Trends of Healthcare-associated Infections in a Tuinisian University Hospital and Impact of COVID-19 Pandemic

BACKGROUND

Although efforts to manage coronavirus disease 2019 (COVID-19) pandemic have understandably taken immediate priority, the impacts on traditional healthcare-associated infection (HAI) surveillance and prevention efforts remain concerning.

AIM

To describe trends in HAIs in a Tunisian university hospital through repeated point prevalence surveys over 9 years, assess the impact of measures implemented for COVID-19 pandemic, and to identify associated factors of HAI.

METHODS

The current study focused on data collected from annual point prevalence surveys conducted from 2012 to 2020. All types of HAIs as defined by the Centers for Disease Control and Prevention (CDC) were included. Data collection was carried out using NosoTun plug. Univariate and multivariate logistic analysis were used to identify HAI risk factors.

RESULTS

Overall, 2729 patients were observed in the 9 surveys; the mean age was 48.3 ± 23.3 years and 57.5% were male. We identified 267 infected patients (9.8%) and 296 HAIs (10.8%). Pneumonia/lower respiratory tract infections were the most frequent HAI (24%), followed by urinary tract infection (20.9%).The prevalence of infected patients increased from 10.6% in 2012 to 14.9% in 2020. However, this increase was not statistically significant. The prevalence of HAIs increased significantly from 12.3% to 15.5% (P =.003). The only decrease involved is bloodstream infections (from 2% to 1%). Independent risk factors significantly associated with HAI were undergoing surgical intervention (aOR = 1.7), the use of antibiotic treatment in previous 6 months (aOR = 1.8), peripheral line (aOR=2), parenteral nutrition (aOR=2.4), urinary tract within 7 days (aOR=2.4), central line (aOR = 6.3), and prosthesis (aOR = 12.8), length of stay (aOR = 3), and the year of the survey. Young age was found as protective factor (aOR = .98).

CONCLUSION

Contrary to what was expected, we noticed an increase in the HAIs rates despite the preventive measures put in place to control the COVID-19 pandemic. This was partly explained by the vulnerability of hospitalized patients during this period.

Novel risk factors for central-line associated bloodstream infections in critically ill children

OBJECTIVE

Central-line-associated bloodstream infections (CLABSI) cause morbidity and mortality in critically ill children. We examined novel and/or modifiable risk factors for CLABSI to identify new potential targets for infection prevention strategies.

METHODS

This single-center retrospective matched case-control study of pediatric intensive care unit (PICU) patients was conducted in a 60-bed PICU from April 1, 2013, to December 31, 2017. Case patients were in the PICU, had a central venous catheter (CVC), and developed a CLABSI. Control patients were in the PICU for ≥2 days, had a CVC for ≥3 days, and did not develop a CLABSI. Cases and controls were matched 1:4 on age, number of complex chronic conditions, and hospital length of stay.

RESULTS

Overall, 72 CLABSIs were matched to 281 controls. Univariate analysis revealed 14 risk factors, and 4 remained significant in multivariable analysis: total number of central line accesses in the 3 days preceding CLABSI (80+ accesses: OR, 4.8; P = .01), acute behavioral health needs (OR, 3.2; P = .02), CVC duration >7 days (8-14 days: OR, 4.2; P = .01; 15-29 days: OR, 9.8; P < .01; 30-59 days: OR, 17.3; P < .01; 60-89 days: OR, 39.8; P < .01; 90+ days: OR, 4.9; P = .01), and hematologic/immunologic disease (OR, 1.5; P = .05).

CONCLUSIONS

Novel risk factors for CLABSI in PICU patients include acute behavioral health needs and >80 CVC accesses in the 3 days before CLABSI. Interventions focused on these factors may reduce CLABSIs in this high-risk population.

Prevention of healthcare-associated infections in low- and middle-income Countries: The 'bundle approach'

Background

Healthcare-associated infections (HCAI/HAIs) are one of the most common adverse events in patient care and account for substantial morbidity and mortality. The high rates of HCAIs in a facility are an indicator of poor quality of healthcare services. According to the World Health Organization, at any time, up to 7% of patients in developed and 10% in developing countries will acquire at least one HAI. These infections also present a significant economic burden at the societal level. However, a large percentage of HAIs are preventable through effective infection prevention and control measures.

Objectives

Prevention of these infections also needs to be prioritised in view of the growing antimicrobial resistance in HAIs. The bundle approach to the prevention of HAIs is a relatively new concept that is revolutionising the care of high-risk patients in the Intensive Care Units. This report details the bundle approach for the prevention of HAIs, particularly the device-associated infections, for low- and middle-income countries.

Conclusion

With the escalating armamentarium of antimicrobial resistance, healthcare sector has to go back to the very basics of hospital infection control; develop, assess and implement bundles of prevention. These are cost-effective and easily adaptable, to cater to the increasing HCAIs and MDR infections in the LMICs.

The Epidemiology of Healthcare-associated Infections in Pediatric Cardiac Intensive Care Units

BACKGROUND

Healthcare-associated infections (HAIs) represent serious complications for patients within pediatric cardiac intensive care units (CICU). HAIs are associated with increased morbidity, mortality and resource utilization. There are few studies describing the epidemiology of HAIs across the entire spectrum of patients (surgical and nonsurgical) receiving care in dedicated pediatric CICUs.

METHODS

Retrospective analyses of 22,839 CICU encounters from October 2013 to September 2016 across 22 North American CICUs contributing data to the Pediatric Cardiac Critical Care Consortium clinical registry.

RESULTS

HAIs occurred in 2.4% of CICU encounters at a rate of 3.3 HAIs/1000 CICU days, with 73% of HAIs occurring in children <1 year. Eighty encounters (14%) had ≥2 HAIs. Aggregate rates for the 4 primary HAIs are as follows: central line-associated blood stream infection, 1.1/1000 line days; catheter-associated urinary tract infections, 1.5/1000 catheter days; ventilator-associated pneumonia, 1.9/1000 ventilator days; surgical site infections, 0.81/100 operations. Surgical and nonsurgical patients had similar HAIs rates/1000 CICU days. Incidence was twice as high in surgical encounters and increased with surgical complexity; postoperative infection occurred in 2.8% of encounters. Prematurity, younger age, presence of congenital anomaly, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Categories (STAT) 4-5 surgery, admission with an active medical condition, open sternum and extracorporeal membrane oxygenation were independently associated with HAIs. In univariable analysis, HAI was associated with longer hospital length of stay and durations of urinary catheter, central venous catheter and ventilation. Mortality was 24.4% in patients with HAIs versus 3.4% in those without, P < 0.0001.

CONCLUSIONS

We provide comprehensive multicenter benchmark data regarding rates of HAIs within dedicated pediatric CICUs. We confirm that although rare, HAIs of all types are associated with significant resource utilization and mortality.

Infection prevention in pediatric anesthesia practice

Healthcare-associated infections are an important source of morbidity and mortality in pediatric patients. Anesthesiologists have a unique role in infection prevention. Hand hygiene and anesthesia workspace decontamination decrease infection rates in surgical patients. Standard protocols exist for insertion and handling of central lines, arterial lines, and regional procedures, which should be strictly adhered to in order to prevent infectious complications. Temperature control and timely administration of antibiotics contribute to the prevention of surgical site infections. Education, culture shift, staff engagement, and effective change management are necessary for successful implementation of infection prevention strategies.

