Clinical and economic burden of bloodstream infections in critical care patients with central venous catheters

The performance and complications of long peripheral venous catheters: A retrospective single-centre study

BACKGROUND

Intravenous therapies are essential for hospitalised patients. The rapid dissemination of portable ultrasound machines has eased ultrasound-guided intravenous access and facilitated increased use of long peripheral venous catheters (LPCs). This study aimed to evaluate the clinical performance and complications of LPCs.

METHODS

Retrospective, observational single-site study. Data from all consecutively inserted LPCs during a period of 18 months was evaluated. The primary endpoint was the all-cause incidence rate of catheter removal. Secondary endpoints included specific reasons for the catheter removal and the associations between predefined characteristics of the patients, the infusions and the catheters with catheter failure.

RESULTS

During the period, 751 PVCs were inserted in 457 patients. The reasons for catheter removal were recorded in 563 cases. The overall incidence rate of catheter removal was 95.8/1000 catheter days (95% CI 88.4-103.8). The median dwell time was 8 days (IQR 5-14), and the total dwell time was 6136 days. Catheter failure occurred in 283 (50.3%) cases, of which the most common cause was phlebitis (n = 101, 17.9%). In multivariable analyses, the use of the cephalic vein was significantly associated with both all-cause catheter failure (p < .001) and catheter failure due to phlebitis (p < .001). In multivariable analyses, vancomycin infusion was not significantly associated with all-cause catheter failure (HR 1.15 (0.55-2.42), p = .71) or catheter failure due to phlebitis (HR 1.49 (0.49-4.53), p = .49).

CONCLUSION

The overall incidence rate of catheter removal was 95.8/1000 catheter days, and the most common causes of catheter failure were phlebitis, infiltration and unintended catheter removal. The use of the cephalic vein was significantly associated with catheter failure in multivariable analyses. We did not find an association between vancomycin infusion and catheter failure in multivariable analyses.

Reducing Central Line-Associated Bloodstream Infections With a Multipronged Nurse-Driven Approach

BACKGROUND

Despite implementation of central catheter bundles, central line [catheter]-associated bloodstream infections (CLABSIs) remain a preventable hospital-acquired infection.

LOCAL PROBLEM

A new population of patients with pulmonary artery catheters was introduced to the cardiac progressive care unit, increasing central catheter days, device use, and CLABSI rate.

METHODS

A quality improvement project was conducted. Nursing staff implemented a standardized central catheter rounding process 3 days a week to critically assess all central catheter dressings, deter-mine the necessity of each central catheter, and educate patients on the importance of keeping central catheter dressings clean, dry, and intact. Data were collected during central catheter rounds for each patient, entered in an electronic survey tool via mobile devices, and analyzed.

RESULTS

From July 2019 through June 2022, a total of 2692 rounds were conducted for 707 individual patients with 3064 central catheters. Main interventions were dressing management, monitoring insertion site bleeding that extended beyond edges of the chlorhexidine gluconate pad, treating patients' allergies to products, and maintaining sustainability within the unit. Central catheter rounds decreased the CLABSI rate from 1.86 to 0.0 despite the continued increase in central catheter days.

CONCLUSIONS

Central catheter dressing assessment, intervention, and education help reduce CLABSIs. Central catheter rounds are an important adjunct to the CLABSI bundle. A central catheter dressing management algorithm helps nurses decide when to change a dressing and which type of dressing to use.

Nurses' knowledge, attitudes, and practices on CLABSI prevention in the Intensive Care Unit: An observational study

BACKGROUND

Management of central venous catheters (CVC) is a frequent procedure in intensive care units (ICUs) and the risk of bloodstream infections (CLABSI) is found to be high. The literature provides healthcare professionals with guidelines to prevent the risk of CLABSI infections. The aim of this study was to observe the knowledge, attitudes, and practices of ICU nurses on the prevention of CLABSI.

METHODS

A multicenter cross-sectional study was conducted between March 2023 and September 2023; the research was carried out among six ICUs in Bari both on the web and in paper mode. The survey consisted of multiple-choice questions structured in two sections: demographic sample data and the 2017 Esposito MR questionnaire, drawn up based on the 2011 guidelines of the Centers for Disease Control and Prevention, consisting of four dimensions: knowledge, attitudes, practices, information.

