Sustained reduction of central line-associated bloodstream infections outside the intensive care unit with a multimodal intervention focusing on central line maintenance

Innovative Approaches to Monitor Central Line Associated Bloodstream Infections (CLABSIs) Bundle Efficacy in Intensive Care Unit (ICU): Role of Device Standardized Infection Rate (dSIR) and Standardized Utilization Ratio (SUR)-An Italian Experience

In several settings, the COVID-19 pandemic determined a negative impact on the occurrence of healthcare-associated infection, particularly for on central lines associated bloodstream infections (CLABSI). In our setting, we observed a significant increase in CLABSI in our intensive care unit (ICU) during 2020 and 2021 vs. 2018 to 2019. A refresher training activity on central venous catheter (CVC) management bundles was carried out in September-October 2021 for the ICU health staff. We assessed the impact of bundle implementation by means of standardized indicators, such as the Device Utilization Ratio (DUR), in this case, the Central Line Utilization Ratio, the Standardized Utilization Ratio (SUR), and the device Standardized Infection Ratio (dSIR). Standardized ratios for device use and infection ratio were computed using data from 2018 and 2019 as expectation data. After bundle implementation, we observed a significant reduction of dSIR (p < 0.001), which dropped from 3.23 and 2.99 in the 2020-2021 biennium to 1.11 in 2022 (CLABSI in the first quarter only); no more CLABSI were observed afterwards. Standardized ratios proved helpful in identify increasing trends of CLABSI in the ICU and monitoring the impact of a simple effective tool, i.e., training on and implementation of a bundle for CVC management.

An Analysis of Outcomes Following a Central Line Associated Blood Stream Infections (CLABSI) Reduction Quality Improvement Project in a Tertiary Care Center

Central Line Associated Blood Stream Infections (CLABSI) continue to be a significant complication for hospitalized patients. Hospitals have used various strategies to reduce CLABSI events due to the significant complications and associated costs. In this QI analysis, we examined the impact of a CLABSI reduction quality improvement project within a single ICU at a tertiary care medical center. Absolute CLABSI counts were compared between this ICU and other health system ICUs that did not implement the bundle. A sustained reduction in absolute CLABSI counts to or near zero was observed over 17 months after implementation. ICUs not performing the interventions during this time consistently reported ≥ 2 CLABSI per month. Further analysis is needed to assess causality and the generalizability of bundle components to other ICUs. These findings may provide other health systems with additional strategies to prevent CLABSI and provide consistent, evidence-based supportive care to critically ill patients.

Positive and Neutral Needleless Connectors: A Comparative Study of Central-line Associated Bloodstream Infection, Occlusion, and Bacterial Contamination of the Connector Lumen

A pragmatic, multiphase prospective quality improvement initiative was performed to determine whether a positive displacement connector (PD) causes reduction of central line-associated bloodstream infection (CLABSI), occlusion, and catheter hub colonization when compared with a neutral displacement connector with alcohol disinfecting cap (AC). Patients with an active central vascular access device (CVAD) were enrolled March 2018 to February 2019 (P2) and compared to the prior year (P1). Two hospitals were randomized to use PD without AC (Hospital A) and with AC (Hospital B). Two hospitals utilized a neutral displacement connector with AC (Hospitals C and D). CVADs were monitored for CLABSI, occlusion, and bacterial contamination during P2. Of the 2454 lines in the study, 1049 were cultured. CLABSI decreased in all groups between P1 and P2: Hospital A, 13 (1.1%) to 2 (0.2%); Hospital B, 2 (0.3%) to 0; and Hospitals C and D, 5 (0.5%) to 1 (0.1%). CLABSI reduction was equivalent between P1 and P2 with and without AC, at around 86%. The rate of occlusion per lumen was 14.4%, 12.1%, and 8.5% for Hospitals A, B and C, D, respectively. Hospitals using PD had a higher rate of occlusion than those that did not (P = .003). Lumen contamination with pathogens was 1.5% for Hospitals A and B and 2.1% for Hospitals C and D (P = .38). The rate of CLABSI was reduced with both connectors, and PD reduced infections with and without the use of AC. Both connector types had low-level catheter hub colonization with significant bacteria. The lowest rates of occlusion were found in the group using neutral displacement connectors.

