Improving compliance with central venous catheter care bundles using electronic records

Care bundles and peripheral arterial catheters

HIGHLIGHTS

What we know about the topic: Recommendations for the use of vascular access care bundles to reduce infection are followed for different devices. The risk of arterial catheter-related infection is comparable with short-term, non-cuffed central venous catheters. There are practice concerns for clinicians inserting and caring for peripheral arterial catheters. What this paper adds: The selected studies had a theme of decreased infection after using bundled strategies for all devices. Few studies addressed use of bundles for care of peripheral arterial catheters. High-quality research should be performed about using care bundles for insertion and care of arterial catheters.

INTRODUCTION

A scoping review of the literature was performed.

AIMS/OBJECTIVES

To find information on the use of care bundles for care of arterial, central, and peripherally inserted venous catheters.

METHODS

Data was extracted by 2 independent researchers using standardized methodology.

RESULTS

Results of 84 studies included 2 (2.4%) randomized controlled trials, 38 (45.2%) observational studies, 29 (34.5%) quality projects, and 15 (17.9%) reviews. Populations had more adults than pediatric patients. All studies had the most prominent theme of decreased infection in all devices after using bundle strategies.

DISCUSSION AND CONCLUSIONS

The mapping of available evidence strongly supports the use of care bundles to reduce infection in the care of all intravascular devices. However, deficiencies regarding practice concerns about insertion and care of arterial catheters highlight areas for future research with the aim to eliminate the gap in the evidence of studies of care bundles for peripheral arterial catheters.

Nurses' Perceptions of Adherence to the Central Line Maintenance Bundle: Linkages to Thoughts, Emotions, and Behavior

The U.S. Centers for Disease Control established the central line maintenance care bundle in 2011, yet nurses' adherence to all seven components remains challenging. The specific aim of this study was to explore and understand intensive care nurses' perceptions and beliefs regarding central line maintenance, bundle care elements, and associated adherence. This qualitative study used a phenomenological approach. Three main themes emerged as follows: (1) thoughts about the ability to adhere to the central line bundle created feelings about central line maintenance care, (2) feelings about the nurses' ability to adhere to the central line bundle influenced behaviors, and (3) behaviors for central line bundle adherence reinforced thoughts. Each theme had several subthemes. Organizations must assess and mitigate the unique cognitive and behavioral factors that affect nurses' adherence to the central line-associated bloodstream infection (CLABSI) maintenance bundle. In addition, nursing adherence requires knowledge of CLABSI rates and direct care nurse involvement in identifying solutions.

A Quality Improvement Initiative to Increase Central Line Maintenance Bundle Compliance through Nursing-led Rounds

Introduction:

Improvements in maintenance bundle compliance around central line-associated bloodstream infections (CLABSIs) lack standardization. The objective was to implement a formalized nursing-led rounding process, Rounds for Influence, with a goal of 12 rounds/wk on each inpatient unit and Ambulatory Infusion Center, achieving > 90% maintenance bundle compliance.

Methods:

Nurses served as peer “influencers” to perform rounds. The CLABSI prevention team created three comprehensive rounding tools (line access, dressing change/port needle insertion, and cap change) on a digital platform. The team designed these tools to assess clinical competence for maintenance bundle components and implemented nine plan-do-study-act cycles throughout the study period.

Results:

Influencers completed 191 rounds after the first month of implementation, resulting in a 264.2% increase from the baseline of 52.5 rounds per month. Over the 2.5 years postimplementation, rounds resulted in 7836 total observations. Maintenance bundle compliance decreased from 86.9% (centerline value from November 2017 to September 2018) to 40.8% after the first month of implementation. Compliance increased iteratively (two separate centerline shifts) to a current centerline value of 87.1%. The CLABSI 12-month cumulative standardized infection ratio (SIR) was 0.9 in November 2017 and dropped to 0.53 in June 2021.

Conclusion:

Implementing a formalized nursing-led rounding process led to increased maintenance bundle compliance, decreased CLABSI SIR, and is an integral part of nursing practice. Given this success, there is interest from other hospital-acquired condition improvement teams in applying this rounding practice to their improvement work.

OUP accepted manuscript

Objectives

(1) Systematically review the literature on computerized audit and feedback (e-A&F) systems in healthcare. (2) Compare features of current systems against e-A&F best practices. (3) Generate hypotheses on how e-A&F systems may impact patient care and outcomes.

Methods

We searched MEDLINE (Ovid), EMBASE (Ovid), and CINAHL (Ebsco) databases to December 31, 2020. Two reviewers independently performed selection, extraction, and quality appraisal (Mixed Methods Appraisal Tool). System features were compared with 18 best practices derived from Clinical Performance Feedback Intervention Theory. We then used realist concepts to generate hypotheses on mechanisms of e-A&F impact. Results are reported in accordance with the PRISMA statement.