Are quality improvement collaboratives effective? A systematic review

Background

Quality improvement collaboratives (QIC) have proliferated internationally, but there is little empirical evidence for their effectiveness.

Method

We searched Medline, Embase, CINAHL, PsycINFO and the Cochrane Library databases from January 1995 to December 2014. Studies were included if they met the criteria for a QIC intervention and the Cochrane Effective Practice and Organisation of Care (EPOC) minimum study design characteristics for inclusion in a review. We assessed study bias using the EPOC checklist and the quality of the reported intervention using a subset of SQUIRE 1.0 standards.

Results

Of the 220 studies meeting QIC criteria, 64 met EPOC study design standards for inclusion. There were 10 cluster randomised controlled trials, 24 controlled before-after studies and 30 interrupted time series studies. QICs encompassed a broad range of clinical settings, topics and populations ranging from neonates to the elderly. Few reports fully described QIC implementation and methods, intensity of activities, degree of site engagement and important contextual factors. By care setting, an improvement was reported for one or more of the study’s primary effect measures in 83% of the studies (32/39 (82%) hospital based, 17/20 (85%) ambulatory care, 3/4 nursing home and a sole ambulance QIC). Eight studies described persistence of the intervention effect 6 months to 2 years after the end of the collaborative. Collaboratives reporting success generally addressed relatively straightforward aspects of care, had a strong evidence base and noted a clear evidence-practice gap in an accepted clinical pathway or guideline.

Conclusions

QICs have been adopted widely as an approach to shared learning and improvement in healthcare. Overall, the QICs included in this review reported significant improvements in targeted clinical processes and patient outcomes. These reports are encouraging, but most be interpreted cautiously since fewer than a third met established quality and reporting criteria, and publication bias is likely.

Efficacy of a care bundle to prevent multiple infections in the intensive care unit: A quasi-experimental pretest-posttest design study

BACKGROUND

Healthcare-associated infections extend hospitalization time, increase treatment costs and increase morbidity-mortality rates.

OBJECTIVES

To evaluate the efficacy of a care bundle aimed at preventing three most frequent intensive care unit-acquired infections.

MATERIALS AND METHOD

This quasi-experimental study occurred in an 18-bed tertiary care intensive care unit at a university hospital in Turkey. The sample consisted of 120 patients older than 18years and receiving invasive mechanical ventilation therapy, or had a central venous catheter or urinary catheter. The study comprised three stages. In stage one, the intensive care unit nurses were trained in infection measures, VAP, CA-UTIs and CLABSIs sections of the care bundle. In stage two, the trained nurses applied the care bundle and received feedback on any problematic issues. In stage three, the nurses' compatibility and efficacy of the infection prevention care bundle on the infection rates of VAP, CA-UTIs and CLABSIs were evaluated over three 3-month periods.

RESULTS

Over 1000 ventilation days, ventilator-associated pneumonia infection rates were 23.4, 12.6, and 11.5, during January-March, April-June and July-September, respectively, with January-March and April-June showing a significant decrease (χ²=6.934, p=0.031). The central line-associated bloodstream infection rates were 8.9, 4.2, and 9.9 per 1000 catheter days, during January-March, April-June and July-September, respectively, but were not significantly different based on pair-wise comparisons (p>0.05). The catheter-associated urinary tract infection rates were higher during July-September (6.7/1000 catheter days) compared to January-March (5.7/1000 catheter days) and April-June (10.4/1000 catheter days) but the differences were not significant (p>0.05).

CONCLUSIONS

The infection rates decreased with increased compatibility of the care bundle prepared from evidence-based guidelines.

Quality indicators in intensive care medicine for Germany - third edition 2017

Quality improvement in medicine is depending on measurement of relevant quality indicators. The quality indicators for intensive care medicine of the German Interdisciplinary Society of Intensive Care Medicine (DIVI) from the year 2013 underwent a scheduled evaluation after three years. There were major changes in several indicators but also some indicators were changed only minimally. The focus on treatment processes like ward rounds, management of analgesia and sedation, mechanical ventilation and weaning, as well as the number of 10 indicators were not changed. Most topics remained except for early mobilization which was introduced instead of hypothermia following resuscitation. Infection prevention was added as an outcome indicator. These quality indicators are used in the peer review in intensive care, a method endorsed by the DIVI. A validity period of three years is planned for the quality indicators.

Using quality improvement methods to reduce clear fluid fasting times in children on a preoperative ward

OBJECTIVES

We applied quality improvement (QI) methodology to identify the different aspects of why children fasted for prolonged periods in our institution. Our aim was for 75% of all children to be fasted for clear fluid for less than 4 hours.

BACKGROUND

Prolonged fasting in children can increase thirst and irritability and have adverse effects on haemodynamic stability on induction. By reducing this, children may be less irritable, more comfortable and more physiologically stable, improving the preoperative experience for both children and carers.

METHODS

We conducted a QI project from January 2014 until August 2016 at a large tertiary pediatric teaching hospital. Baseline data and the magnitude of the problem were obtained from pilot studies. This allowed us to build a key driver diagram, a process map and conduct a failure mode and effects analysis. Using a framework of Plan-Do-Study-Act cycles our key interventions primarily focused on reducing confusion over procedure start times, giving parents accurate information, empowering staff and reducing variation by allowing children to drink on arrival (up to one hour) before surgery.

RESULTS

Prior to this project, using the 6,4,2 fasting rule for solids, breast milk, and clear fluids, respectively, 19% of children were fasted for fluid for less than 4 hours, mean fluid fasting time was 6.3 hours (SD 4.48). At the conclusion 72% of patients received a drink within 4 hours, mean fluid fasting reduced to 3.1 hours (SD 2.33). The secondary measures of aspiration (4.14:10 000) and cancellations have not increased since starting this project.

CONCLUSIONS

By using established QI methodology we reduced the mean fluid fasting time for day admissions at our hospital to 3.1 hours and increased the proportion of children fasting for less than 4 hours from 19% to 72%.

Prevalence, risk factors, and outcomes of idle intravenous catheters: An integrative review

OBJECTIVE

Complications of intravenous catheters remain a major contributor to health care costs and are a patient safety problem. An intravenous catheter not actively in use-an idle catheter-may increase the risk of infectious and noninfectious complications. We conducted an integrative review of the available literature to evaluate the prevalence, risk factors, and outcomes associated with idle intravenous catheters.

METHODS

Searches of multiple computerized databases were conducted to identify studies on idle intravenous catheters. Data on definitions of idle catheter, type of catheter, prevalence, risk factors, and patient outcomes were extracted.

RESULTS

Thirteen studies met inclusion criteria and were included in the review. The location and setting of the studies were diverse, including cross-sectional, retrospective, and prospective, and were conducted in varied geographic locations. The definition of an idle catheter was variable across studies. Although studies varied in terms of line-days or number of catheters placed, the primary definition of idle device was based on number of days or percent of devices left in situ without use. Four studies evaluated patient outcomes associated with idle catheters and found increased risk of infection, intensive care unit admission, and phlebitis.

CONCLUSIONS

Idle intravenous catheters are common and are associated with adverse outcomes. Prospective studies incorporating uniform definitions of idle catheters to test interventions to reduce idle catheter use are urgently needed.

A Quality Improvement Collaborative to Improve the Discharge Process for Hospitalized Children

OBJECTIVE

To assess the impact of a quality improvement collaborative on quality and efficiency of pediatric discharges.