RESULTS

121 nurses (57.1%) participated in the study. 72% were unfamiliar with the guidelines, especially nurses aged 41-50 years (RR = 1.88; CI = 0.78-4.51; p = 0.13) and more than 10 years' work experience (RR = 1.56; CI = 0.76-3.23; p = 0.20). Regarding attitudes, nurses were aware of the usefulness of the guidelines (Me = 10; IQR = 8-10) and the importance of hand washing for prevention (Me = 10; IQR = 10-10) despite 39.7% (n = 48) believing that gloves replace hand washing, and there were no statistically significant differences in comparing scores with age, work experience, and educational qualification. 96.7% always substituted dressing for CVC; 120 nurses (99.2%) were always replacing infusion sets and 71.2% always sanitized the access ports before infusions. Finally, 102 participants (84.3%) felt the need to get more information about the prevention of CLABSI.

CONCLUSIONS

We observed a reduced knowledge of the guidelines for the prevention of CLABSI despite the attitudes and practices of the nurses being satisfactory. In addition to implementing training, strategies for disseminating guidelines should be adopted.

Determinants of bacterial survival and proliferation in blood

Bloodstream infection is a major public health concern associated with high mortality and high healthcare costs worldwide. Bacteremia can trigger fatal sepsis whose prevention, diagnosis, and management have been recognized as a global health priority by the World Health Organization. Additionally, infection control is increasingly threatened by antimicrobial resistance, which is the focus of global action plans in the framework of a One Health response. In-depth knowledge of the infection process is needed to develop efficient preventive and therapeutic measures. The pathogenesis of bloodstream infection is a dynamic process resulting from the invasion of the vascular system by bacteria, which finely regulate their metabolic pathways and virulence factors to overcome the blood immune defenses and proliferate. In this review, we highlight our current understanding of determinants of bacterial survival and proliferation in the bloodstream and discuss their interactions with the molecular and cellular components of blood.

Effect of Infusion Set Replacement Intervals on Central Line-Associated Bloodstream Infection in the Intensive Care Unit: Study Protocol of the INSPIRATION Study

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.

Major immediate insertion-related complications after central venous catheterisation and associations with mortality, length of hospital stay, and costs: A prospective observational study

BACKGROUND

It is well-known that infectious complications after central venous catheterisation are associated with increased mortality, length of hospital stay and costs. However, there are limited data regarding such associations for immediate insertion-related complications. Therefore, the aim of this study was to investigate whether major immediate insertion-related complications are associated with mortality, length of hospital stay and costs.

METHODS

This was a preplanned substudy to the CVC-MECH trial on immediate insertion-related complications after central venous catheterisation in the ultrasound-guided era. Patients receiving central venous catheters at Skåne University Hospital from 2 March 2019 to 31 December 2020 were prospectively included. Patient characteristics, clinical data and costs were automatically collected from medical journals and the patient administration system. Associations between major immediate insertion-related complications and mortality, length of hospital stay and costs were studied by multivariable logistic and linear regression analyses.

RESULTS

In total, 6671 patients were included, of whom 0.5% suffered major immediate insertion-related complications. Multivariable analyses, including surrogates for general morbidity, showed associations between major immediate insertion-related complications and 30-day (odds ratio 2.46 [95% CI 1.05-5.77]), 90-day (2.90 [1.35-6.21]) and 180-day (2.26 [1.05-4.83]) mortality. There were no associations between major immediate insertion-related complications and increased length of hospital stay or costs.

CONCLUSION

This study showed that major immediate insertion-related complications, although not directly responsible for any death, were associated with increased 30-day, 90-day and 180-day mortality. These findings clearly demonstrate the importance of using all possible means to prevent avoidable insertion-related complications after central venous catheterisation.

Burden of bacterial bloodstream infections and recent advances for diagnosis

Bloodstream infections (BSIs) and subsequent organ dysfunction (sepsis and septic shock) are conditions that rank among the top reasons for human mortality and have a great impact on healthcare systems. Their treatment mainly relies on the administration of broad-spectrum antimicrobials since the standard blood culture-based diagnostic methods remain time-consuming for the pathogen's identification. Consequently, the routine use of these antibiotics may lead to downstream antimicrobial resistance and failure in treatment outcomes. Recently, significant advances have been made in improving several methodologies for the identification of pathogens directly in whole blood especially regarding specificity and time to detection. Nevertheless, for the widespread implementation of these novel methods in healthcare facilities, further improvements are still needed concerning the sensitivity and cost-effectiveness to allow a faster and more appropriate antimicrobial therapy. This review is focused on the problem of BSIs and sepsis addressing several aspects like their origin, challenges, and causative agents. Also, it highlights current and emerging diagnostics technologies, discussing their strengths and weaknesses.

