Length of stay, cost, and mortality of healthcare-acquired bloodstream infections in children and neonates: A systematic review and meta-analysis

Pediatric blood cultures-turning up the volume: a before and after intervention study

The major determinant of blood culture (BC) diagnostic performance is blood volume, and pediatric sample volumes are frequently low. We aimed to assess BC volumes in our institution, design an intervention to increase volumes, and assess its impact. All pediatric BCs submitted over a 7-month period to the microbiology laboratory in a university hospital (including emergency department, pediatric ward, and neonatal unit) were included. A pre-intervention period assessed current practice. A multi-faceted intervention (education, guideline introduction, active feedback strategies) was collaboratively designed by all stakeholders. Impact was assessed in a post-intervention period. The main outcome measures included the percentage of samples adequately filled using three measures of sample adequacy (1) manufacturer-recommended minimum validated volume-> 0.5 ml, (2) manufacturer-recommended optimal minimum volume-> 1.0 ml, (3) newly introduced age-specific recommendations. Three hundred ninety-eight pre-intervention and 388 post-intervention samples were included. Initial volumes were low but increased significantly post-intervention (median 0.77 ml vs. 1.52 ml), with multivariable regression analysis estimating volumes increased 89% post-intervention. There were significant increases in all measures of volume adequacy, including an increase in age-appropriate filling (20.4-53.1%), with less improvement in those aged > 3 years. Overall, 68.4% of pathogens were from adequately filled cultures, while 76% of contaminants were from inadequately filled cultures. A pathogen was detected in a higher proportion of adequately filled than inadequately filled cultures (9.4% vs. 2.2%, p < 0.001).  Conclusion: Blood volume impacts BC sensitivity, with lower volumes yielding fewer pathogens and more contaminants. Focused intervention can significantly improve volumes to improve diagnostic performance. What is Known: • Blood volume is the major determinant of blood culture positivity, and yet pediatric blood culture volumes are frequently low, resulting in missed pathogens and increased contamination. What is New: • Adequately filled (for age) blood cultures have a pathogen detection rate three times higher than inadequately filled blood cultures. • This interventional study shows that collaboratively designed multi-modal interventions including focus on accurate volume measurement can lead to significant increases in blood volumes and improve blood culture diagnostic performance.

Attributable Mortality for Pediatric and Neonatal Central Line-Associated Bloodstream Infections in Greece

Central line-associated bloodstream infections (CLABSIs) are the most frequent pediatric hospital-acquired infections and significantly impact outcomes. The aim of this study was to estimate the attributable mortality for CLABSIs in pediatric and neonatal patients in Greece. A retrospective matched-cohort study was performed, in two tertiary pediatric hospitals. Inpatients with a central line in neonatal and pediatric intensive care units (NICUs and PICUs), hematology/oncology units, and a bone marrow transplantation unit between June 2012 and June 2015 were eligible. Patients with confirmed CLABSI were enrolled on the day of the event and were matched (1:1) to non-CLABSI patients by hospital, hospitalization unit, and length of stay prior to study enrollment (188 children enrolled, 94 CLABSIs). Attributable mortality was estimated. During the study period, 22 patients with CLABSI and nine non-CLABSI patients died (23.4 vs. 9.6%, respectively, p  = 0.011), leading to an attributable mortality of 13.8% (95% confidence interval [CI] = 3.4-24.3%). Children in PICUs were more likely to die, presenting an attributable mortality of 20.2% (95% CI = - 1.4-41.8%), without reaching, however, statistical significance. After multiple logistic regression, patients with CLABSI were four times more likely to die (odds ratio [OR] = 4.29, 95% CI = 1.28-14.36, p  = 0.018). Survival analysis showed no difference in time to death after study enrollment between patients with CLABSI and non-CLABSI patients (log-rank p  = 0.137, overall median survival time = 7.8 months). Greek pediatric mortality rates are increased by the CLABSI occurrence, highlighting the importance of infection prevention strategies.

Nosocomial Infections in the Neonatal Intensive Care Unit

Nosocomial infections are relatively common in the NICU. These infections increase morbidity and mortality, particularly in the smallest and most fragile infants. The impact of these infections on long-term outcomes and health-care costs is devastating. Worldwide efforts to decrease the incidence of nosocomial infections have focused on implementing specific prevention protocols such as handwashing, central line teams, care bundles, and antimicrobial stewardship. This review summarizes common nosocomial infections in patients in the NICU.