METHODS

This was a multicenter quality improvement collaborative including 11 tertiary-care freestanding children's hospitals in the United States, conducted between November 1, 2011 and October 31, 2012. Sites selected interventions from a change package developed by an expert panel. Multiple plan-do-study-act cycles were conducted on patient populations selected by each site. Data on discharge-related care failures, family readiness for discharge, and 72-hour and 30-day readmissions were reported monthly by each site. Surveys of each site were also conducted to evaluate the use of various change strategies.

RESULTS

Most sites addressed discharge planning, quality of discharge instructions, and providing postdischarge support by phone. There was a significant decrease in discharge-related care failures, from 34% in the first project quarter to 21% at the end of the collaborative (P < .05). There was also a significant improvement in family perception of readiness for discharge, from 85% of families reporting the highest rating to 91% (P < .05). There was no improvement in unplanned 72-hour (0.7% vs 1.1%, P = .29) and slight worsening of the 30-day readmission rate (4.5% vs 6.3%, P = .05).

CONCLUSIONS

Institutions that participated in the collaborative had lower rates of discharge-related care failures and improved family readiness for discharge. There was no significant improvement in unplanned readmissions. More studies are needed to evaluate which interventions are most effective and to assess feasibility in non-children's hospital settings.

Outcomes Analysis and Quality Improvement in Children With Congenital and Acquired Cardiovascular Disease

OBJECTIVES

In this review, the current state of outcomes analysis and quality improvement in children with acquired and congenital cardiovascular disease will be discussed, with an emphasis on defining and measuring outcomes and quality in pediatric cardiac critical care medicine and risk stratification systems.

DATA SOURCE

MEDLINE and PubMed

CONCLUSION

: Measuring quality and outcomes in the pediatric cardiac critical care environment is challenging owing to many inherent obstacles, including a diverse patient mix, difficulty in determining how the care of the ICU team contributes to outcomes, and the lack of an adequate risk-adjustment method for pediatric cardiac critical care patients. Despite these barriers, new solutions are emerging that capitalize on lessons learned from other quality improvement initiatives, providing opportunities to build upon previous successes.

The Association of Central-Line-Associated Bloodstream Infections With Central-Line Utilization Rate and Maintenance Bundle Compliance Among Types of PICUs

OBJECTIVE

Central-line-associated bloodstream infections comprise 25% of device-associated infections. Compared with other units, PICUs demonstrate a higher central-line-associated bloodstream infections prevalence. Prior studies have not investigated the association of central-line-associated bloodstream infections prevalence, central-line utilization, or maintenance bundle compliance between specific types of PICUs.

DESIGN

This study analyzed monthly aggregate data regarding central-line-associated bloodstream infections prevalence, central-line utilization, and maintenance bundle compliance between three types of PICUs: 1) PICUs that do not care for cardiac patients (PICU); 2) PICUs that provide care for cardiac and noncardiac patients (C/PICU); or 3) designated cardiac ICUs (CICU).

SETTING

The included units submitted data as part of The Children's Hospital Association PICU central-line-associated bloodstream infections collaborative from January 1, 2011, to December 31, 2013.

PATIENTS

Patients admitted to PICUs in collaborative institutions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The overall central-line-associated bloodstream infections prevalence was low (1.37 central-line-associated bloodstream infections events/1,000 central-line days) and decreased over the time of the study. Central-line-associated bloodstream infections prevalence was not related to the type of PICU although C/PICU tended to have a higher central-line-associated bloodstream infections prevalence (p = 0.055). CICU demonstrated a significantly higher central-line utilization ratio (p < 0.001). However, when examined on a unit level, central-line utilization was not related to the central-line-associated bloodstream infections prevalence. The central-line maintenance bundle compliance rate was not associated with central line-associated bloodstream infections prevalence in this unit-level investigation. Neither utilization rate nor compliance rate changed significantly over time in any of the types of units.

CONCLUSIONS

Although this unit-level analysis did not demonstrate an association between central-line-associated bloodstream infections prevalence and central-line utilization and maintenance bundle compliance, optimization of both should continue, further decreasing central-line-associated bloodstream infections prevalence. In addition, investigation of patient-specific factors may aid in further central-line-associated bloodstream infections eradication.

Immunologic and Infectious Diseases in Pediatric Cardiac Critical Care: Proceedings of the 10th International Pediatric Cardiac Intensive Care Society Conference

Since the inception of the Pediatric Cardiac Intensive Care Society (PCICS) in 2003, remarkable advances in the care of children with critical cardiac disease have been developed. Specialized surgical approaches, anesthesiology practices, and intensive care management have all contributed to improved outcomes. However, significant morbidity often results from immunologic or infectious disease in the perioperative period or during a medical intensive care unit admission. The immunologic or infectious illness may lead to fever, which requires the attention and resources of the cardiac intensivist. Frequently, cardiopulmonary bypass leads to an inflammatory state that may present hemodynamic challenges or complicate postoperative care. However, inflammation unchecked by a compensatory anti-inflammatory response may also contribute to the development of capillary leak and lead to a complicated intensive care unit course. Any patient admitted to the intensive care unit is at risk for a hospital acquired infection, and no patients are at greater risk than the child treated with mechanical circulatory support. In summary, the prevention, diagnosis, and management of immunologic and infectious diseases in the pediatric cardiac intensive care unit is of paramount importance for the clinician. This review from the tenth PCICS International Conference will summarize the current knowledge in this important aspect of our field.

Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line-associated bloodstream infection (CLABSI) prevention efforts. This document updates “Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Significant reduction of central line-associated bloodstream infection rates in a tertiary neonatal unit

To evaluate the effectiveness of a quality initiative in reducing central line-associated bloodstream infections (CLABSIs) in our neonatal intensive care unit, we designed a prospective study (January 2012-September 2013) estimating CLABSI incidence before and after our implementation. CLABSI rates were significantly decreased after our intervention, from 12 cases per 1,000 central vascular catheter (CVC) days during the preinterventional period to 3.4 cases per 1,000 CVC days during the postinterventional period (P = .004).

Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis

BACKGROUND

Central-line-associated bloodstream infections (CLABSIs) are a major problem in intensive care units (ICUs) worldwide. We aimed to quantify the effectiveness of central-line bundles (insertion or maintenance or both) to prevent these infections.

METHODS

We searched Embase, MEDLINE OvidSP, Web-of-Science, and Cochrane Library to identify studies reporting the implementation of central-line bundles in adult ICU, paediatric ICU (PICU), or neonatal ICU (NICU) patients. We searched for studies published between Jan 1, 1990, and June 30, 2015. For the meta-analysis, crude estimates of infections were pooled by use of a DerSimonian and Laird random effect model. The primary outcome was the number of CLABSIs per 1000 catheter-days before and after implementation. Incidence risk ratios (IRRs) were obtained by use of random-effects models.

FINDINGS

We initially identified 4337 records, and after excluding duplicates and those ineligible, 96 studies met the eligibility criteria, 79 of which contained sufficient information for a meta-analysis. Median CLABSIs incidence were 5·7 per 1000 catheter-days (range 1·2-46·3; IQR 3·1-9·5) on adult ICUs; 5·9 per 1000 catheter-days (range 2·6-31·1; 4·8-9·4) on PICUs; and 8·4 per 1000 catheter-days (range 2·6-24·1; 3·7-16·0) on NICUs. After implementation of central-line bundles the CLABSI incidence ranged from 0 to 19·5 per 1000 catheter-days (median 2·6, IQR 1·2-4·4) in all types of ICUs. In our meta-analysis the incidence of infections decreased significantly from median 6·4 per 1000 catheter-days (IQR 3·8-10·9) to 2·5 per 1000 catheter-days (1·4-4·8) after implementation of bundles (IRR 0·44, 95% CI 0·39-0·50, p<0·0001; I(2)=89%).