Implementation Strategies for Preventing Healthcare-Associated Infections across the Surgical Pathway: An Italian Multisociety Document

Healthcare-associated infections (HAIs) result in significant patient morbidity and can prolong the duration of the hospital stay, causing high supplementary costs in addition to those already sustained due to the patient’s underlying disease. Moreover, bacteria are becoming increasingly resistant to antibiotics, making HAI prevention even more important nowadays. The public health consequences of antimicrobial resistance should be constrained by prevention and control actions, which must be a priority for all health systems of the world at all levels of care. As many HAIs are preventable, they may be considered an important indicator of the quality of patient care and represent an important patient safety issue in healthcare. To share implementation strategies for preventing HAIs in the surgical setting and in all healthcare facilities, an Italian multi-society document was published online in November 2022. This article represents an evidence-based summary of the document.

Early prediction of central line associated bloodstream infection using machine learning

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) are associated with significant morbidity, mortality, and increased healthcare costs. Despite the high prevalence of CLABSIs in the U.S., there are currently no tools to stratify a patient's risk of developing an infection as the result of central line placement. To this end, we have developed and validated a machine learning algorithm (MLA) that can predict a patient's likelihood of developing CLABSI using only electronic health record data in order to provide clinical decision support.

METHODS

We created three machine learning models to retrospectively analyze electronic health record data from 27,619 patient encounters. The models were trained and validated using an 80:20 split for the train and test data. Patients designated as having a central line procedure based on International Statistical Classification of Diseases and Related Health Problems 10 codes were included.

RESULTS

XGBoost was the highest performing MLA out of the three models, obtaining an AUROC of 0.762 for CLABSI risk prediction at 48 hours after the recorded time for central line placement.

CONCLUSIONS

Our results demonstrate that MLAs may be effective clinical decision support tools for assessment of CLABSI risk and should be explored further for this purpose.

Bundle approach used to achieve zero central line-associated bloodstream infections in an adult coronary intensive care unit

Background

Central venous catheterisation is commonly used in critical patients in intensive care units (ICU). It may cause complications and attribute to increase mortality and morbidity. At coronary ICU (CICU) of cardiac hospital, central line-associated bloodstream infection (CLABSI) rate was 2.82/1000 central line days in 2015 and 3.11/1000 central line days in 2016. Working in collaboration with Institute for Healthcare Improvement (IHI), we implemented evidence-based practices in the form of bundles in with the aim of eliminating CLABSI in CICU.

Methods

In collaboration with IHI, we worked on this initiative as multidisciplinary team and tested several changes. CLABSI prevention bundles were tested and implemented, single kit for line insertion, simulation-based training for line insertions, standardised and real-time bundle monitoring by direct observations are key interventions tested. We used model for improvement and changes were tested using small Plan-Do-Study-Act cycles. Surveillance methods and CLABSI definition used according to National Healthcare Safety Network.

Results

The CLABSI rate per 1000 patient-days dropped from 3.1 per 1000 device-days to 0.4 per 1000 device-days. We achieved 757 days free of CLABSI in the unit till December 2018 when a single case happened. After that we achieved 602 free days till July 2020 and still counting.

Conclusions

Implementation of evidence-based CLABSI prevention bundle and process monitoring by direct observation led to significant and subsequently sustained improvement in reducing CLABSI rate in adult CICU.

Use of alcohol containing caps for preventing bloodstream infections: A randomized controlled trial

BACKGROUND

A majority of bloodstream infections seen in intensive care units stem from intravascular catheters used on patients. Catheter hubs are the entrance for pathogenic microorganisms into the inner surfaces of the catheters. The pathogenic microorganisms colonization in the mentioned areas can cause central line-associated bloodstream infection (CLABSI).

METHODS

This study was conducted as a randomized controlled trial to investigate the effect of alcohol-containing caps on the prevention of CLABSI. Total of 95 patients participated in the study. Isopropyl alcohol-containing caps were used for protecting the needle-free connectors closing the hubs of the central venous catheters in the intervention group. However, the control group patient received standard catheter caps.

RESULT

There was a statistically significant difference between groups in terms of infection distribution (X2 = 13.058; p < 0.001). The risk of infection in the control group was 13.7 times higher than the risk of infection in the intervention group.

DISCUSSION

Our results suggest that alcohol-containing caps are effective or in preventing CLABSI.

CONCLUSION

These findings suggest that alcohol-containing caps on ports are effective in preventing CLABSI.

