Removing nonessential central venous catheters: evaluation of a quality improvement intervention

Development and implementation of a clinical decision support system-based quality initiative to reduce central line-associated bloodstream infections

Background

Central venous lines (CVLs) are frequently utilized in critically ill patients and confer a risk of central line-associated bloodstream infections (CLABSIs). CLABSIs are associated with increased mortality, extended hospitalization, and increased costs. Unnecessary CVL utilization contributes to CLABSIs. This initiative sought to implement a clinical decision support system (CDSS) within an electronic health record (EHR) to quantify the prevalence of potentially unnecessary CVLs and improve their timely removal in six adult intensive care units (ICUs).

Methods

Intervention components included: (1) evaluating existing CDSS' effectiveness, (2) clinician education, (3) developing/implementing an EHR-based CDSS to identify potentially unnecessary CVLs, (4) audit/feedback, and (5) reviewing EHR/institutional data to compare rates of removal of potentially unnecessary CVLs, device utilization, and CLABSIs pre- and postimplementation. Data was evaluated with statistical process control charts, chi-square analyses, and incidence rate ratios.

Results

Preimplementation, 25.2% of CVLs were potentially removable, and the mean weekly proportion of these CVLs that were removed within 24 hours was 20.0%. Postimplementation, a greater proportion of potentially unnecessary CVLs were removed (29%, p < 0.0001), CVL utilization decreased, and days between CLABSIs increased. The intervention was most effective in ICUs staffed by pulmonary/critical care physicians, who received monthly audit/feedback, where timely CVL removal increased from a mean of 18.0% to 30.5% (p < 0.0001) and days between CLABSIs increased from 17.3 to 25.7.

Conclusions

A significant proportion of active CVLs were potentially unnecessary. CDSS implementation, in conjunction with audit and feedback, correlated with a sustained increase in timely CVL removal and an increase in days between CLABSIs.

Using a standardized algorithm to decrease central venous catheter utilization

Central venous catheters (CVCs) have many benefits in patient care but are associated with increasing risks with catheter duration. A level II trauma-certified community hospital sought to decrease CVC duration utilizing a daily assessment algorithm in the critical care unit. After implementation, CVC days decreased from 490 CVC days per 1,000 patient days to 452 (odds ratio 0.86, P < .01) and catheter duration decreased from 7.71 days to 6.57 (P = .19).

A Quality Improvement Initiative to Decrease Central Line-Associated Bloodstream Infections During the COVID-19 Pandemic: A "Zero Harm" Approach

INTRODUCTION

Central line-associated bloodstream infections (CLABSIs) are associated with significant patient harm and health care costs. Central line-associated bloodstream infections are preventable through quality improvement initiatives. The COVID-19 pandemic has caused many challenges to these initiatives. Our community health system in Ontario, Canada, had a baseline rate of 4.62 per 1000 line days during the baseline period.

OBJECTIVES

Our aim was to reduce CLABSIs by 25% by 2023.

METHODS

An interprofessional quality aim committee performed a root cause analysis to identify areas for improvement. Change ideas included improving governance and accountability, education and training, standardizing insertion and maintenance processes, updating equipment, improving data and reporting, and creating a culture of safety. Interventions occurred over 4 Plan-Do-Study-Act cycles. The outcome was CLABSI rate per 1000 central lines: process measures were rate of central line insertion checklists used and central line capped lumens used, and balancing measure was the number of CLABSI readmissions to the critical care unit within 30 days.

RESULTS

Central line-associated bloodstream infections decreased over 4 Plan-Do-Study-Act cycles from a baseline rate of 4.62 (July 2019-February 2020) to 2.34 (December 2021-May 2022) per 1000 line days (51%). The rate of central line insertion checklists used increased from 22.8% to 56.9%, and central line capped lumens used increased from 72% to 94.3%. Mean CLABSI readmissions within 30 days decreased from 1.49 to 0.1798.

CONCLUSIONS

Our multidisciplinary quality improvement interventions reduced CLABSIs by 51% across a health system during the COVID-19 pandemic.