Preparation of Silver Ion Antimicrobial Dressings and Prevention and Treatment of Central Venous Catheter-Related Infection on Burn Wounds of Critically Burned Patients

To further understand the characteristics of Ag+ antimicrobial dressings and its application value in the prevention and treatment of infections in burn patients, in the study, the Ag+ gel dressings were prepared and their physical and chemical characteristics were analyzed, and relationship between the gel dressing and central venous catheter (CVC)-related infections was further explored. The results showed that silver nitrate was made into nano silver particles, and its structure was clearly visible under microscope, and nano silver was further applied to preparation of Ag+ antibacterial dressings. Fibrocytes were clearly visible in Ag+ gel dressing and arranged uniformly, which indicated that Ag+ gel dressing had good compatibility with biological materials and had no obvious toxicity. Further clinical trials showed that Ag+ gel dressing can effectively reduce CVC-related infections. From 1 to 4 weeks of the experiment, the bacterial infection rate in burn wounds and blood of the treatment group (TG), which applied Ag+ gel dressing, was lower than the control group (P < 0.05). During the treatment, the burn healing rate of the TG was also greatly higher than the control group (P < 0.05). In addition, the burn wound exudate in the TG was greatly less than the control group (P < 0.05). In summary, the Ag+ gel dressing prepared has good biological and physical and chemical properties, which have bright prospects in the prevention and treatment of burn wounds and CVC-related infections. This study provides an experimental basis for clinical application of Ag+ gel dressing.

Chlorhexidine Bathing to Prevent Central Line-Associated Bloodstream Infections in Hematology Units: A Prospective, Controlled Cohort Study

BACKGROUND

Chlorhexidine (CHG) bathing decreases the incidence of bloodstream infections in intensive care units, but its effect has been understudied in patients with hematological malignancies in noncritical care units.

METHODS

Adults with hematological malignancies hospitalized for cytotoxic chemotherapy in noncritical care units were offered daily 2% CHG bathing. We compared outcomes of patients who chose CHG bathing (CHG group) with outcomes of those who did not choose CHG bathing (usual-care group). The primary outcome was gram-positive cocci-related, skin flora-related, or central line-associated bloodstream infection. The negative control outcome was gut-origin bacteremia.

RESULTS

The CHG group (n = 485) had a crude incidence rate of the primary outcome that was 60% lower than the rate for the usual-care group (n = 408; 3.4 vs 8.4 per 1000 patient-days, P = .02) but had a similar crude incidence rate of the negative control outcome (4.5 vs 3.2 per 1000 patient-days; P = .10). In multivariable analyses, CHG bathing was associated with a 60% decrease in the primary outcome (adjusted hazard ratio [HR], 0.4; P < .001). In contrast, CHG bathing had no effect on the negative control outcome (adjusted HR, 1.1; P = .781). CHG bathing was well tolerated by participants in the CHG group.

CONCLUSIONS

CHG bathing could be a highly effective approach for preventing gram-positive cocci-related, skin flora-related, or central line-associated bacteremia in patients with hematological malignancies who are hospitalized for cytotoxic chemotherapy in noncritical care units.

Safety and efficacy of vasopressor administration through midline catheters

CONTEXT

Vasopressors are commonly administered through Central Venous Catheters (CVCs) as it is considered unsafe to administer them via peripheral IVs, mainly due to the concern of local tissue injury. Unlike peripheral IVs, midline catheters provide a wider lumen with the catheter tip ending in a large peripheral vein. The use of vasopressors through midline catheters has not yet been evaluated.

OBJECTIVE

The primary objective of this study is to determine the safety and efficacy of long term administration of vasopressors through a midline catheter.

DESIGN

This is a retrospective study between 2016 and 2019 looking at the outcomes of midline catheters.