Racial and ethnic disparities in common inpatient safety outcomes in a children's hospital cohort

BACKGROUND

Emerging evidence has shown racial and ethnic disparities in rates of harm for hospitalised children. Previous work has also demonstrated how highly heterogeneous approaches to collection of race and ethnicity data pose challenges to population-level analyses. This work aims to both create an approach to aggregating safety data from multiple hospitals by race and ethnicity and apply the approach to the examination of potential disparities in high-frequency harm conditions.

METHODS

In this cross-sectional, multicentre study, a cohort of hospitals from the Solutions for Patient Safety network with varying race and ethnicity data collection systems submitted validated central line-associated bloodstream infection (CLABSI) and unplanned extubation (UE) data stratified by patient race and ethnicity categories. Data were submitted using a crosswalk created by the study team that reconciled varying approaches to race and ethnicity data collection by participating hospitals. Harm rates for race and ethnicity categories were compared with reference values reflective of the cohort and broader children's hospital population.

RESULTS

Racial and ethnic disparities were identified in both harm types. Multiracial Hispanic, Combined Hispanic and Native Hawaiian or other Pacific Islander patients had CLABSI rates of 2.6-3.6 SD above reference values. For Black or African American patients, UE rates were 3.2-4.4 SD higher. Rates of both events in White patients were significantly lower than reference values.

CONCLUSIONS

The combination of harm data across hospitals with varying race and ethnicity collection systems was accomplished through iterative development of a race and ethnicity category framework. We identified racial and ethnic disparities in CLABSI and UE that can be addressed in future improvement work by identifying and modifying care delivery factors that contribute to safety disparities.

Prevalence and risk factors associated with drug resistant bacteria in neonatal and pediatric intensive care units: A retrospective study in Saudi Arabia

Successful empirical antibiotic therapy for infected patients with multi drug resistant bacteria (MDR) can be challenging task in various healthcare settings, including neonatal and pediatric intensive care units (NICU and PICU, respectively), unless an up-to-date comprehensive local antibiogram data is available. Thus, this project aimed to investigate the prevalence of MDR among PICU and NICU patients as well as the identification of risk factors associated with recovered MDR bacteria. This was a retrospective study of PICU and NICU patients admitted with bacterial infection of MDR organisms between October 2020 and May 2021. Frequency distribution, Chi-square test were applied to verify the significance differences among subgroups and to identify risk factor associated with each group. About 36.4% of recruited patients were neonates, while the remaining percentage (63.6%) were pediatric. The most predominant site of infection among these patients were revealed as urinary tract (35%), followed by bloodstream (20.0%), wound/skin (12.9%) and respiratory system (11.4%). Methicillin-resistant Staphylococcus aureus (MRSA) was identified as the most common microbe across these sites of infections (30.7%), followed by Escherichia coli (25.0%), Klebsiella pneumoniae (22.9%) and Serratia (10.0%). High mortality rate was significantly associated with patients who were on mechanical ventilators (28.9%, OR 5.5; 95% CI), followed by patients had invasive operation (27.5%, OR, 8.04; 95% CI) and those who required a total parental nutrition (TPN) since almost one-half of these cases have (46.2%) died. In addition, mortality rate was relatively higher among patients infected with species of Serratia (28.6%) and Enterobacter (20.0%). These data highlighted that MRSA was the main MDR bacteria isolated from PICU and NICU followed by gram-negative bacteria, which were associated with high mortality rate. Therefore, infection control measures and continuous monitoring of emerging MDR bacteria should be applied to limit the bacterial infections in NICU and PICU patients.

Using Quality Improvement to Improve Value and Reduce Waste

Value is defined as health outcomes achieved per dollar spent. Addressing value in quality improvement (QI) efforts can help optimize patient outcomes while reducing unnecessary spending. In this article, we discuss how QI focused on reducing morbidities frequently reduces costs, and how proper cost accounting can help demonstrate improvements in value. We provide examples of high-yield opportunities for value improvement in neonatology and review the literature associated with these topics. Opportunities include reducing neonatal intensive care admissions for low-acuity infants, sepsis evaluations in low-risk infants, unnecessary total parental nutrition use, and utilization of laboratory and imaging.

Next Steps for Health Care-Associated Infections in the Neonatal Intensive Care Unit

We discuss the burden of health care-associated infections (HAIs) in the neonatal ICU and the role of quality improvement (QI) in infection prevention and control. We examine specific QI opportunities and approaches to prevent HAIs caused by Staphylococcus aureus , multidrug-resistant gram-negative pathogens, Candida species, and respiratory viruses, and to prevent central line-associated bloodstream infections (CLABSIs) and surgical site infections. We explore the emerging recognition that many hospital-onset bacteremia episodes are not CLABSIs. Finally, we describe the core tenets of QI, including engagement with multidisciplinary teams and families, data transparency, accountability, and the impact of larger collaborative efforts to reduce HAIs.