The effect of the multimodal intervention including an automatic notification of catheter days on reducing central line-related bloodstream infection: a retrospective, observational, quasi-experimental study

BACKGROUND

A central venous catheter (CVC) is an important medical device, but it could be preceding infection and the risk of central line-associated bloodstream infection (CLABSI). CLABSI is a common healthcare-associated infection but results in high cost and mortality; therefore, various efforts to reduce CLABSI have been attempted.

METHODS

This is a retrospective, observational, quasi-experimental study in the intensive care unit (ICU) of a single tertiary care hospital. We reviewed and analysed the data of CLABSI rates and days from the insertion to the removal of the temporary CVC between January 2018 and June 2021 with transient periods over 9 months. Sequentially, all patients with the CVC in the ICU underwent the following interventions: maximal barrier precaution, automatic notification of catheter days and 2% chlorhexidine gluconate bathing. A segmented regression analysis of interrupted time series was conducted to compare the CLABSI rates before and after the introduction of multimodal interventions. During study periods, the impact of interventions on CLABSI was evaluated using multivariate logistic regression analyses.

RESULTS

A total of 76,504 patient-days, 28,312 catheter days and 66 CLABSI cases were reviewed in ICU-hospitalised patients. As additional interventions, the CLABSI rate declined from 3.1 per 1000 CVC days to 1.2 per 1000 CVC days in post-interventions. In the pre-intervention and post-intervention periods, 4146 patents had one more short-term CVC. In the multivariate logistic regression analyses, multimodal intervention was one of determinants reducing CLABSI rates (odds ratio (OR), 0.52 [95% confidence interval {CI}, 0.28-0.94]). Indwelling time of CVC over 10 days was the risk factor for CLABSI rates (OR, 6.27 [95% CI, 3.36-12.48]). Of the three interventions, the automatic notification of catheter days was associated with decreased median monthly total CVC days and duration of CVC days per patient.

CONCLUSIONS

Multidisciplinary and evidence-based interventions could lead to a decrease in the CLABSI rates. Moreover, the automatic notification of catheter days of the electronic medical healthcare system has shortened the time of indwelling CVC.

Stewardship Intervention to Optimize Central Venous Catheter Utilization in Critically Ill Children

We aimed to describe utilization and indication(s) for long-term central venous catheters (CVCs) in a pediatric intensive care unit (PICU) and identify potential strategies to decrease CVC utilization.

Systematic Evaluation of the Effect of Bedside Ward Round Checklist on Clinical Outcomes of Critical Patients

Objective

To systematically evaluate the effect of bedside ward round checklists on the clinical outcomes of critical patients and thus provide a scientific and rational basis for decision-making in its clinical application.

Methods

PubMed, EMBASE, Web of Science, Cochrane Library, CNKI, and Wanfang databases were searched to collect the literature studies about randomized controlled trials (RCTs) and cohort studies involving the effect of bedside ward round checklists on the clinical outcomes of critical patients, and the retrieval time limit was from the establishment of the database to August 2019. After two researchers independently screened the literature studies, extracted the literature data, and evaluated the risk of bias in included studies, meta-analysis was carried out by using Stata 12.0 software.

Results

Two RCTs and nine cohort studies were included in this study. The results of meta-analysis showed that compared with the ordinary bedside ward round, the application of checklist in bedside ward round could shorten the ICU hospitalization time (standardized mean difference (SMD) = - 0.37, 95% CI (- 0.78, 0.04), P ≤ 0.001) and mechanical ventilation time (SMD = - 0.24, 95% CI (- 0.44, -0.04), P = 0.037) and reduce the incidence of ventilator-associated pneumonia (VAP) (SMD = 0.61, 95% CI (0.38, 0.99), P = 0.057) in critical patients. However, there were no significant differences in central venous catheter (CVC) retention time and incidence and mortality of deep venous thrombosis (DVT) between ordinary ward round and bedside ward round checklist.

Conclusion

The existing evidence shows that compared with the ordinary ward round, the application of bedside ward round checklists can shorten ICU hospitalization time and mechanical ventilation time and reduce VAP incidence and ICU mortality in critical patients. However, due to the limitations of the quality of the included studies, the above conclusions need to be verified with more high-quality studies.