SETTING

45 bed Tertiary level ICU in a 600-bed teaching hospital.

PATIENTS

A total of 248 patients received vasopressors via midline catheters.

RESULTS

The average midline dwell time was 14.7 ± 12.8 days and the average duration of continuous vasopressor infusion was 7.8 ± 9.3 days. Vasopressors used with their average dose (AD) were norepinephrine (n = 165, 16.8 CE ± 10.7 μg/min), epinephrine (n = 56, 9.1 CE ± 6.0 μg/min), vasopressin (n = 123, 0.05 CE ± 0.02 units/min), phenylephrine (n = 158, 91.4 CE ± 64.7 μg/min) and Angiotensin II (50 CE ± 27.6 ng/kg/min). Early Complication rate was 3.6% due to Bloodstream infection (n = 6), drug extravasation (n = 1), thrombophlebitis (n = 1) and arterial puncture (n = 1). Late Complication rate was 0.8% (n = 2) due to midline-associated DVTs. There were no complications related to ineffective drug delivery or limb endangerment.

CONCLUSIONS

Many medical centers are attempting to limit the use of central venous catheters (CVCs) to avoid central line-associated bloodstream infections (CLABSIs). This study demonstrates that midline catheters are a safe alternative to CVCs, for the safe and efficacious administration of vasopressors for prolonged periods of time.

Procalcitonin for predicting catheter-associated bloodstream infection: A meta-analysis

OBJECTIVE

The predictive accuracies of procalcitonin (PCT) in the diagnosis of catheter-associated bloodstream infection (CABSI) vary widely. This meta-analysis aimed to explore the predictive value of PCT for CABSI.

METHODS

We searched PubMed, EMBase, Web of Science, ScienceDirect, Cochrane Library, and studies published up to 10 March 2019. Odds ratios (ORs) with 95% confidence intervals (95%CIs) were calculated to evaluate PCT predictive value using Stata 14.0 software.

RESULTS

The meta-analysis was composed of 7 studies, consisting of 347 subjects. Pooled analysis demonstrated that a high PCT was significantly correlated with CABSI (pooled OR = 23.36, 95%CI 12.43-43.91, P < .001) and medium heterogenicity (I = 36.9%, P = .147). The pooled sensitivity and specificity were 85% (95%CI 0.76-0.91) and 89% (95%CI 0.68-0.97), respectively. Although Begg funnel plot (P = .007) indicated the presence of publication bias among the included studies, the stability of the pooled outcomes was verified by the trim-and-fill method. Furthermore, sensitivity analyses did not show important differences in effect estimation.

CONCLUSION

PCT is an effective predictor of CABSI. However, high-quality randomized controlled trials are needed to determine whether PCT could predict CABSI.

Health Care-Associated Infections and the Radiology Department

Health care-associated infections (HCAIs) are a significant concern for both health care workers (HCWs) and patients. They are a major contributing factor of disease in industrialized countries, and are responsible for significant morbidity, mortality, and a direct annual financial loss of $6-7 billion in North America alone. They are an increasingly challenging health issue due to multidrug-resistant pathogens such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococci among others, along with an increasing number of susceptible patients. Over the last three decades, the risk of HCAIs has increased in the radiology department (RD) in part because of an increased number of patients visiting the department and an increase in the utilization of imaging modalities. In this review, we will discuss how patients and staff can be exposed to HCAIs in the RD, including contaminated inanimate surfaces, radiology equipment, and associated medical devices. As the role of medical imaging has extended from primarily diagnosis to include more interventions, the implementation and development of standardized infection minimization protocols and infection control procedures are vital in the RD, particularly in interventional radiology. With globalisation and the rapid movement of people regionally, nationally, and globally, there is greater risk of exposure to contagious diseases such as Ebola, especially if infected patients are undiagnosed when they travel. For effective infection control, advanced training and education of HCWs in the RD is essential. The purpose of this article is to provide an overview of HCAIs as related to activities of the RD. We will discuss the following major topics including the variety of HCAIs commonly encountered, the role of the RD in HCAIs, transmission of infections to patients and HCWs in the RD, standard infection prevention measures, and the management of susceptible/infected patients in the RD. We shall also examine the role of, and the preparedness of, HCWs, including RD technologists and interventional radiologists, who may be exposed to undiagnosed, yet infected patients. We shall conclude with a brief discussion of the role of further research related to HCAIs. Learning Objectives After the completion of this review article, the readers will • Understand the exposure and role of radiology department in health care-associated infections, • Know the causes/modes/transmission of infections in radiology department, • Be conscious of standard disinfection protocols, • Be aware of current and future strategies required for the effective control of health care-associated infection in the radiology department. This is a CME article and provides the equivalent of 2 hours of continuing education that may be applied to your professional development credit system. A 10-question multiple-choice quiz follows this reading. Please note that no formalized credit (category A) is available from CAMRT.