Clinical application of a modified predeposit autologous red blood cell apheresis in multistage spinal fusion: a single-center retrospective study

Purpose

This study aimed to evaluate the efficacy and safety of predeposit autologous RBC apheresis (PARA) in patients undergoing multilevel spinal fusion surgery.

Methods

A total of 112 patients from January 2020 to June 2022 were divided into two groups according to PARA: the PARA group (n = 51) and the control group (n = 61). The baseline characteristics of the patients, outcomes, transfusion cost, hospitalization cost, length of stay, complications, and changes in hemoglobin and hematocrit levels between the two groups were compared.

Results

The baseline characteristics were similar in both groups. No significant differences were found in functional outcomes, including VAS score (p = 0.159), ODI score (p = 0.214), JOA score (p = 0.752), and SF-36 score (p = 0.188) between the PARA and control groups. The amount and rate of intraoperative and perioperative allogeneic RBC transfusion were significantly higher in the control group than in the PARA group (p < 0.001). The postoperative (9.04 ± 3.21 vs. 11.05 ± 3.84, p = 0.004) and total length of stay (15.78 ± 3.79 vs. 17.36 ± 4.08, p = 0.038) in the PARA group were significantly lower than those in the control group, respectively. Despite no difference in hospitalization cost (p = 0.737), the total blood transfusion cost in the PARA group was significantly lower, compared with the control group (p < 0.001). For safety evaluation, there were no significant differences in Hb and Hct levels between the two groups at admission, on postoperative day 1, and postoperative day 3, respectively (p > 0.05). Moreover, the number of postoperative infections in the PARA group was significantly lower than that in the control group (p = 0.038).

Conclusion

PARA was a novel, safe, and highly efficient technique for mass autologous blood preparation in a quite short preparation time. This method could significantly reduce the amount of allogeneic blood transfusion and length of stay, which could provide a theoretical basis for following clinical practice about the technique.

Incremental costs of hospital-acquired infections in COVID-19 patients in an adult intensive care unit of a tertiary hospital from a low-resource setting

BACKGROUND

Hospital-acquired infections (HAIs) are a global public health problem and put patients at risk of complications, including death. HAIs increase treatment costs, but their financial impact on Serbia's healthcare system is unknown. Our goal was to assess incremental costs of HAIs in a tertiary care adult intensive care unit (ICU) that managed COVID-19 patients.

METHODS

A retrospective study from March 6th to December 31st, 2020 included patients with microbiologically confirmed COVID-19 (positive rapid antigen test or real-time polymerase chain reaction) treated in the ICU of the Teaching Hospital for Infectious and Tropical Diseases, University Clinical Centre of Serbia. Demographic and HAI-specific data acquired in our ICU were collected, including total and stratified medical costs (services, materials, laboratory testing, medicines, occupancy costs). Median total and stratified costs were compared in relation to HAI acquisition. Linear regression modelling was used to assess incremental costs of HAIs, adjusted for age, biological sex, prior hospitalisation, Charlson Comorbidity Index (CCI), and Glasgow Coma Scale (GCS) on admission. Outcome variables were length of stay (LOS) in days and mortality.

RESULTS

During the study period, 299 patients were treated for COVID-19, of which 214 were included. HAIs were diagnosed in 56 (26.2%) patients. Acinetobacter spp. was the main pathogen in respiratory (38, 45.8%) and bloodstream infections (35, 42.2%), the two main HAI types. Median total costs were significantly greater in patients with HAIs (€1650.4 vs. €4203.2, p < 0.001). Longer LOS (10.0 vs. 18.5 days, p < 0.001) and higher ICU mortality (51.3% vs. 89.3%, p < 0.001) were seen if HAIs were acquired. Patients with ≥ 2 HAIs had the highest median total costs compared to those without HAIs or with a single HAI (€1650.4 vs. €3343.4 vs. €7336.9, p < 0.001). Incremental costs in patients with 1 and ≥ 2 HAIs were €1837.8 (95% CI 1257.8-2417.7, p < 0.001) and €5142.5 (95% CI 4262.3-6022.7, p < 0.001), respectively.

CONCLUSIONS

This is the first economic evaluation of HAIs in Serbia, showing significant additional costs to our healthcare system. HAIs prolong LOS and influence ICU mortality rates. Larger economic assessments are needed to enhance infection control practices.