INTERPRETATION

Implementation of central-line bundles has the potential to reduce the incidence of CLABSIs.

FUNDING

None.

Critical Care Delivery: The Importance of Process of Care and ICU Structure to Improved Outcomes: An Update From the American College of Critical Care Medicine Task Force on Models of Critical Care

In 2001, the Society of Critical Care Medicine published practice model guidelines that focused on the delivery of critical care and the roles of different ICU team members. An exhaustive review of the additional literature published since the last guideline has demonstrated that both the structure and process of care in the ICU are important for achieving optimal patient outcomes. Since the publication of the original guideline, several authorities have recognized that improvements in the processes of care, ICU structure, and the use of quality improvement science methodologies can beneficially impact patient outcomes and reduce costs. Herein, we summarize findings of the American College of Critical Care Medicine Task Force on Models of Critical Care: 1) An intensivist-led, high-performing, multidisciplinary team dedicated to the ICU is an integral part of effective care delivery; 2) Process improvement is the backbone of achieving high-quality ICU outcomes; 3) Standardized protocols including care bundles and order sets to facilitate measurable processes and outcomes should be used and further developed in the ICU setting; and 4) Institutional support for comprehensive quality improvement programs as well as tele-ICU programs should be provided.

Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line-associated bloodstream infection (CLABSI) prevention efforts. This document updates “Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Implementing a Daily Maintenance Care Bundle to Prevent Central Line-Associated Bloodstream Infections in Pediatric Oncology Patients

Eliminating central line-associated bloodstream infection (CLABSI) is a national priority. Central venous catheter (CVC) care bundles are composed of a series of interventions that, when used together, are effective in preventing CLABSI. A CVC daily maintenance care bundle includes procedural guidelines for hygiene, dressing changes, and access as well as specific timeframes. Failure to complete one of the components of the care bundle predisposes the patient to a bloodstream infection. A nurse-led multidisciplinary team implemented and, for six months, sustained a daily maintenance care bundle for pediatric oncology patients. This quality improvement project focused on nursing staffs' implementation of the daily maintenance care bundle and the sustainment of the intervention. The project used a pre-post program design to evaluate outcomes of CVC daily maintenance care bundle compliancy and CLABSI. A statistically significant increase between the pre- and post-assessments of the compliance was noted with the CVC daily maintenance care bundle. CLABSI infection rates decreased during the intervention. Strategies to implement practice change and promote sustainability are discussed.

The Past, Present, and Future of Healthcare-Associated Infection Prevention in Pediatrics: Catheter-Associated Bloodstream Infections

Central line–associated bloodstream infections cause morbidity and mortality in children. We explore the evidence for prevention of central line–associated bloodstream infections in children, assess current practices, and propose research topics to improve prevention strategies.

Risk Factors for Central Line–Associated Bloodstream Infection in Pediatric Intensive Care Units

Objective.

We sought to identify risk factors for central line-associated bloodstream infection (CLABSI) to describe children who might benefit from adjunctive interventions.

Design.

Case-control study of children admitted to the medical-surgical intensive care unit (ICU) or cardiac ICU from January 1, 2004, through December 31, 2007.

Setting.

Children's Hospital Boston is a freestanding, 396-bed quaternary care pediatric hospital with a 29-bed medical-surgical ICU and a 24-bed cardiac ICU.

Patients.

Case patients were patients with CLABSI who were identified by means of prospective surveillance. Control subjects were patients with a central venous catheter who were matched by ICU admission date.

Methods.

Multivariate conditional logistic regression models were used to identify independent risk factors for CLABSI and to derive and to validate a prediction rule.

Results.

Two hundred three case patients were matched with 406 control subjects. Independent predictors of CLABSI included duration of ICU central access (odds ratio [OR] for 15 or more days, 18.41 [95% confidence interval {CI} 4.10-82.56]; P < .001), central venous catheter placement in the ICU (OR for 2 or more ICU-placed catheters, 8.63 [95% CI, 2.63-28.38]; P = .001), nonoperative cardiovascular disease (OR, 7.44 [95% CI, 2.13-25.98]; P = .012), presence of gastrostomy tube (OR, 3.48 [95% CI, 1.55-7.79]; P = .003), receipt of parenteral nutrition (OR, 3.12 [95% CI, 1.55-6.32]; P= .002), and receipt of blood transfusion (OR, 2.55 [95% CI, 1.21-5.36]; P = .014). By use of risk factors known before central venous catheter placement, our model predicted CLABSI with a positive predictive value of 54% and a negative predictive value of 79%.

Conclusions.

Duration of central access, receipt of parenteral nutrition, and receipt of blood transfusion were confirmed as risk factors for CLABSI among children in the ICU. Newly identified risk factors include presence of gastrostomy tube, nonoperative cardiovascular disease, and ICU placement of central venous catheter. Children with these risk factors may be candidates for adjunctive interventions for CLABSI prevention.

Impact of universal disinfectant cap implementation on central line-associated bloodstream infections

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) result in increased length of stay, cost, and patient morbidity and mortality. One CLABSI prevention method is disinfection of intravenous access points. The literature suggests that placing disinfectant caps over needleless connectors decreases CLABSI risk.

METHODS

A quasi-experimental intervention study was conducted in a >430-bed trauma I center. In addition to an existing standard central line bundle, a new intervention consisting of a luer-lock disinfectant cap with 70% alcohol was implemented in all intravenous (IV) needleless connectors on patients with peripheral and central lines. Compliance to the disinfectant cap was monitored weekly. A generalized linear model using a Poisson distribution was fit to determine if there were significant relationships between CLABSIs and disinfectant cap use. Impacts on costs were also examined.

RESULTS

The rate of CLABSI decreased following implementation of the disinfectant cap. The incidence rate ratios (.577, P = .004) for implementing the disinfectant caps was statistically significant, indicating that the rate of patient infections decreased by >40%. Increased compliance rates were associated with lower infection rates. Disinfectant cap use was associated with an estimated savings of almost $300,000 per year in the hospital studied.

CONCLUSIONS

Use of a disinfectant cap on IV needleless connectors in addition to an existing standard central line bundle was associated with decreased CLABSI and costs.

Pulsative flushing as a strategy to prevent bacterial colonization of vascular access devices

Central venous device infections are associated with increased physical and psychological morbidity, mortality, length of stay, and costs. The aim of this study was to prove the efficacy of pulsatile flushing to prevent the bacterial colonization of vascular access devices. One hundred and forty four tests using 576 polyurethane short venous access catheters were performed. Four catheters per test were polluted with a fibronectin-serum albumin solution. Three were filled with a Staphylococcus aureus broth; one served as negative control. One contaminated catheter was not flushed (positive control), and two were flushed (10 mL.sec(-1)) with normal saline solution, either by ten successive boluses of 1 mL each or by one bolus of 10 mL. Each catheter was cultivated. The S. aureus quantity observed after continuous flushing was significantly higher than that observed after pulsative flushing (P<0.001). Unflushed catheters were 20.71 and 6.42 times more polluted than catheters flushed with the pulsative method or the continuous method, respectively. Pulsative flushing was at least twice as effective as continuous flushing in reducing the S. aureus count. Pulsative flushing is more effective than continuous flushing in reducing the endoluminal contamination. Pulsative flushing is a simple, effective, and inexpensive technique to reduce catheter bacterial colonization.