A 1-year survey of catheter-related infections in a pediatric university hospital: A prospective study

BACKGROUND

Central venous catheters (CVCs) provide a great comfort for hospitalized children. However, CVCs increase the risk of severe infection. As there are few data regarding pediatric epidemiology of catheter-related infections (CRIs), the main objective of this study was to measure the incidence rate of CRIs in our pediatric university hospital. We also sought to characterize the CRIs and to identify risk factors.

MATERIALS AND METHODS

We conducted an epidemiological prospective monocentric study including all CVCs, except Port-a-Caths and arterial catheters, inserted in children from birth to 18 years of age between April 2015 and March 2016 in the pediatric University Hospital of Nantes. Our main focus was the incidence rate of CRIs, defined according to French guidelines, while distinguishing between bloodstream infections (CRBIs) and non-bloodstream infections (CRIWBs). The incidence rate was also described for each pediatric ward. We analyzed the association between infection and potential risk factors using univariate and multivariate analysis by Cox regression.

RESULTS

We included 793 CVCs with 60 CRBIs and four CRIWBs. The incidence rate was 4.6/1000 catheter-days, with the highest incidence rate occurring in the neonatal intensive care unit (13.7/1000 catheter-days). Coagulase-negative staphylococci were responsible for 77.5% of the CRIs. Factors independently associated with a higher risk of infection in neonates were invasive ventilation and low gestational age.

CONCLUSIONS

The incidence of CRIs in children hospitalized in our institution appears to be higher than the typical rate of CRIs reported in the literature. This was particularly true for neonates. These results should lead us to reinforce preventive measures and antibiotic stewardship but they also raise the difficulty of diagnosing with certainty CRIs in neonates.

The impact of a rapid molecular identification test on positive blood cultures from critically ill with bacteremia: A pre-post intervention study

Objectives

Bloodstream infections in critically ill require a speeded-up microbiological diagnosis to improve clinical outcomes. In this pre-post intervention study, we evaluated how a molecular identification test directly performed on positive blood cultures of critically ill improves patient’s therapeutic management.

Methods

All adult patients staying at the intensive care unit (ICU) at the time of positive blood culture detection were study-eligible. In the 8-month pre-intervention period (P0), standard positive blood culture management was performed. In the 10-month intervention period (P1), a BioFire^® FilmArray^® blood culture identification (FA-BCID) test (bioMérieux) was additionally performed 24/7 at detection. The evaluated clinical outcome was time to optimal antimicrobial treatment of the bloodstream infection. FA-BCID microbiological test performances were also analysed.

Results

163 positive blood culture episodes were allocated to P0 and 166 to P1. After the withdrawal of episodes in accordance with defined exclusion criteria, outcome analysis was performed on 110 bloodstream infections both in P0 and P1. Time to optimal antimicrobial treatment in P0 was 14h41 compared to 4h39 in P1. FA-BCID test results led to a treatment adjustment in 35/110 (31.8%) P1 episodes including 26 where the adjustment was the optimal antimicrobial treatment. FA-BCID testing identified 96.2% of the on-panel microorganisms thereby covering 85.2% of our ICU-strain epidemiology. Time to identification with FA-BCID testing was calculated at 1h35. Resistance detection was in complete concordance with routine results. Considering 150 FA-BCID tests were initially performed in P1, 4,3 tests were required to have 1 test leading to an improved therapeutic outcome.

Conclusions

FA-BCID testing drastically reduced time to optimal antimicrobial treatment in critically ill with bloodstream infections.

Clinical Features of Bloodstream Infections Associated with Peripheral Versus Central Venous Catheters

Introduction

This study aimed to compare the clinical characteristics and prognoses of central venous catheter-associated bloodstream infections (CVC-BSIs) with peripheral venous catheter-associated BSIs (PVC-BSIs).