Results

Our search yielded 4301 unique articles. We included 88 studies evaluating 65 e-A&F systems, spanning a diverse range of clinical areas, including medical, surgical, general practice, etc. Systems adopted a median of 8 best practices (interquartile range 6–10), with 32 systems providing near real-time feedback data and 20 systems incorporating action planning. High-confidence hypotheses suggested that favorable e-A&F systems prompted specific actions, particularly enabled by timely and role-specific feedback (including patient lists and individual performance data) and embedded action plans, in order to improve system usage, care quality, and patient outcomes.

Conclusions

e-A&F systems continue to be developed for many clinical applications. Yet, several systems still lack basic features recommended by best practice, such as timely feedback and action planning. Systems should focus on actionability, by providing real-time data for feedback that is specific to user roles, with embedded action plans.

Protocol Registration

PROSPERO CRD42016048695.

How does innovative technology impact nursing in infectious diseases and infection control? A scoping review

Aim

Considering the increasing number of emerging infectious diseases, innovative approaches are strongly in demand. Additionally, research in this field has expanded exponentially. Thus, faced with this diverse information, we aim to clarify key concepts and knowledge gaps of technology in nursing and the field of infectious diseases.

Design

This scoping review followed the methodology of scoping review guidance from Arksey and O’Malley.

Methods

Six databases were searched systematically (PubMed, Web of Science, IEEE Explore, EBSCOhost, Cochrane Library and Summon). After the removal of duplicates, 532 citations were retrieved and 77 were included in the analysis.

Results

We identified five major trends in technology for nursing and infectious diseases: artificial intelligence, the Internet of things, information and communications technology, simulation technology and e‐learning. Our findings indicate that the most promising trend is the IoT because of the many positive effects validated in most of the reviewed studies.

A systematic review of the effects of implementing clinical pathways supported by health information technologies

OBJECTIVE

Health information technology (HIT) interventions include electronic patient records, prescribing, and ordering systems. Clinical pathways are multidisciplinary plans of care that enable the delivery of evidence-based healthcare. Our objective was to systematically review the effects of implementing HIT-supported clinical pathways.

MATERIALS AND METHODS

A systematic review protocol was developed including Medline, Embase, and CENTRAL database searches. We recorded data relating to study design, participants, intervention, and outcome characteristics and formally assessed risk of bias.

RESULTS

Forty-four studies involving more than 270 000 patients were included. Investigation methodologies included before-after (n = 16, 36.4%), noncomparative (n = 14, 31.8%), interrupted time series (n = 5, 11.4%), retrospective cohort (n = 4, 9.1%), cluster randomized (n = 2, 4.5%), controlled before-after (n = 1, 2.3%), prospective case-control (n = 1, 2.3%), and prospective cohort (n = 1, 2.3%) study designs. Clinical decision support (n = 25, 56.8%), modified electronic documentation (n = 23, 52.3%), and computerized provider order entry (n = 23, 52.3%) were the most frequently utilized HIT interventions. The majority of studies (n = 38, 86.4%) reported benefits associated with HIT-supported pathways. These included reported improvements in objectively measured patient outcomes (n = 15, 34.1%), quality of care (n = 29, 65.9%), and healthcare resource utilization (n = 10, n = 22.7%).

DISCUSSION

Although most studies reported improvements in outcomes, the strength of evidence was limited by the study designs that were utilized.

CONCLUSIONS

Ongoing evaluations of HIT-supported clinical pathways are justified but would benefit from study designs that report key outcomes (including adverse events) and minimize the risk of bias.

Technology-enabled performance monitoring in intensive care: An integrative literature review

BACKGROUND

Implementation of evidence-based bundles in intensive care units is integral to improving quality of care and patient outcomes. However, it increases the burden of data collection and analysis required for performance monitoring and feedback of an inter-disciplinary care team. Health information technology including electronic health records and data analytic tools could automate this process and provide real-time feedback to the team.

AIM

This integrative literature review aimed to examine the extent to which technology-enabled performance monitoring and feedback contributed to improving quality of care and patient outcomes when implementing evidence-based bundles.

METHODS

A literature search of scientific databases was conducted using PubMed, Embase, Scopus, CINHAL and Ovid Medline.

RESULTS

Of nine studies included in this review, all reported improved compliance of the team with evidence-based bundles, ranging from 3% to 60% post implementation of technology-enabled performance monitoring and feedback. Significant reductions (p < .05) in hospital acquired infections were also reported in five studies.

CONCLUSIONS

Overall, the addition of documentation fields to electronic health records was essential in providing real-time feedback to teams and improving their compliance with evidence-based bundles. Further research is needed to assess the effectiveness of technology-enabled performance monitoring and feedback in improving patient outcomes on a larger scale, especially in resource-limited settings such as community hospitals.

Improving outcome of sepsis on the ward: introducing the 'Sepsis Six' bundle

BACKGROUND

The Sepsis Six bundle is designed to facilitate early intervention with three diagnostic and three therapeutic steps to be delivered within 1 h to patients with suspected sepsis.

AIMS AND OBJECTIVES

To investigate the effects of delivering the 'Sepsis Six' bundle by the Critical Care Outreach team on patient outcomes.

DESIGN

In a prospective observational study, all adult patients on the general wards from June 2012 to January 2014 with sepsis who were screened and treated by the Critical Care Outreach team were included.