Practice Guidelines for Central Venous Access 2020

These practice guidelines update the Practice Guidelines for Central Venous Access: A Report by the American Society of Anesthesiologists Task Force on Central Venous Access, adopted by the American Society of Anesthesiologists in 2011 and published in 2012. These updated guidelines are intended for use by anesthesiologists and individuals under the supervision of an anesthesiologist and may also serve as a resource for other physicians, nurses, or healthcare providers who manage patients with central venous catheters.

Supplemental Digital Content is available in the text.

Implementation of a Vascular Access Team to Reduce Central Line Usage and Prevent Central Line-Associated Bloodstream Infections

Central line-associated bloodstream infections (CLABSIs) account for one-third of all hospital-acquired infections and can cost the health care system between $21,000 and $100,000 per infection. A dedicated vascular access team (VAT) can help develop, implement, and standardize policies and procedures for central line usage that address insertion, maintenance, and removal as well as educate nursing staff and physicians. This article presents how 1 hospital developed a VAT and implemented evidence-based guidelines. Central line utilization decreased by 45.2%, and CLABSI incidence decreased by 90%. The results of the study demonstrated that a reduced utilization of central lines minimized the risk of patients developing a CLABSI.

Effect of a Systemwide Approach to a Reduction in Central Line-Associated Bloodstream Infections

BACKGROUND

Unit-based initiatives were deployed independently creating silos in practice variability across the system with little impact on reduction of central line-associated bloodstream infections (CLABSI).

PROBLEM

The goal was to decrease CLABSI systemwide by establishing standardized evidence-based practice (EBP) procedures to advance nursing practice.

APPROACH

A new innovative method, the Ferrari Method for Practice Standardization, enhanced the quality infrastructure by merging EBP and lean methodology to translate nursing innovations into practice. Leveraging a culture of shared decision making to support autonomy, as well as collaborating interprofessionally, allowed the organization to standardize and sustain CLABSI prevention.

OUTCOMES

The Ferrari Method for Practice Standardization successfully reduced CLABSI rates by 48% over a 1-year improvement cycle. Eight standardized EBP clinical procedures were developed and implemented across the organization.

CONCLUSION

The implementation of the Ferrari Method for Practice Standardization swiftly moves new knowledge into clinical practice to improve outcomes. Using standardized improvement methodology, it eases the interprofessional approval processes, maximizes autonomy, and focuses on quality care.

Reducing Three Infections Across Cardiac Surgery Programs: A Multisite Cross-Unit Collaboration

Using a pre–post design, this study examined the impact of a multifaceted program to simultaneously improve 3 health care–associated infections and patient safety culture throughout the cardiac surgery service line in 11 hospitals. Interventions included the Comprehensive Unit-based Safety Program to improve safety culture and evidence-based bundles to prevent central line–associated bloodstream infection (CLABSI), surgical site infection (SSI), and ventilator-associated pneumonia (VAP). CLABSIs and SSIs showed a downward trend over 2 years, then the rates returned to levels similar to baseline in the third year. VAP rate changes were difficult to interpret because of the VAP definition change. Patient safety culture domain “hospital management support” showed significant improvement, but feedback and communication about errors and staffing declined. Simultaneous implementation of multiple interventions across units is challenging. The findings highlight the importance of sustainment efforts and suggest future work should anticipate both positive and negative change in safety culture dimensions.

Appraising the quality standard underpinning international clinical practice guidelines for the selection and care of vascular access devices: a systematic review of reviews

OBJECTIVE

Catheter-related bloodstream infections are one of the most important adverse events for patients. Evidence-based practice embraces interventions to prevent and reduce catheter-related bloodstream infections in patients. At present, a growing number of guidelines exist worldwide. The purpose of the study was to assess clinical practice guidelines for peripheral and central venous access device care and prevention of related complications.

DESIGN

Systematic review of clinical practice guidelines: We conducted a search of the literature published from 2005 to 2018 using Medline/PubMed, Embase, CINAHL, Ovid, ScienceDirect, Scopus and Web of Science. We also evaluated grey literature sources and websites of organisations that compiled or produced guidelines. Guideline quality was assessed with the Appraisal of Guidelines for Research and Evaluation, Second Edition tool by three independent reviewers. Cohen's kappa coefficient was used to evaluate the concordance between reviewers.