Reducing mortality and infections after congenital heart surgery in the developing world

BACKGROUND

There is little information about congenital heart surgery outcomes in developing countries. The International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries uses a registry and quality improvement strategies with nongovernmental organization reinforcement to reduce mortality. Registry data were used to evaluate impact.

METHODS

Twenty-eight sites in 17 developing world countries submitted congenital heart surgery data to a registry, received annual benchmarking reports, and created quality improvement teams. Webinars targeted 3 key drivers: safe perioperative practice, infection reduction, and team-based practice. Registry data were audited annually; only verified data were included in analyses. Risk-adjusted standardized mortality ratios (SMRs) and standardized infection ratios among participating sites were calculated.

RESULTS

Twenty-seven sites had verified data in at least 1 year, and 1 site withdrew. Among 15,049 cases of pediatric congenital heart surgery, unadjusted mortality was 6.3% and any major infection was 7.0%. SMRs for the overall International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries were 0.71 (95% confidence interval [CI] 0.62-0.81) in 2011 and 0.76 (95% CI 0.69-0.83) in 2012, compared with 2010 baseline. SMRs among 7 sites participating in all 3 years were 0.85 (95% CI 0.71-1.00) in 2011 and 0.80 (95% CI 0.66-0.96) in 2012; among 14 sites participating in 2011 and 2012, the SMR was 0.80 (95% CI 0.70-0.91) in 2012. Standardized infection ratios were similarly reduced.

CONCLUSIONS

Congenital heart surgery risk-adjusted mortality and infections were reduced in developing world programs participating in the collaborative quality improvement project and registry. Similar strategies might allow rapid reduction in global health care disparities.

Attributable costs of central line-associated bloodstream infections in a pediatric hematology/oncology population

BACKGROUND

Although several studies have estimated the attributable cost and length of stay (LOS) of central line-associated bloodstream infections (CLABSIs) in the pediatric intensive care unit setting, little is known about the attributable costs and LOS of CLABSIs in the vulnerable pediatric hematology/oncology population.

METHODS

We studied a total of 1562 inpatient admissions for 291 pediatric hematology/oncology patients at a single tertiary care children's hospital in the mid-Atlantic region between January 2008 and May 2011. Costs were normalized to year 2011 dollars. Propensity score matching was used to estimate the effect of CLABSIs on total cost and LOS while controlling for other covariates.

RESULTS

Sixty CLABSIs occurred during the 1562 admissions. Compared with the patients without a CLABSI, those who developed a CLABSI tended to be older (9.0 years vs 7.5 years; P = .026) and to have a tunneled catheter (46.7% vs 27.0%) and a peripherally inserted central catheter (20.0% vs 11.2%) as opposed to other types of catheters (P < .0001). Propensity score matching yielded matched groups without significant differences in patient characteristics. In the propensity score analysis, the attributable LOS of a CLABSI was 21.2 days (P < .0001), and the attributable cost of a CLABSI was $69,332 (P < .0001).

CONCLUSIONS

Among pediatric hematology/oncology patients, CLABSI was associated with an additional LOS of 21 days and increased costs of nearly $70,000. These findings may inform decisions regarding the value of investing in efforts to prevent CLABSIs in this vulnerable population.

Risk of bloodstream infection in children admitted to paediatric intensive care units in England and Wales following emergency inter-hospital transfer

Purpose

Adherence to full sterile procedures may be compromised when central venous catheters are inserted as part of emergency resuscitation and stabilisation, particularly outside the intensive care unit. Half of emergency admissions to paediatric intensive care units (PICU) in the UK occur after stabilisation at other hospitals. We determined whether bloodstream infection (BSI) occurred more frequently in children admitted to PICU after inter-hospital transfer compared to within-hospital admissions.

Methods

Data on emergency admissions to 20 PICUs in England and Wales for children <16 years between 2003–2012 were linked from the national PICU audit database (PICANet) and national infection surveillance (LabBase2). PICU-acquired BSI was defined as any positive blood culture sampled between 2 days after admission and 2 days following discharge from PICU.

Results

A total of 32,861/62,515 (53 %) admissions were inter-hospital transfers. Multivariable regression showed no significant difference in rates of PICU-acquired BSI by source of admission (incidence-rate ratio for inter-hospital transfer versus within-hospital admission = 0.97; 95 % CI 0.87–1.07) after adjusting for other risk-factors. Rates decreased more rapidly between 2003 and 2012 for inter-hospital transfers: 17.0 % (95 % CI 14.9–19.0 % per year) compared with 12.4 % (95 % CI 9.9–14.9 % per year) for within-hospital admissions. The median time to first PICU-acquired BSI did not differ significantly between inter-hospital transfers (7 days; IQR 4–13) and within-hospital admissions (8 days; IQR 4–15).

Conclusions

Nationally, inter-hospital transfer is no longer a significant risk factor for PICU-acquired BSI. Given the large proportion of infection occurring in the second week of admission, initiatives to further reduce PICU-acquired BSI should focus on maintaining sterile procedures after admission.

Infection prevention practices in neonatal intensive care units reporting to the national healthcare safety network

BACKGROUND

Patients in the neonatal intensive care unit (NICU) are at high risk for healthcare-associated infections. Variability in reported infection rates among NICUs exists, possibly related to differences in prevention strategies. A better understanding of current prevention practices may help identify prevention gaps and areas for further research.

METHODS

We surveyed infection control staff in NICUs reporting to the National Healthcare Safety Network (NHSN) to assess strategies used to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and central line-associated bloodstream infections in NICUs.

RESULTS

Staff from 162 of 342 NICUs responded (response rate, 47.3%). Most (92.3%) NICUs use central line insertion and maintenance bundles, but maintenance practices varied, including agents used for antisepsis and frequency of dressing changes. Forty-two percent reported routine screening for MRSA colonization upon admission for all patients. Chlorhexidine gluconate (CHG) use for central line care for at least 1 indication (central line insertion, dressing changes, or port/cap antisepsis) was reported in 82 NICUs (51.3%). Among sixty-five NICUs responding to questions on CHG use restrictions, 46.2% reported no restrictions.

CONCLUSIONS

Our survey illustrated heterogeneity of CLABSI and MRSA prevention practices and underscores the need for further research to define optimal strategies and evidence-based prevention recommendations for neonates.

Impact of needleless connector change frequency on central line-associated bloodstream infection rate

BACKGROUND

Bloodstream infection is the most common pediatric health care-associated infection and is strongly associated with catheter use. These infections greatly increase the cost of hospital stay.

METHODS

To assess the association between needleless connector (NC) change frequency and central line-associated bloodstream infection (CLABSI) rate, we modeled monthly pediatric stem cell transplant (SCT) CLABSI rate in 3 periods: baseline period during which NC were changed every 96 hours regardless of infusate (period 1); trial period in which NC were changed every 24 hours with blood or lipid infusions (period 2); and a return to NC change every 96 hours regardless of infusate (period 3). Data on potential confounders were collected retrospectively. Autocorrelated segmented regression models were used to compare SCT CLABSI rates in each period, adjusting for potential confounders. CLABSI rates were also assessed for a nonequivalent control group (oncology unit) in which NC were changed every 24 hours with blood or lipid use in periods 2 and 3.