Reducing Central Line Associated Bloodstream Infections (CLABSIs) by Reducing Central Line Days

Purpose of Review

While reducing unnecessary days present of central venous catheters (CVCs) is part of central line associated bloodstream infection (CLABSI) best practices, there is limited information regarding compliance with this recommendation as well as addressing barriers to compliance.

Recent Findings

Significant work has been directed towards daily audits of necessity and improving communication between members of the medical team. Other critical interventions include utilization of the electronic health record (EHR), leadership support of CLABSI reduction goals, and avoiding CVC placement over more appropriate vascular access.

Summary

Institutions have varied approaches to addressing the issue of removing idle CVCs, and more standardized approaches in checklists as well as communication, particularly on multidisciplinary rounds, will be key to CVC removal. Utilization of the EHR for reminders or appropriate documentation of necessity is a factor. Avoidance of placing a CVC or appropriateness of the CVC is also important to consider.

Prevention of Central Line-Associated Bloodstream Infections Through Educational Interventions in Adult Intensive Care Units: A Systematic Review

Central line-associated bloodstream infections (CLABSIs) represent a severe systemic threat to patients admitted in ICUs and contribute to increased mortality, prolonged length of stay in ICUs, and increased costs. The majority of CLABSIs are preventable. The current systematic review aimed to investigate the effectiveness of educational methods on CLABSI rates in adult ICUs. A systematic literature search was conducted using the electronic databases of Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, and Cochrane Database of Systematic Reviews for studies published from the beginning of 1995 to March 2020. The terms used for the search were as follows: central venous catheters, infection, central line-associated bloodstream infections, intensive care unit, and education intervention in all possible combinations and using the word 'and' between them. Data were extracted independently and crosschecked by two authors using a standard data collection form. The quality of the studies included in the review was assessed using the Methodological Index for Non-randomized Studies (MINORS). The current systematic review included 27 interventional studies of central line insertion or maintenance or both in adult ICU settings with documentation of the CLABSI incidence expressed per 1,000 catheter days. A large deviation between the length of time and type of educational interventions was found. Statistical significance was found in all studies (except one) in terms of CLABSI reduction despite the large variation of the length or the type of the educational intervention. Continuing education on infection prevention may be necessary to maintain the post-intervention results and improve clinical outcomes.

Interventions to reduce unnecessary central venous catheter use to prevent central-line–associated bloodstream infections in adults: A systematic review

Objective

To identify, describe, and evaluate interventions to reduce unnecessary central venous catheter (CVC) use to prevent central-line–associated bloodstream infections (CLABSIs) in adults.

Design

Systematic review.

Methods

The review has been registered in PROSPERO, an international prospective register of systematic reviews. We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and the Cumulative Index to Nursing and Allied Health (CINAHL) from inception until August 28, 2018, to collect experimental and observational studies. We included all studies that implemented interventions to reduce unnecessary CVC use, defined as interventions aimed at improving appropriateness, awareness of device presence, or prompt removal of devices.

Results

In total, 1,892 unique citations were identified. Among them, 1 study (7.1%) was a randomized controlled trial, 9 studies (64.3%) were quasi-experimental studies, and 4 studies (28.6%) were cohort studies. Furthermore, 13 studies (92.9%) demonstrated a decrease in CVC use after intervention despite different reporting methods, and the reduction rate varied from 6.8% to 85%. Also, 7 studies (50.0%) that reported the incidence of CLABSI described a reduction in CLABSIs ranging from 24.4% to 100.0%. Data on secondary outcomes were limited, and results of the descriptive analysis showed 70%–84% compliance with these interventions, less catheter occlusion, shorter duration of hospitalization, and cost savings.

Conclusions

Interventions to reduce unnecessary CVC use significantly decrease the rate of CLABSI. Healthcare providers should strongly consider implementing these interventions for prevention of CLABSI in adults.