RESULTS

We included seven guidelines in the evaluation. The concordance between observers was substantial, K=0.6364 (95% CI 0.0247 to 1.2259). We identified seven international guidelines, which scored poorly on crucial domains such as applicability (medium 39%), stakeholder involvement (medium 65%) and methodological rigour (medium 67%). Guidelines by Spanish Health Ministry and UK National Institute for Health and Care Excellence presented the highest quality.

CONCLUSIONS

It is crucial to critically evaluate the validity and reliability of clinical practice guidelines so the best, most context-specific document is selected. Such choice is a necessary prior step to encourage and support health organisations to transfer research results to clinical practice. The gaps identified in our study may explain the suboptimal clinical impact of guidelines. Such low adoption may be mitigated with the use of implementation guides accompanying clinical documents.

Implementation of a knowledge mobilization model to prevent peripheral venous catheter-related adverse events: PREBACP study-a multicenter cluster-randomized trial protocol

Background

Peripheral venous catheters are the most commonly used invasive devices in hospitals worldwide. Patients can experience multiple adverse events during the insertion, maintenance, and management of these devices. Health professionals aim to resolve the challenges of care variability in the use of peripheral venous catheter through adherence to clinical practice guidelines. The aim of this cluster-randomized controlled trial is to determine the efficacy of a multimodal intervention on incidence of adverse events associated with the use of peripheral venous catheters in adult hospital patients. Additional aims are to analyze the fidelity of nurses and the relationship between contextual factors on the use of best available and the outcomes of the intervention.

Methods

Five public hospitals in the Spanish National Health System, with diverse profiles, including one university hospital and four second-level hospitals, will be included. In total, 20 hospitalization wards will be randomized for this study by ward to one of two groups. Those in the first group receive an intervention that lasts 12 months implementing evidence-based practice in healthcare related to peripheral catheters through a multimodal strategy, which will contain updated and poster protocols insertion, maintenance and removal of peripheral venous catheters, technologies applied to e-learning, feedback on the results, user and family information related to peripheral catheter, and facilitation of the best evidence by face-to-face training session. Primary outcome measures: Incidence of adverse events associated with the use of peripheral venous catheters is measured by assessing hospital records. Secondary outcome measures: Nurses’ adherence to clinical practice guidelines, clinical outcomes, and the cost of implementing the multimodal intervention.

Discussion

Clinical implementation is a complex, multifaceted phenomenon which requires a deep understanding of decision-making, knowledge mobilization, and sense making in routine clinical practice. Likewise, the inclusion of strategies that promote fidelity to recommendations through multicomponent and multimodal intervention must be encouraged. The use of a transfer model could counterbalance one of the greatest challenges for organizations, the evaluation of the impact of the implementation of evidence in the professional context through quality indicators associated with prevention and control of infections.

Trial registration

Current Controlled Trials ISRCTN10438530. Registered 20 March 2018.

A Novel Needle-Free Blood Draw Device for Sample Collection From Short Peripheral Catheters

A new US Food and Drug Administration-cleared needleless blood collection device (PIVO; Velano Vascular, San Francisco, CA) for short peripheral catheters was compared with conventional venipuncture for collecting blood samples for routine laboratory analysis from adult healthy volunteers. The PIVO device was comparable with venipuncture in terms of providing high-integrity samples (no hemolysis or clotting), equivalent laboratory values, and better patient experience as assessed by pain scores. Further studies to assess the overall utility of the PIVO device are warranted.

Prospective observational study on central line-associated bloodstream infections and central venous catheter occlusions using a negative displacement connector with an alcohol disinfecting cap

BACKGROUND

Major complications of central venous catheter (CVC) use include bloodstream infection and occlusion. We performed a prospective, observational study to determine the rate of central line-associated bloodstream infection (CLABSI) and CVC occlusion using a negative displacement connector with an alcohol disinfecting cap.

METHODS

Patients were followed from the time of CVC insertion through 2 days after removal, at the time of hospital discharge if there was no documentation of removal, or 90 days after the insertion of the CVC if it was not removed. CLABSI was defined using National Healthcare Safety Network criteria. Data for evidence of lumen occlusions were extracted from the electronic health record. Direct observations were performed to assess adherence to hospital policy regarding CVC insertion practice.