Setting the Stage: Innovation in Port Access Education for Pediatric Emergency Nurses

INTRODUCTION

Pediatric port access can be challenging in the emergency department; however, it must be performed promptly and safely. Port education for nurses traditionally includes procedural practice on adult-size, tabletop manikins, which lacks the situational and emotional aspects inherent in pediatrics. The purpose of this foundational study was to describe the knowledge and self-efficacy gain from a simulation curriculum that promotes effective situational dialogue and sterile port access technique, while incorporating a wearable port trainer to enhance simulation fidelity.

METHODS

An educational intervention impact study was conducted using a curriculum integrating a comprehensive didactic session with simulation. A unique element included a novel port trainer worn by a standardized patient, along with a second actor portraying a distressed parent at the bedside. Participants completed precourse and postcourse surveys on the day of simulation and a 3-month follow-up survey. Sessions were video recorded for review and content analysis.

RESULTS

Thirty-four pediatric emergency nurses participated in the program and demonstrated an overall increase in knowledge and self-efficacy with port access that was sustained at the 3-month follow-up. Data revealed positive feedback regarding the participants' simulation experience.

DISCUSSION

Effective port access education for nurses requires a comprehensive curriculum integrating procedural aspects and situational techniques to address the components of a true port access experience involving pediatric patients and families. Our curriculum successfully combined skill-based practice with situational management, and promoted nursing self-efficacy and competence with port access in the pediatric population.

Child characteristics and health conditions associated with paediatric hospitalisations and length of stay: a population-based study

Background

Paediatric hospital length of stay (LoS) is often used as a benchmark for resource use of hospitalisations. Previous studies have mostly focused on LoS of admissions for specific conditions or medical specialties. We aimed to conduct an evaluation of LoS of all paediatric hospitalisations exploring the frequency and characteristics; and associated childhood conditions.

Methods

This population-based cross-sectional study included all hospital admissions in children aged <16 years between January 2017 and December 2019 in New South Wales, Australia. LoS was categorised into: day or overnight stay, 2-7, 8-21 and ≥ 22 days. Socio-demographic and health service characteristics of each individual admission by LoS and age groups were evaluated.

Findings

A total of 324,083 children had 518,768 admissions comprising 1,064,032 bed days. Most admissions wereday/overnight stays (71.9%) or 2-7 days (25.3%). While LoS >7 days represented 2.8% of total admissions, they accounted for 27% of total bed days. Children aged 1-4 years had the highest proportion of admissions (35%), with a majority lasting ≤7 days, whereas 45.6% of admissions ≥22 days were for children aged ≥12 years. Respiratory conditions, diseases of the digestive system and traumatic injuries were the most common reasons for hospitalization. LoS >7 days were more common in children from most disadvantaged backgrounds, residing further from hospital and those aged ≥12 years with mental health conditions.

Interpretation

The majority of paediatric hospitalizations are for short stay and require programs that target acute conditions that can be managed in primary care. Interventions such as care coordination, tailored models of care and enhanced outpatient/community treatment programs for high-risk groups will help reduce extended LoS and improving child health and well-being.

Funding

Australian National Health and Medical Research Council.

A national study of antibiotic use in Greek pediatric hematology oncology and bone marrow transplant units

OBJECTIVE

We surveyed antimicrobials used in Greek pediatric hematology-oncology (PHO) and bone marrow transplant (BMT) units before and after an intervention involving education regarding the 2017 clinical practice guidelines (CPG) for the management of febrile neutropenia in children with cancer and hematopoietic stem-cell transplant recipients.

DESIGN

Antibiotic prescribing practices were prospectively recorded between June 2016 and November 2017.

INTERVENTION

In December 2017, baseline data feedback was provided, and CPG education was provided. Prescribing practices were followed for one more year. For antibiotic stewardship, days of therapy, and length of therapy were calculated.

SETTING

Five of the 6 PHO units in Greece and the single pediatric BMT unit participated.

PARTICIPANTS

Admitted children in each unit who received the first 15 new antibiotic courses each month.

RESULTS

Administration of ≥4 antibiotics simultaneously and administration of antibiotics with overlapping activity for ≥2 days were significantly more common in PHO units in general hospitals compared to children's hospitals. Use of at least 1 antifungal was recorded in ∼47% of the patients before and after the intervention. De-escalation and/or discontinuation of antibiotics on day 6 of initial treatment increased significantly from 43% to 53.5% (P = .032). Although the number of patients requiring intensive care support for sepsis did not change, a significant drop was noted in all-cause mortality (P = .008).

CONCLUSIONS

We recorded the antibiotic prescribing practices in Greek PHO and BMT units, we achieved improved prescribing with a simple intervention, and we identified areas in need of improvement.