RESULTS

SCT CLABSI rates were 0.41, 3.56, and 0.03 per 1,000 central line-days in periods 1, 2, and 3, respectively. In multivariable analysis, the CLABSI rate was significantly higher in period 2 compared with both period 1 (P = .01) and period 3 (P = .003). In contrast, CLABSI rates on the oncology unit were not significantly different among periods.

CONCLUSION

In pediatric SCT patients, changing needleless connectors every 24 hours when blood or lipids are infused is associated with increased CLABSI rates. National recommendations regarding NC change frequency should be clarified.

Prevention of central venous catheter infections: a survey of paediatric ICU nurses' knowledge and practice

BACKGROUND

Central venous catheters are important in the management of paediatric intensive care unit patients, but can have serious complications which worsen the patients' health, prolong hospital stays and increase the cost of care. Evidence-based recommendations for preventing catheter-related bloodstream infections are available, but it is unknown how widely these are known or practiced in the paediatric intensive care environment.

OBJECTIVES

To assess nursing knowledge of evidence based guidelines to prevent catheter-related bloodstream infections; the extent to which Australia and New Zealand paediatric intensive cares have adopted prevention practices; and to identify the factors that encouraged their adoption and improve nursing knowledge.

DESIGN

Cross-sectional surveys using convenience sampling.

SETTINGS

Tertiary level paediatric intensive care units in Australia and New Zealand.

PARTICIPANTS

Paediatric intensive care nursing staff and nurse managers.

METHODS

Between 2010 and 2011, the 'Paediatric Intensive Care Nurses' Knowledge of Evidence-Based Catheter-Related Bloodstream Infection Prevention Questionnaire' was distributed to paediatric intensive care nursing staff and the 'Catheter-Related Bloodstream Infection Prevention Practices Survey' was distributed to nurse managers to measure knowledge, practices and culture.

RESULTS

The questionnaires were completed by 253 paediatric intensive care nurses (response rate: 34%). The mean total knowledge score was 5.5 (SD=1.4) out of a possible ten, with significant variation of total scores between paediatric intensive care sites (p=0.01). Other demographic characteristics were not significantly associated with variation in total knowledge scores. All nursing managers from Australian and New Zealand paediatric intensive care units participated in the survey (n=8; response rate: 100%). Wide practice variation was reported, with inconsistent adherence to recommendations. Safety culture was not significantly associated with mean knowledge scores per site.

CONCLUSIONS

This study has identified that there is variation in the infection prevention approach and nurses' knowledge about catheter-related bloodstream infection prevention. The presence of an improved safety culture, years of paediatric intensive care experience and higher qualifications did not influence the nurses' uptake of recommendations, therefore further factors need to be explored in order to improve understanding and implementation of best practice.

Transferring central line care evidence into practice on pediatric acute care units

The purpose of this study was to examine the effectiveness of an educational intervention to implement evidence based guidelines for central line care. Full-time nurses working on pediatric inpatient units were surveyed before and after the multi-component educational intervention directed at implementation of the central line care bundle. There was a statistically significant increase in the nurses' self-reported compliance with components of the care bundle 6 months after the educational intervention (p<.001), thus improving central line care and infection prevention.

Implementation of a children's hospital-wide central venous catheter insertion and maintenance bundle

BACKGROUND

Central venous catheter-associated bloodstream infections in children are an increasingly recognized serious safety problem worldwide, but are often preventable. Central venous catheter bundles have proved effective to prevent such infections. Successful implementation requires changes in the hospital system as well as in healthcare professionals' behaviour. The aim of the study is to evaluate process and outcome of implementation of a state-of-the-art central venous catheter insertion and maintenance bundle in a large university children's hospital.

METHODS/DESIGN

An interrupted time series design will be used; the study will encompass all children who need a central venous catheter. New state-of-the-art central venous catheter bundles will be developed. The Pronovost-model will guide the implementation process. We developed a tailored multifaceted implementation strategy consisting of reminders, feedback, management support, local opinion leaders, and education. Primary outcome measure is the number of catheter-associated infections per 1000 line-days. The process outcome is degree of adherence to use of these central venous catheter bundles is the secondary outcome. A cost-effectiveness analysis is part of the study. Outcomes will be monitored during three periods: baseline, pre-intervention, and post-intervention for over 48 months.

DISCUSSION

This model-based implementation strategy will reveal the challenges of implementing a hospital-wide safety program. This work will add to the body of knowledge in the field of implementation. We postulate that healthcare workers' willingness to shift from providing habitual care to state-of-the-art care may reflect the need for consistent care improvement. Trial registration: Dutch trials registry, trial # 3635.

TRIAL REGISTRATION

Dutch trials registry (http://www.trialregister.nl), trial # 3635.

The German quality indicators in intensive care medicine 2013--second edition

Quality indicators are key elements of quality management. The quality indicators for intensive care medicine of the German Interdisciplinary Society of Intensive Care Medicine (DIVI) from the year 2010 were recently evaluated when their validity time expired after two years. Overall one indicator was replaced and further three were in part changed. The former indicator I “elevation of head of bed” was replaced by the indicator “Daily multi-professional ward rounds with the documentation of daily therapy goals” and added to the indicator IV “Weaning and other measures to prevent ventilator associated pneumonias (short: Weaning/VAP Bundle)” (VAP = ventilator-associated pneumonia) which aims at the reduction of VAP incidence. The indicator VIII “Documentation of structured relative-/next-of-kin communication” was refined. The indicator X “Direction of the ICU by a specially trained certified intensivist with no other clinical duties in a department” was also updated according to recent study results. These updated quality indicators are part of the Peer Review in intensive care medicine. The next update of the quality indicators is due in 2016.

Incidence trends in pathogen-specific central line-associated bloodstream infections in US intensive care units, 1990-2010

OBJECTIVE

To quantify historical trends in rates of central line-associated bloodstream infections (CLABSIs) in US intensive care units (ICUs) caused by major pathogen groups, including Candida spp., Enterococcus spp., specified gram-negative rods, and Staphylococcus aureus.

DESIGN

Active surveillance in a cohort of participating ICUs through the Centers for Disease Control and Prevention, the National Nosocomial Infections Surveillance system during 1990-2004, and the National Healthcare Safety Network during 2006-2010. Setting. ICUs. Participants. Patients who were admitted to participating ICUs.

RESULTS

The CLABSI incidence density rate for S. aureus decreased annually starting in 2002 and remained lower than for other pathogen groups. Since 2006, the annual decrease for S. aureus CLABSIs in nonpediatric ICU types was -18.3% (95% confidence interval [CI], -20.8% to -15.8%), whereas the incidence density rate for S. aureus among pediatric ICUs did not change. The annual decrease for all ICUs combined since 2006 was -17.8% (95% CI, -19.4% to -16.1%) for Enterococcus spp., -16.4% (95% CI, -18.2% to -14.7%) for gram-negative rods, and -13.5% (95% CI, -15.4% to -11.5%) for Candida spp.

CONCLUSIONS

Patterns of ICU CLABSI incidence density rates among major pathogen groups have changed considerably during recent decades. CLABSI incidence declined steeply since 2006, except for CLABSI due to S. aureus in pediatric ICUs. There is a need to better understand CLABSIs that still do occur, on the basis of microbiological and patient characteristics. New prevention approaches may be needed in addition to central line insertion and maintenance practices.