Impact of a Sequential Intervention on Albumin Utilization in Critical Care

OBJECTIVES

Literature generally finds no advantages in mortality risk for albumin over cheaper alternatives in many settings. Few studies have combined financial and nonfinancial strategies to reduce albumin overuse. We evaluated the effect of a sequential multifaceted intervention on decreasing albumin use in ICU and explore the effects of different strategies.

DESIGN

Prospective prepost cohort study.

SETTING

Eight ICUs at two hospitals in an academic healthcare system.

PATIENTS

Adult patients admitted to study ICUs from September 2011 to August 2014 (n = 22,004).

INTERVENTIONS

Over 2 years, providers in study ICUs participated in an intervention to reduce albumin use involving monthly feedback and explicit financial incentives in the first year and internal guidelines and order process changes in the second year.

MEASUREMENTS AND MAIN RESULTS

Outcomes measured were albumin orders per ICU admission, direct albumin costs, and mortality. Mean (SD) utilization decreased 37% from 2.7 orders (6.8) per admission during the baseline to 1.7 orders (4.6) during the intervention (p < 0.001). Regression analysis revealed that the intervention was independently associated with 0.9 fewer orders per admission, a 42% relative decrease. This adjusted effect consisted of an 18% reduction in the probability of using any albumin (p < 0.001) and a 29% reduction in the number of orders per admission among patients receiving any (p < 0.001). Secondary analysis revealed that probability reductions were concurrent with internal guidelines and order process modification while reductions in quantity occurred largely during the financial incentives and feedback period. Estimated cost savings totaled $2.5M during the 2-year intervention. There was no significant difference in ICU or hospital mortality between baseline and intervention.

CONCLUSIONS

A sequential intervention achieved significant reductions in ICU albumin use and cost savings without changes in patient outcomes, supporting the combination of financial and nonfinancial strategies to align providers with evidence-based practices.

Using Incentives to Improve Resource Utilization: A Quasi-Experimental Evaluation of an ICU Quality Improvement Program

OBJECTIVES

Healthcare systems strive to provide quality care at lower cost. Arterial blood gas testing, chest radiographs, and RBC transfusions provide an important example of opportunities to reduce excess resource utilization within the ICU. We describe the effect of a multifaceted quality improvement program designed to decrease the avoidable arterial blood gases, chest radiographs, and RBC utilization on utilization of these resources and patient outcomes.

DESIGN

Prospective pre-post cohort study.

SETTING

Seven ICUs in an academic healthcare system.

PATIENTS

All adult ICU patients admitted to study ICUs during consecutive baseline (n = 7,357), intervention (n = 7,553), and follow-up (n = 7,657) years between September 2010 and August 2013.

INTERVENTIONS

A multifaceted quality improvement program including provider education, audit and feedback, and unit-based provider financial incentives targeting arterial blood gas, chest radiograph, and RBC utilization.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the number of orders for arterial blood gases, chest radiographs, and RBCs per patient. Compared with the baseline period, unadjusted arterial blood gas, chest radiograph, and RBC utilization in the intervention period was reduced by 42%, 26%, and 17%, respectively (p < 0.01). After adjusting for potentially relevant patient factors, the intervention was associated with 128 fewer arterial blood gases, 73 fewer chest radiographs, and 16 fewer RBCs per 100 patients (p < 0.01). This effect was durable during the follow-up year. This reduction yielded an approximate net savings of $1.5 M in direct costs over the intervention and follow-up years after accounting for the direct costs of the program. Unadjusted hospital mortality decreased from 7% in the baseline period to 5.2% in the intervention period (p < 0.01). This reduction remained significant after adjusting for patient factors (odds ratio = 0.43; p < 0.01).

CONCLUSIONS

Implementation of a multifaceted quality improvement program including financial incentives was associated with significant improvements in resource utilization. Our findings provide evidence supporting the safety, effectiveness, and sustainability of incentive-based quality improvement interventions.

Influence of a multifaceted intervention on central line days in intensive care units: results of a national multisite study

BACKGROUND

Removing unnecessary central lines is a critical step in reducing risk of infection and was 1 focus of a national quality improvement collaborative. We examined if participating adult intensive care units (ICUs) reduced central line days during the project period compared with the period before implementation of the "On the CUSP: Stop BSI" program.