Methods

This retrospective observational study was conducted between April 2011 and March 2013 at a teaching hospital in Tokyo, Japan. Adult patients who developed CVC-BSIs and PVC-BSIs more than 2 days after admission were included. Patients with both CVC-BSIs and PVC-BSIs were excluded. Clinical characteristics of patients with CVC-BSIs and PVC-BSIs were obtained from medical records, and 30-day all-cause mortality was measured as the clinical outcome.

Results

We enrolled 124 PVC-BSI cases and 110 CVC-BSI cases. Median age, age-adjusted Charlson score, Sequential Organ Failure Assessment score, sex, and ward type at BSI onset did not differ significantly between the two groups. The median duration of catheter indwelling was significantly shorter in the PVC-BSI group than in the CVC-BSI group. Staphylococcus aureus and Gram-negative bacilli infections were more frequent and coagulase-negative staphylococci (CNS) and Candida spp. infections were less frequent in the PVC-BSI group than in the CVC-BSI group. The prevalence of oxacillin resistance among causative S. aureus and CNS, 30-day all-cause mortality, and appropriateness of empirical and definitive antimicrobial therapies did not differ significantly between the two groups.

Conclusion

The pathogen species distribution varies between PVC-BSIs and CVC-BSIs. However, all-cause mortality does not differ between the two groups. PVCs are not safer than CVCs with respect to BSIs; therefore, it is necessary to use similar precautions relevant to CVC use in order to avoid unnecessary use of PVCs.

Increased Clinical and Economic Burden Associated With Peripheral Intravenous Catheter-Related Complications: Analysis of a US Hospital Discharge Database

The burden of complications associated with peripheral intravenous use is underevaluated, in part, due to the broad use, inconsistent coding, and lack of mandatory reporting of these devices. This study aimed to analyze the clinical and economic impact of peripheral intravenous-related complications on hospitalized patients. This analysis of Premier Perspective® Database US hospital discharge records included admissions occurring between July 1, 2013 and June 30, 2015 for pneumonia, chronic obstructive pulmonary disease, myocardial infarction, congestive heart failure, chronic kidney disease, diabetes with complications, and major trauma (hip, spinal, cranial fractures). Admissions were assumed to include a peripheral intravenous. Admissions involving surgery, dialysis, or central venous lines were excluded. Multivariable analyses compared inpatient length of stay, cost, admission to intensive care unit, and discharge status of patients with versus without peripheral intravenous-related complications (bloodstream infection, cellulitis, thrombophlebitis, other infection, or extravasation). Models were conducted separately for congestive heart failure, chronic obstructive pulmonary disease, diabetes with complications, and overall (all 7 diagnoses) and adjusted for demographics, comorbidities, and hospital characteristics. We identified 588 375 qualifying admissions: mean (SD), age 66.1 (20.6) years; 52.4% female; and 95.2% urgent/emergent admissions. Overall, 1.76% of patients (n = 10 354) had peripheral intravenous-related complications. In adjusted analyses between patients with versus without peripheral intravenous complications, the mean (95% confidence interval) inpatient length of stay was 5.9 (5.8-6.0) days versus 3.9 (3.9-3.9) days; mean hospitalization cost was $10 895 ($10 738-$11 052) versus $7009 ($6988-$7031). Patients with complications were less likely to be discharged home versus those without (62.4% [58.6%-66.1%] vs 77.6% [74.6%-80.5%]) and were more likely to have died (3.6% [2.9%-4.2%] vs 0.7% [0.6%-0.9%]). Models restricted to single admitting diagnosis were consistent with overall results. Patients with peripheral intravenous-related complications have longer length of stay, higher costs, and greater risk of death than patients without such complications; this is true across diagnosis groups of interest. Future research should focus on reducing these complications to improve clinical and economic outcomes.

Impact and Safety Associated with Accidental Dislodgement of Vascular Access Devices: A Survey of Professions, Settings, and Devices

Background: Dislodgement rates with intravenous catheters are reported at 1.8%–24% events per year resulting in failed access, interrupted treatment, and greater resource consumption with catheter replacement. The purpose of this study was to quantitatively evaluate the perceptions of frequency, impact, contributing factors, and safety issues from accidental dislodgement affecting intravenous (IV) devices as reported by healthcare clinicians.