METHODS

The main outcome measure was the change in National Early Warning Score following the delivery of the Sepsis Six bundle within 24 h. Secondary outcomes were 90-day mortality and overall bundle compliance.

RESULTS

A total of 207 patients were included in the analysis. Overall bundle compliance was 84%. National Early Warning Scores decreased significantly 24 h after administering the Sepsis Six, from 7·4 ± 2·6 to 3·1 ± 2·4 (p < 0·001). The distribution of the National Early Warning Score changed significantly. Mortality was lower at 90 days when patients who presented with signs of sepsis within 48 h of hospital admission were compared with those who presented with signs of sepsis after 48 h of hospital admission (14·5% versus 35·4% p < 0·03) despite similar baseline physiological variables.

CONCLUSIONS

We found better outcomes after the administration of Sepsis Six. Reliable delivery of the bundle, defined as 80% of patients receiving the standard of care, is achievable, and our quality improvement data suggest that it is likely to be sustainable in our environment.

RELEVANCE TO CLINICAL PRACTICE

Sepsis Six can reduce physiological impairment, monitored by the National Early Warning Scores. Consistent delivery of the bundle can lead to better patient outcomes.

Review of Strategies to Reduce Central Line-Associated Bloodstream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI) in Adult ICUs

Central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) are costly and morbid. Despite evidence-based guidelines, Some intensive care units (ICUs) continue to have elevated infection rates. In October 2015, we performed a systematic search of the peer-reviewed literature within the PubMed and Cochrane databases for interventions to reduce CLABSI and/or CAUTI in adult ICUs and synthesized findings using a narrative review process. The interventions were categorized using a conceptual model, with stages applicable to both CAUTI and CLABSI prevention: (stage 0) avoid catheter if possible, (stage 1) ensure aseptic placement, (stage 2) maintain awareness and proper care of catheters in place, and (stage 3) promptly remove unnecessary catheters. We also looked for effective components that the 5 most successful (by reduction in infection rates) studies of each infection shared. Interventions that addressed multiple stages within the conceptual model were common in these successful studies. Assuring compliance with infection prevention efforts via auditing and timely feedback were also common. Hospitalists with patient safety interests may find this review informative for formulating quality improvement interventions to reduce these infections.

Impact of two bundles on central catheter-related bloodstream infection in critically ill patients

Objective:

To evaluate the impact of the implementation of insertion and maintenance bundles on the rates of catheter-related bloodstream infection in an intensive care unit.

Method:

This is a quasi-experimental, before-and-after study with a non-equivalent control group. During a six-month period, insertion and maintenance bundles for the central venous catheters were implemented. Supervision guidelines were developed to assess compliance with the bundle and catheter characteristics.

Results:

A total of 444 central catheters corresponding to 390 patients were observed, of which 68.7% were inserted in the unit. The maintenance and insertion bundles reached 62.9% and 94.7% compliance, respectively, and 50.7% of the insertions were supervised. It was possible to observe a 54.5% decrease in the rate of central catheter infection (3.48 vs 1.52 x 1000 days/catheter, p<0.05) when compared with the control group.

Conclusion:

The simultaneous implementation of insertion and maintenance bundles has a positive impact on the reduction of catheter-related bloodstream infection; therefore it is an efficient alternative to improve the quality and safety of care in high complexity units.

Creatively Improving Care Delivery

The medical community has been challenged to improve upon deficiencies in the delivery of patient care. Quality improvement methods are therefore increasingly used in everyday clinical practice. As demonstrated in this review, creative and impactful improvement projects within pediatric gastroenterology can be successfully achieved as either multicenter projects or single-center efforts. Through our willingness to accept the challenge to improve, practitioners within the pediatric gastroenterology community have become leaders in using quality improvement to change practice and improve clinical outcomes.

A novel approach to leveraging electronic health record data to enhance pediatric surgical quality improvement bundle process compliance

PURPOSE

Quality improvement (QI) bundles have been widely adopted to reduce surgical site infections (SSI). Improvement science suggests when organizations achieve high-reliability to QI processes, outcomes dramatically improve. However, measuring QI process compliance is poorly supported by electronic health record (EHR) systems. We developed a custom EHR tool to facilitate capture of process data for SSI prevention with the aim of increasing bundle compliance and reducing adverse events.

METHODS

Ten SSI prevention bundle processes were linked to EHR data elements that were then aggregated into a snapshot display superimposed on weekly case-log reports. The data aggregation and user interface facilitated efficient review of all SSI bundle elements, providing an exact bundle compliance rate without random sampling or chart review.

RESULTS

Nine months after implementation of our custom EHR tool, we observed centerline shifts in median SSI bundle compliance (46% to 72%). Additionally, as predicted by high reliability principles, we began to see a trend toward improvement in SSI rates (1.68 to 0.87 per 100 operations), but a discrete centerline shift was not detected.

CONCLUSION

Simple informatics solutions can facilitate extraction of QI process data from the EHR without relying on adjunctive systems. Analyses of these data may drive reductions in adverse events. Pediatric surgical departments should consider leveraging the EHR to enhance bundle compliance as they implement QI strategies.