Modification of anesthesia practice reduces catheter-associated bloodstream infections: a quality improvement initiative

BACKGROUND

A major strategic hospital goal is the prevention of catheter associated bloodstream infections (CABSI). In 2009, at our institution, the CABSI rate for patients who traveled out of the ICU to the operating room and other procedural areas under the care of an anesthesiologist was increased compared to patients who remained on the unit.

AIMS

Our objective was to develop countermeasures to improve intraoperative cleanliness by anesthesia providers, minimize contamination of intravenous access points, and ultimately reduce CABSIs.

MATERIALS & METHODS

A multidisciplinary team identified barriers to following best practices for reducing contamination of intravenous line entry-ports. Using Continuous Performance Improvement (CPI) or Lean techniques, staff directly impacted by the changes developed countermeasures to improve anesthesia practice. Compliance with the new "best practices" improved with coaching and feedback.

RESULTS

Postimplementation, CABSI rates for patients traveling off the ICU with anesthesiology providers decreased from 14.1 per thousand trips off the ICU preintervention in 2009 to 9.7 per 1000 trips in 2010 and to 0 per 1000 trips in 2011 postintervention. Hospital-wide CABSI rates decreased from 3.5 per 1000 central line days preintervention to 2.2 per 1000 central line days after.

CONCLUSION

Practice modification by anesthesiology providers in the operating room can decrease workspace contamination and is associated with decreased CABSI rates.

Improving on-time starts for patients scheduled with general anesthesia in a MRI suite

OBJECTIVE

We applied quality improvement methodology to identify unnecessary, redundant parts of processes that can lead to delayed on-time starts for patients scheduled with general anesthesia (GA) in the radiology department.

AIM

To address the issue of delayed on-time starts by improving work flow for the first patient scheduled with GA.

BACKGROUND

Unplanned imaging in a high-volume MRI suite can result in a significant ripple effect throughout the day. Delayed on-time starts can lead to patient, family, and staff dissatisfaction due to significant wait times.

MATERIALS AND METHODS

The team conducted a 5 month improvement project. Baseline data were obtained from pilot time studies allowed the team to identify reasons why the first case was not starting on time and to identify several key drivers to improve the process. Using the framework of small tests of change or the Plan-Do-Study-Act model, our key interventions primarily focused on standardizing the processes for completing the preimaging evaluation and for anesthesia induction. The primary objective measure of successful on-time start was defined as obtaining the first MRI image within 10 min of the scheduled start time, for the first patients of the day scheduled with GA. The secondary outcome measure was the extent of the delay quantified in minutes.

RESULTS

Prior to the initiation of the project, only 36% of the first patients scheduled with GA each day met the primary objective measure. At the conclusion of the project 84% started on time. The secondary measure also showed significant improvement.

CONCLUSIONS

Process improvement projects in anesthesia can yield positive results, using small incremental standardized changes. We used a quality improvement methods to successfully improve on-time start for patients scheduled with GA in high-volume MRI suite.

Video observation of anesthesia practice: a useful and reliable tool for quality improvement initiatives

AIMS

Patients with central venous catheters who are transferred out of the Intensive Care Unit to the care of an anesthesiology team for an operation or interventional radiology procedure had excessive rates of catheter associated blood stream infection (CABSI).

METHODS

We convened a multi-disciplinary team to audit anesthesia practice and to develop countermeasures for those aspects of practice that were thought to be contributing to CABSI's. It was noted that provider behavior changed in the presence of an auditor (Hawthorne effect) and so videorecordings were used, in the hope that this Hawthorne effect would be reduced. Clips were chosen from the hours of video (without audio) recordings that showed medication administration, airway management and touching the anesthesia cart of equipment/supplies.

RESULTS

These clips were viewed by three observers and measurements were made to assess intra-rater and inter-rater reliability. The clips were then viewed to quantify differences in practice before and after our bundle of "best practices" was introduced.

CONCLUSIONS

Although video recording has been used to evaluate adherence to resuscitation protocols in both trauma and in neonatal resuscitation, (Pediatric Emergency Care, 26, 2010, 803; Pediatrics, 117, 2006, 658; Pediatrics, 106, 2000, 654) we believe this is the first time that video has been used to record before and after behaviors for an anesthesia quality improvement initiative.

The impact of a quality improvement intervention to reduce nosocomial infections in a PICU

OBJECTIVE

To evaluate whether a quality improvement intervention could reduce nosocomial infection rates in a PICU and improve patient outcomes.

DESIGN

Prospective interventional cohort study conducted during three periods: preintervention period, intervention period, and long-term follow-up.

SETTING

A 14-bed medical and surgical PICU in a university hospital for children.

INTERVENTIONS

The quality improvement intervention consisted of the creation of an infection control team, a program targeting hand hygiene, and quality practices focused on preventing nosocomial infections.

MEASUREMENTS AND MAIN RESULTS

We included 851 patients in the preintervention period, 822 in the intervention period, and 940 in the long-term follow-up period. Compared with the preintervention period, in the intervention period, the rates of central line-associated bloodstream infection decreased from 8.1 to 6/1,000 central venous catheter-days (p = 0.640), ventilator-associated pneumonia decreased from 28.3 to 10.6/1,000 days' ventilation (p = 0.005), and catheter-associated urinary tract infection decreased from 23.3 to 5.8/1,000 urinary catheter-days (p < 0.001). Furthermore, hospital length of stay decreased from 18.56 to 14.57 days (p = 0.035) and mortality decreased from 5.1% to 3.3% (p = 0.056). Multivariable logistic regression found that nosocomial infections was independently associated with increased mortality (odds ratio, 2.35 [95% CI, 1.02-5.55]; p = 0.046). Compared with the preintervention period, in the long-term follow-up period, central line-associated bloodstream infection decreased to 4.6/1,000 central venous catheter-days (p = 0.205); ventilator-associated pneumonia decreased to 9.1/1,000 ventilation-days (p = 0.001), and catheter-associated urinary tract infection decreased to 5.2/1,000 urinary catheter-days (p < 0.001). Hospital length of stay (14.45 days; p = 0.048) and mortality (3.2%; p = 0.058) also decreased.

CONCLUSIONS

A multifaceted quality improvement intervention reduced nosocomial infection rates, hospital length of stay, and mortality in our PICU. The effects of the intervention were sustained over time.

Evaluating application of the National Healthcare Safety Network central line-associated bloodstream infection surveillance definition: a survey of pediatric intensive care and hematology/oncology units

OBJECTIVE

To evaluate the application of the National Healthcare Safety Network (NHSN) central line-associated bloodstream infection (CLABSI) definition in pediatric intensive care units (PICUs) and pediatric hematology/oncology units (PHOUs) participating in a multicenter quality improvement collaborative to reduce CLABSIs; to identify sources of variability in the application of the definition.

DESIGN

Online survey using 18 standardized case scenarios. Each described a positive blood culture in a patient and required a yes- or-no answer to the question "Is this a CLABSI?" NHSN staff responses were the reference standard.

SETTING

Sixty-five US PICUs and PHOUs.

PARTICIPANTS

Staff who routinely adjudicate CLABSIs using NHSN definitions.