Methodology: A cross-sectional descriptive survey was conducted via a voluntary online web-based survey of clinicians. Subjects were divided as those actively working in a clinical healthcare setting and those no longer active. Analysis of data was performed quantifying responses of clinicians on question of dislodgement.

Results: Survey results indicate clinicians routinely observe a significant percentage of accidental dislodgement, with 68% of the 1561 respondents reporting often, daily, or multiple times daily occurrence and 96.5% identifying peripheral intravenous catheters as most common device experiencing accidental dislodgement. Respondents prioritized 10 contributing factors, with confused patient (80%), patient physically removes catheter (74%), and IV catheter tape or securement loose (65%) as the top 3 causes. Over 95% of respondents consider IV dislodgement a safety risk to patients.

Conclusions: This study reports perceptions and impact of accidental dislodgement with IV devices. Inconsistencies exist with use, application, and management of catheter securement and dressings for IV catheters. Risk of additional complications and complete device failure are increased when dislodgement occurs. Given possible complications, along with necessitating replacement of the IV device in many cases, IV catheter dislodgement was considered a safety risk to patients by nearly all respondents.

Sepsis in Intensive Care Unit Patients: Worldwide Data From the Intensive Care over Nations Audit

Background

There is a need to better define the epidemiology of sepsis in intensive care units (ICUs) around the globe.

Methods

The Intensive Care over Nations (ICON) audit prospectively collected data on all adult (>16 years) patients admitted to the ICU between May 8 and May 18, 2012, except those admitted for less than 24 hours for routine postoperative surveillance. Data were collected daily for a maximum of 28 days in the ICU, and patients were followed up for outcome data until death, hospital discharge, or for 60 days. Participation was entirely voluntary.

Results

The audit included 10069 patients from Europe (54.1%), Asia (19.2%), America (17.1%), and other continents (9.6%). Sepsis, defined as infection with associated organ failure, was identified during the ICU stay in 2973 (29.5%) patients, including in 1808 (18.0%) already at ICU admission. Occurrence rates of sepsis varied from 13.6% to 39.3% in the different regions. Overall ICU and hospital mortality rates were 25.8% and 35.3%, respectively, in patients with sepsis, but it varied from 11.9% and 19.3% (Oceania) to 39.5% and 47.2% (Africa), respectively. After adjustment for possible confounders in a multilevel analysis, independent risk factors for in-hospital death included older age, higher simplified acute physiology II score, comorbid cancer, chronic heart failure (New York Heart Association Classification III/IV), cirrhosis, use of mechanical ventilation or renal replacement therapy, and infection with Acinetobacter spp.

Conclusions

Sepsis remains a major health problem in ICU patients worldwide and is associated with high mortality rates. However, there is wide variability in the sepsis rate and outcomes in ICU patients around the globe.

Nurses' compliance with central line associated blood stream infection prevention guidelines

Objectives:

To assess nurses’ compliance with central line associated bloodstream infection (CLABSI) prevention guidelines related to maintenance of the central line and the predictors of compliance.

Method:

This was an observational study that used a descriptive cross-sectional design. A sample of 171 intensive care unit (ICU) nurses were observed and their compliance was recorded on a structured observational sheet. The study was conducted in the ICUs of 15 hospitals located in 5 cities in Jordan. Data were collected over a 5-month period from March to July 2017. Central lines were all inserted by physicians inside the ICUs.

Results:

One hundred and twenty participants (70%) showed sufficient compliance. The mean compliance scores were 14.2±4.7 (min=8, max=20); however, the rate of CLABSI was variable across the participating ICUs. Logistic regression with 4 independent variables (years of experience, previous education with CLABSI, nurse-patient ratio and the ICU’s bed capacity) was conducted to investigate predictors of sufficient compliance. The model was significant (χ²(4)=133.773, p=0.00). The nurse-patient ratio was the only significant predictor. Nurses with a 1:1 nurse:patient ratio demonstrated superior compliance over their counterparts with a 1:2 ratio.

Conclusion:

Further improvement in compliance and patients’ outcomes could be achieved by lowering the nurse-patient ratio.

