters. We also reviewed studies reporting rates of ED equipment contamination. PubMed was searched for studies that included adherence rates among ED personnel to HH during routine patient care, aseptic technique during the placement of central venous catheters and urinary catheters, and rates of equipment contamination.

RESULTS

In total, 853 studies was screened, and 589 abstracts were reviewed. The full texts of 36 papers were examined, and 23 articles were identified as meeting inclusion criteria. Eight studies used various scales to measure HH compliance, which ranged from 7.7% to 89.7%. Seven articles examined central venous catheters inserted in the ED or by emergency medicine residents. Detail of aseptic technique practices during urinary catheterization was lacking. Four papers described equipment contamination in the ED.

CONCLUSION

Standardized methods and definitions of compliance monitoring are needed to compare results across settings.

Central venous catheter-related bloodstream infections in the intensive care unit

CONTEXT

Central venous catheter-related bloodstream infection (CRBSI) is associated with high rates of morbidity and mortality in critically ill patients.

AIMS

This study was conducted to determine the incidence of central venous catheter-related infections (CRIs) and to identify the factors influencing it. So far, there are very few studies that have been conducted on CRBSI in the intensive care unit in India.

SETTINGS AND DESIGN

This was a prospective, observational study carried out in the medical intensive care unit (MICU) over a period of 1 year from January to December 2004.

MATERIALS AND METHODS

A total of 54 patients with indwelling central venous catheters of age group between 20 and 75 years were included. The catheters were cultured using the standard semiquantitative culture (SQC) method. Statistical analysis used SPSS-10 version statistical software.

RESULTS

A total of 54 CVC catheters with 319 catheter days were included in this study. Of 54 patients with CVCs studied for bacteriology, 39 (72.22%) catheters showed negative SQCs and also negative blood cultures. A total of 15 (27.77%) catheters were positive on SQC, of which 10 (18.52%) were with catheter-associated infection and four (7.41%) were with catheter-associated bacteremia; the remaining one was a probable catheter-associated bacteremia. CRIs were high among catheters that were kept in situ for more than 3 days and emergency procedures where two or more attempts were required for catheterization (P < 0.05). In multivariate analysis of covariance duration of catheter in situ for >3 days, inexperienced venupucturist, more number of attempts and emergency CVC were associated with more incidence of CVCBSIs, with P <0.02. The duration of catheter in situ was negatively correlated (-0.53) and number of attempts required to put CVC was positively correlated (+0.39) with incidence of CVCBSIs. Sixty-five percent of the isolates belonged to the CONS group (13/20). Staphylococcus epidermidis showed maximum susceptibility to amikacin, doxycycline and amoxycillin with clavulanic acid and was susceptible to vancomycin (100%). Klebsiella pneumoniae was 100% susceptible to amikacin and ciprofloxacin. Escherichia coli was susceptible to amikacin and cefotaxime.

CONCLUSIONS

The overall incidence of CRI was 27.77% (15/54). Catheter-associated BSIs were 47.31 per 1000 catheter-days. CRI was low in the catheters inserted by the experienced venipuncturists, elective procedure and CVC kept in situ for ≤3 days. S. epidermidis was the most common isolate.