RESULTS

A total of 2,512 catheters from 2,264 patients were enrolled for this study. There were 21 CLABSIs (0.84%; 95% confidence interval [CI], 0.48%-1.19%; 0.62 per 1,000 line days) and 378 occlusions (15.05%; 95% CI, 13.65%-16.45%; 11.23 per 1,000 line days). Eighty-five direct observations demonstrated insertion protocol adherence in 881 of 925 (95.24%; 95% CI, 93.87%-96.61%) measured criteria.

CONCLUSIONS

Lines placed following a standardized protocol using a negative displacement connector with an alcohol cap have low rates of infection compared with historically published findings. We also established that the occlusion rate is >15-fold the CLABSI rate.

Plastic in patient study: Prospective audit of adherence to peripheral intravenous cannula monitoring and documentation guidelines, with the aim of reducing future rates of intravenous cannula-related complications

BACKGROUND

Peripheral intravenous cannula (PIVC) insertion is a universal intervention for inpatients and is associated with multiple complications. Effective, simple, reproducible interventions specific to PIVC complication prevention are few and often extrapolated from central venous catheter complication prevention strategies. The objective of this study is to improve compliance with documentation and monitoring PIVC guidelines in the medical ward of a secondary care center.

METHODS

This study is a prospective run-in audit of adherence to PIVC documentation and monitoring guidelines between the dates of August 30-November 14, 2014, with data recollection from December 25, 2014-January 30, 2015, after intervention implementation. Three interventions were implemented. The Plastic in Patient (PIP) strip is a dedicated column on the journey board, identifying inpatients with PIVCs, prompting assessment of indication at daily multidisciplinary meetings. PIP row is a prompt in the medical admission proforma to review PIVC indication. PIP poster is a visual cue on PIVC trolleys highlighting PIVC management practices.

RESULTS

Baseline demographics were similar in the pre- and postintervention groups. Documentation significantly improved in the postintervention group (36.4 vs 50%, P = .025). Early identification of nonindicated PIVCs improved in the postintervention group (88.8% vs 97.1%, P = .018) and a trend toward a reduced PIVC-related early phlebitis rate (3.7% vs 0, P = .08).

CONCLUSIONS

Simple, cost-effective interventions result in improvements in adherence to practice guidelines. Our results suggest a trend toward reduction in phlebitis rates.

Increasing the Reliability of Fully Automated Surveillance for Central Line–Associated Bloodstream Infections

OBJECTIVE

To increase reliability of the algorithm used in our fully automated electronic surveillance system by adding rules to better identify bloodstream infections secondary to other hospital-acquired infections.

METHODS

Intensive care unit (ICU) patients with positive blood cultures were reviewed. Central line–associated bloodstream infection (CLABSI) determinations were based on 2 sources: routine surveillance by infection preventionists, and fully automated surveillance. Discrepancies between the 2 sources were evaluated to determine root causes. Secondary infection sites were identified in most discrepant cases. New rules to identify secondary sites were added to the algorithm and applied to this ICU population and a non-ICU population. Sensitivity, specificity, predictive values, and kappa were calculated for the new models.

RESULTS

Of 643 positive ICU blood cultures reviewed, 68 (10.6%) were identified as central line–associated bloodstream infections by fully automated electronic surveillance, whereas 38 (5.9%) were confirmed by routine surveillance. New rules were tested to identify organisms as central line–associated bloodstream infections if they did not meet one, or a combination of, the following: (I) matching organisms (by genus and species) cultured from any other site; (II) any organisms cultured from sterile site; (III) any organisms cultured from skin/wound; (IV) any organisms cultured from respiratory tract. The best-fit model included new rules I and II when applied to positive blood cultures in an ICU population. However, they didn’t improve performance of the algorithm when applied to positive blood cultures in a non-ICU population.

CONCLUSION

Electronic surveillance system algorithms may need adjustment for specific populations.

Infect. Control Hosp. Epidemiol. 2015;36(12):1396–1400

Quality Improvement Process in a Large Intensive Care Unit: Structure and Outcomes

Quality improvement in the health care setting is a complex process, and even more so in the critical care environment. The development of intensive care unit process measures and quality improvement strategies are associated with improved outcomes, but should be individualized to each medical center as structure and culture can differ from institution to institution. The purpose of this report is to describe the structure of quality improvement processes within a large medical intensive care unit while using examples of the study institution's successes and challenges in the areas of stat antibiotic administration, reduction in blood product waste, central line-associated bloodstream infections, and medication errors.