RESULTS

Sixty responses were received from 58 (89%) of 65 institutions; 78% of respondents were infection preventionists, infection control officers, or infectious disease physicians. Responses matched those of NHSN staff for 78% of questions. The mean (SE) percentage of concurring answers did not differ for scenarios evaluating application of 1 of the 3 criteria ("known pathogen," 78% [1.7%]; "skin contaminant, >1 year of age," 76% [SE, 2.5%]; "skin contaminant, ≤1 year of age," 81% [3.8%]; [Formula: see text]). The mean percentage of concurring answers was lower for scenarios requiring respondents to determine whether a CLABSI was present or incubating on admission (64% [4.6%]; [Formula: see text]) or to distinguish between primary and secondary bacteremia (65% [2.5%]; [Formula: see text]).

CONCLUSIONS

The accuracy of application of the CLABSI definition was suboptimal. Efforts to reduce variability in identifying CLABSIs that are present or incubating on admission and in distinguishing primary from secondary bloodstream infection are needed.

Interventions to improve professional adherence to guidelines for prevention of device-related infections

BACKGROUND

Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. There are specific risk profiles for each device, but in general, the breakdown of aseptic technique during insertion and care for the device, as well as the duration of device use, are important factors for the development of these serious and costly infections.

OBJECTIVES

To assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device-related infection rates and measures of adherence.

SEARCH METHODS

We searched the following electronic databases for primary studies up to June 2012: the Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. We searched reference lists and contacted authors of included studies. We also searched the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies that complied with the Cochrane EPOC Group methodological criteria, and that evaluated interventions to improve professional adherence to guidelines for the prevention of device-related infections.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane EPOC 'Risk of bias' tool. We contacted authors of original papers to obtain missing information.

MAIN RESULTS

We included 13 studies: one cluster randomised controlled trial (CRCT) and 12 ITS studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards, and more than 3504 patients and 1406 healthcare professionals. Six of the included studies targeted adherence to guidelines to prevent central line-associated blood stream infections (CLABSIs); another six studies targeted adherence to guidelines to prevent ventilator-associated pneumonia (VAP), and one study focused on interventions to improve urinary catheter practices. We judged all included studies to be at moderate or high risk of bias.The largest median effect on rates of VAP was found at nine months follow-up with a decrease of 7.36 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). The one included cluster randomised controlled trial (CRCT) observed, improved urinary catheter practices five weeks after the intervention (absolute difference 12.2 percentage points), however, the statistical significance of this is unknown given a unit of analysis error. It is worth noting that N = 6 interventions that did result in significantly decreased infection rates involved more than one active intervention, which in some cases, was repeatedly administered over time, and further, that one intervention involving specialised oral care personnel showed the largest step change (-22.9 cases per 1000 ventilator days (standard error (SE) 4.0), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002)) among the included studies. We attempted to combine the results for studies targeting the same indwelling medical device (central line catheters or mechanical ventilators) and reporting the same outcomes (CLABSI and VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among included studies (I(2) up to 97%), we did not retain these analyses. Six of the included studies reported post-intervention adherence scores ranging from 14% to 98%. The effect on rates of infection were mixed and the effect sizes were small, with the largest median effect for the change in level (interquartile range (IQR)) for the six CLABSI studies being observed at three months follow-up was a decrease of 0.6 (-2.74 to 0.28) cases per 1000 central line days (six studies and 36 sites). This change was not sustained over longer follow-up times.

AUTHORS' CONCLUSIONS

The low to very low quality of the evidence of studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions involving more than one active element and that are repeatedly administered over time, and interventions employing specialised personnel, who are focused on an aspect of care that is supported by evidence e.g. dentists/dental auxiliaries performing oral care for VAP prevention.

Minimizing complications associated with percutaneous central venous catheter placement in children: recent advances

OBJECTIVES

To summarize existing knowledge regarding the prevalence of complications associated with temporary percutaneous central venous catheters placed in critically ill children, and to review evolving strategies to minimize the prevalence of these complications.

DATA SOURCES

Literature review was performed: PubMed and EBSCOhost were searched using the terms central venous catheter, children, ultrasound, infection, thrombosis, and thromboembolism in various combinations. Citations of interest from identified articles were also reviewed.

STUDY SELECTION

The review focused primarily on pediatric literature relevant to the topic of interest.

DATA EXTRACTION AND SYNTHESIS

Randomized clinical trials and other prospective studies were discussed in greater detail than retrospective, single-center investigations.

CONCLUSIONS

Complications during percutaneous central venous catheter placement in children are not rare and may be in part attributable to abnormalities in vascular anatomy. Thromboses in children with central venous catheters are increasingly recognized as an important problem for which evidence-based preventive measures are lacking. Catheter-associated bloodstream infection rates in critically ill children have markedly decreased over the last decade, associated with an increased emphasis on staff education and the use of insertion and maintenance bundles. Available evidence tends to support the use of two-dimensional ultrasound to augment the landmark technique for catheter placement, but more studies are needed.

Prevention of catheter-related blood stream infections in children with intestinal failure

PURPOSE OF REVIEW

Catheter-related bloodstream infections (CRBSIs) account for a major source of morbidity in children with intestinal failure. Many of these patients require long-term central venous access, placing them at significant risk for these infections. The purpose of this review is to highlight the most current strategies and interventions for minimizing CRBSIs in this population.

RECENT FINDINGS

Strategies for the prevention of CRBSIs continue to evolve, although most have not been specifically evaluated in children with intestinal failure. Some of the more recent interventions that are likely to be effective in this population include creating standardized protocols for catheter insertion and maintenance, ethanol lock therapy, and occasional use of antimicrobial catheters and dressings.

SUMMARY

Every effort must be made to prevent CRBSIs in infants and children with intestinal failure. Disease specific risk factors must be considered when determining the best approach for infection prevention. Because of their long-term access needs, checklists and protocols to maintain strict sterile technique at the time of catheter insertion are useful. Additionally, these children often have some degree of intestinal bacterial overgrowth secondary to dilation and dysmotility. Therefore, the use of antimicrobial locks, catheters and dressings likely provide benefit for some patients.

A Crossover Randomized Prospective Pilot Study Evaluating a Central Venous Catheter Team in Reducing Catheter-Related Bloodstream Infections in Pediatric Oncology Patients

Background: Treatment for most children with cancer includes the use of a central venous catheter (CVC). CVCs provide reliable venous access for delivery of chemotherapy and supportive care. This advantage is mitigated by an increased risk of bloodstream infections (BSIs). Despite the ubiquitous use of CVCs, few prospective studies have been conducted to address infection prevention strategies in pediatric oncology patients. Design: Prospective, crossover pilot study of a CVC team intervention versus standard care. Setting: Two inpatient oncology units in a metropolitan children’s hospital. Patients: A total of 41 patients/135 admissions for the experimental unit (EU) and 41/129 admissions for the control unit (CU). Methods: Patients received a CVC blood draw bundle procedure by a CVC registered nurse (RN) team member (experimental intervention: EU) for 6 months and by the assigned bedside RN (standard care: CU) for 6 months. Feasibility of implementing a CVC RN team; a significant difference in CVC-related BSIs between the team intervention versus standard care and risk factors associated in the development of CVC-related BSIs were determined. Results: There were 7 CVC-related BSIs/1238 catheter days in the EU group (5.7/1000 catheter days) versus 3 CVC-related BSIs/1419 catheter days in the CU group (2.1/1000 catheter days; P = .97). Selected risk factors were not significantly associated with the development of a CVC-related BSI. Conclusions: A CVC team in the care of pediatric oncology patients is feasible; however, a larger cohort will be required to adequately determine the effectiveness of the team reducing CVC-related BSIs.