Changing Patterns of Bloodstream Infections in the Community and Acute Care Across 2 Coronavirus Disease 2019 Epidemic Waves: A Retrospective Analysis Using Data Linkage

BACKGROUND

We examined community- and hospital-acquired bloodstream infections (BSIs) in coronavirus disease 2019 (COVID-19) and non-COVID-19 patients across 2 epidemic waves.

METHODS

We analyzed blood cultures of patients presenting to a London hospital group between January 2020 and February 2021. We reported BSI incidence, changes in sampling, case mix, healthcare capacity, and COVID-19 variants.

RESULTS

We identified 1047 BSIs from 34 044 blood cultures, including 653 (62.4%) community-acquired and 394 (37.6%) hospital-acquired. Important pattern changes were seen. Community-acquired Escherichia coli BSIs remained below prepandemic level during COVID-19 waves, but peaked following lockdown easing in May 2020, deviating from the historical trend of peaking in August. The hospital-acquired BSI rate was 100.4 per 100 000 patient-days across the pandemic, increasing to 132.3 during the first wave and 190.9 during the second, with significant increase in elective inpatients. Patients with a hospital-acquired BSI, including those without COVID-19, experienced 20.2 excess days of hospital stay and 26.7% higher mortality, higher than reported in prepandemic literature. In intensive care, the BSI rate was 421.0 per 100 000 intensive care unit patient-days during the second wave, compared to 101.3 pre-COVID-19. The BSI incidence in those infected with the severe acute respiratory syndrome coronavirus 2 Alpha variant was similar to that seen with earlier variants.

CONCLUSIONS

The pandemic have impacted the patterns of community- and hospital-acquired BSIs, in COVID-19 and non-COVID-19 patients. Factors driving the patterns are complex. Infection surveillance needs to consider key aspects of pandemic response and changes in healthcare practice.

Prevalence, incidence, length of stay and cost of healthcare-acquired pressure ulcers in pediatric populations: A systematic review and meta-analysis

BACKGROUND

Pressure ulcers are a major problem for national healthcare systems since they frequently occur in hospitalized patients, negatively affecting patients' quality of life and extending duration of hospitalization.

OBJECTIVE

To systematically review the available evidence regarding the incidence, prevalence, attributable length of stay and cost of hospital-acquired pressure ulcers in pediatric populations.

DESIGN

A systematic review and meta-analysis.

METHODS

A systematic search (March 15, 2020) was conducted in PubMed, Scopus, and ProQuest databases. Cross-sectional and cohort studies of neonates and children aged <21 years old were eligible for inclusion when full text was available in English and data for at least one of the following criteria was provided: incidence, prevalence, attributable length of stay or healthcare cost due to hospital-acquired pressure ulcers. Study quality was evaluated using the Joanna Briggs Institute Critical Appraisal Tools. Random effects models were used to synthesize data. Heterogeneity and publication bias were evaluated.

RESULTS

From the 1055 studies appeared in literature search, 21 studies were included in the systematic review and 19 were included in the meta-analysis. The overall prevalence ranged from 0.47% to 31.2% and cumulative incidence ranged from 3.7% to 27%. The pooled prevalence was estimated at 7.0% (95% confidence interval (CI): 4.3%-10.4%) and the pooled cumulative incidence at 14.9% (95% CI: 7.7%-23.9%). The pooled prevalence among neonates was 27.0% (95% CI: 22.1%-33.1%) among children aged less than 1 year old was 19.2% (95% CI: 9.4%-31.3%) and among children older than 1 year was 12.3% (95% CI: 2.3%-27.9%). The cumulative incidence of hospital-acquired pressure ulcers in neonates was 9.8% (95% CI: 2.9%-19.8%) and in children aged <1 year old was 11.3% (95% CI: 4.4%-20.7%), while no data was available to estimate this figure for children older than 1 year. The attributable length of stay ranged from 0.9 to 14.1 days and the attributable cost ranged from $894.69 to $98,730.24 (United States dollars; value of a dollar in 2020) per patient with hospital-acquired pressure ulcers.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The results of this meta-analysis indicate that hospital-acquired pressure ulcers occur frequently in pediatric populations with a great variation across different age groups. Moreover, although limited data are available, it seems that hospital-acquired pressure ulcers have significant economic implications for the healthcare systems since they prolong patients' hospitalization stay; these findings further highlight the need for implementation of patient-based prevention strategies.

SYSTEMATIC REVIEW REGISTRATION NUMBER

Not registered Tweetable abstract: Hospital-acquired pressure ulcers occur frequently in pediatric populations, prolonging their hospitalization and increasing the healthcare cost.