Educating intensive care unit nurses to use central venous catheter infection prevention guidelines: effectiveness of an educational course

Background

Nurses' knowledge of central venous catheter-related infection (CVC-RI) prevention guidelines is poor, indicating that nurses do not receive proper education about these guidelines.

Aim

The aim of this study was to evaluate the effectiveness of an educational course that aimed to improve nurses' knowledge about CVC-RI prevention guidelines.

Method

A sample of 131 nurses were randomly assigned to the experimental group (received an educational course) or control group (received no education). Pre-Post data were collected using a structured questionnaire that included a 23-item knowledge assessment.

Results

In the pre-test, all participants demonstrated poor knowledge, with mean scores of 8.2 (standard deviation = 3.6). After completion of the course, knowledge was significantly improved in the experimental group, whereas the control group showed no change (t(106,3) = 25.1, p = 0.00).

Conclusions

An educational course on CVC-RI prevention guidelines had an encouraging effect. Decision makers are recommended to implement such courses in their settings to improve nurses' competency.

Clinical impact of delayed catheter removal for patients with central-venous-catheter-related Gram-negative bacteraemia

BACKGROUND

Gram-negative bacteria are increasingly the cause of catheter-related bloodstream infection (CRBSI), and the prevalence of multi-drug-resistant strains is rising rapidly. This study evaluated the impact of delayed central venous catheter (CVC) removal on clinical outcomes in patients with Gram-negative CRBSI.

METHODS

Between January 2007 and December 2016, patients with Gram-negative bacteraemia and CVC placement, from two tertiary care hospitals, were included retrospectively. Cases with CVC removal more than three days after onset of bacteraemia or without CVC removal were classified as having delayed CVC removal.

RESULTS

In total, 112 patients were included. Of these, 78 had CRBSI (43 definite and 35 probable) and 34 had Gram-negative bacteraemia from another source (non-CRBSI). Enterobacteriaceae were less common pathogens in patients with CRBSI than in patients with non-CRBSI (11.5% vs 41.3%; P<0.001). Delayed CVC removal was associated with increased 30-day mortality (40.5% vs 11.8%; P=0.01) in patients with Gram-negative CRBSI; this was not seen in patients with non-CRBSI (25.0% vs 14.3%; P>0.99). Delayed CVC removal [odds ratio (OR) 6.8], multi-drug-resistant (MDR) Gram-negative bacteraemia (OR 6.3) and chronic renal failure (OR 11.1) were associated with 30-day mortality in patients with CRBSI. The protective effect of early CVC removal on mortality was evident in the MDR group (48.3% vs 18.2%; P=0.03), but not in the non-MDR group (11.1% vs 0%; P=0.43).

CONCLUSION

CVCs should be removed early to improve clinical outcomes in patients with Gram-negative CRBSI, especially in settings where MDR isolates are prevalent.

A quality improvement initiative to reduce central line infection in neonates using checklists

Central line associated blood stream infections (CLABSI) are the most common complication of central catheters in neonates. These infections increase length of hospital stay, hospital costs and impact on mortality and morbidities. We performed a quasi-experimental study, over 24 months, utilising a pre-post design to determine the impact checklists had on central line infections. We introduced checklists for insertion, daily maintenance and procedural access based on the existing clinical guideline. Infections and compliance were monitored and reported back to the unit each month. We utilised the interrupted time series analysis to evaluate the impact of introduction of the checklists. Over the 24 months, 318 infants were included with a total of 509 central lines inserted. In the post intervention phase, definite CLABSI rates declined by 41%, from 13.8 definite CLABSIs per 1000 central-line days to 7.8 definite CLABSIs per 1000 central-line days. There was significant change in the mean levels in the post intervention phase (coefficient crude -0.01015; 95% CI -0.01980-0.00051, p value 0.039). Checklist compliance for insertion was 70%, and daily maintenance compliance overall mean was 66%.

CONCLUSION

Our quality improvement initiative using checklists, supported with education and feedback, significantly reduced CLABSI in our neonatal unit. What is Known: • Central line associated blood stream infection (CLABSI) continue to cause mortality and morbidity in the neonatal population. • Bundles of intervention use quality improvement methodology to reduce CLABSI and checklists can assist with the introduction of these. What is New: • Checklists assist with reducing central line infection. • To ensure the success of checklists, robust education, leadership and continuous feedback are vital.