METHODS

We used a linear regression model on a total of 9,225 ICU-quarters of data to examine the effect of the intervention on total central line days of ICU participants in the national project (2008-2012), adjusting for ICU type, hospital characteristics, project cohort, season, and accounting for repeated measures on the same unit and clustering within states using random intercepts.

RESULTS

The regression results showed no significant change in preintervention quarters. However, significant decreases in total line days started during quarter 4 after intervention and differences were sustained through quarter 6. There were 4% fewer central line catheter days reported at the project's conclusion compared with the baseline.

CONCLUSIONS

To keep central lines from doing patients harm, clinicians must assess the need for lines and remove them as soon as clinically advisable to halt the possibility of infection via the line. Effective communication and empowering providers to identify unnecessarily extended use of central lines could accelerate the realization, someday, of eliminating central line associated bloodstream infections in ICUs.

A survey of preventive measures used and their impact on central line-associated bloodstream infections (CLABSI) in intensive care units (SPIN-BACC)

BACKGROUND

The Quebec central line-associated bloodstream infections (CLABSI) in intensive care units (ICUs) Surveillance Program saw a decrease in CLABSI rates in most ICUs. Given the surveillance trends observed in recent years, we aimed to determine what preventive measures have been implemented, if compliance to measures was monitored and its impact on CLABSI incidence rates.

METHODS

All hospitals participating in the Quebec healthcare-associated infections surveillance program (SPIN-BACC - n = 48) received a 77-question survey about preventive measures implemented and monitored in their ICU. The questionnaire was validated for construct, content, face validity, and reliability. We used Poisson regression to measure the association between compliance monitoring to preventive measures and CLABSI rates.

RESULTS

Forty-two (88%) eligible hospitals completed the survey. Two components from the maximum barrier precautions were used less optimally: cap (88%) and full sterile body drape (71%). Preventive measures reported included daily review of catheter need (79%) and evaluation of insertion site for the presence of inflammation (90%). Two hospitals rewired lines even if an infection was suspected or documented.In adult ICUs, there was a statistically significant greater decrease in CLABSI rates in ICUs that monitored compliance to preventive insertion measures, after adjusting for teaching status and the number of hospital beds (p = 0.036).

CONCLUSIONS

Hospitals participating to the SPIN-BACC program follow recommendations for CLABSI prevention, but only a minority locally monitor their application. Compliance monitoring of preventive measures for catheter insertion was associated with a decrease in CLABSI incidence rates.

Intensive care information system impacts

Introduction:

Today, intensive care needs to be increased with a prospect of an aging population and socioeconomic factors influencing health intervention, but there are some problems in the intensive care environments, it is essential to resolve. The intensive Care information system has the potential to solve many of ICU problems. The objective of the review was to establish the impact of intensive care information systems on the practitioners practice, patient outcomes and ICU performance.

Methods:

Scientific databases and electronic journal citations was searched to identify articles that discussed the impacts of intensive care information system on the practices, patient outcomes and ICU performance. A total of 22 articles discussing ICIS outcomes was included in this study from 609 articles initially obtained from the searches.

Results:

Pooling data across studies, we found that the median impact of ICIS on information management was 48.7%. The median impact of ICIS on user’ outcomes was 36.4%, impact on saving tips by 24%, clinical decision support by a mean of 22.7%, clinical outcomes improved by a mean of 18.6%, and researches improved by 18%.

Conclusion:

The functionalities of ICIS are growing day by day and new functionalities are available with every major release. Better adoption of ICIS by the intensive care environments emphasizes the opportunity of better intensive care services through patient oriented intensive care clinical information systems. There is an immense need for developing guidelines for standardizing ICIS to to maximize the power of ICISs and to integrate with HISs. This will enable intensivists to use the systems in a more meaningful way for better patient care. This study provides a better understanding and greater insight into the effectiveness of ICIS in improving patient care and reducing health care expenses.