Meta-analysis of the central line bundle for preventing catheter-related infections: a case study in appraising the evidence in quality improvement

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.

Multifaceted Quality Improvement Interventions to Prevent Hemodialysis Catheter-Related Bloodstream Infections: A Systematic Review

RATIONALE & OBJECTIVE

Central venous catheters (CVCs) are widely used for hemodialysis but are prone to burdensome and costly bloodstream infections. We determined whether multifaceted quality improvement interventions in hemodialysis units can prevent hemodialysis catheter-related bloodstream infections (HDCRBSI).

STUDY DESIGN

Systematic review.

SETTING & STUDY POPULATIONS

PubMed, EMBASE, and CENTRAL were searched from inception to April 23, 2022, to identify randomized trials, time-series analyses, and before-after studies that examined the effect of multifaceted quality improvement interventions on the incidence of HDCRBSI or access-related bloodstream infections (ARBSI) among people receiving hemodialysis outside of the intensive care unit (ICU).

DATA EXTRACTION

Two people independently extracted data and assessed the risk of bias and quality of evidence using validated tools.

ANALYTICAL APPROACH

Intervention effects, validity, and characteristics of studies with the same design were compared. Differences between study designs were described.

RESULTS

We included 21 studies from 8,824 identified by our search. Among 15 studies that measured HDCRBSI, 2 methodologically heterogenous cluster randomized trials reported discordant intervention effects, 2 interrupted time-series analyses reported favorable interventions with discordant patterns of effect, and 11 before-after studies reported favorable interventions with a very high risk of bias. Among 6 studies that only measured ARBSI, 1 time-series analysis and 1 before-after study did not find a favorable intervention effect, and 4 before-after studies reported a favorable effect with a very high risk of bias. The overall quality of evidence was low for HDCRBSI and very low for ARBSI.

LIMITATIONS

Nine definitions of HDCRBSI were used. Ten studies included hospital-based and satellite facilities but did not report separate intervention effects for each type of facility.

CONCLUSIONS

Multifaceted quality improvement interventions may prevent HDCRBSI outside the ICU. However, evidence supporting them is of low quality, and further carefully conducted studies are warranted.

REGISTRATION

Registered at PROSPERO with registration number CRD42021252290.

PLAIN-LANGUAGE SUMMARY

People with kidney failure rely on central venous catheters to facilitate life-sustaining hemodialysis treatments. Unfortunately, hemodialysis catheters are a common source of problematic bloodstream infections. Quality improvement programs have effectively prevented catheter-related infections in intensive care units, but it is unclear whether they can be adapted to patients using hemodialysis catheters in the community. In a systematic review that included 21 studies, we found that most quality improvement programs were reported to be successful. However, the findings were mixed among higher-quality studies, and overall the quality of evidence was low. Ongoing quality improvement programs should be complemented by more high-quality research.

Streamlining the External Ventricular Drain and Intracranial Pressure Monitor Procedural Setup: A Quality Improvement Initiative

OBJECTIVE

External ventricular drain (EVD) and intracranial pressure (ICP) monitor placements are among the most common critical care procedures for severe brain injury. Quality improvement initiatives have streamlined similar processes. The aim of the project was to decrease the time to collect supplies for EVD or ICP monitor placement by 25% by April 1, 2021.

METHODS

The project followed the define-measure-analyze-improve-control 6 sigma framework. Several quality gaps were identified: equipment stored separately, delays in replacing faulty items, and wasted resources. The team defined the process using the suppliers-inputs-processes-outputs-customers + requirements method, measured time to collect supplies, and analyzed data with an Ishikawa/fishbone diagram. The improve phase included a kaizen burst to generate solutions and an impact/effort grid to evaluate options. The team concluded that the optimal plan was to stock a mobile EVD cart and an ICP monitor pole with disposable go-bags.

RESULTS

The average time for nurses to collect EVD placement supplies decreased from 411 to 63 seconds (7-1 minute), and the average time for nurses to collect ICP monitor placement supplies decreased from 418 to 53 seconds (7-<1 minute). Residents decreased the time to obtain EVD placement supplies from 330 to 56 seconds (6-<1 minute) and ICP monitor supplies from 489 to 77 seconds (8-1 minute). Feedback was overwhelmingly positive and focused on improved process efficiency and reduced waste.

CONCLUSIONS

The time reduction and enthusiasm are likely associated with the simplicity and comprehensiveness of the intervention design. Including key stakeholders in decision-making and succinct communications reduced resistance to change.

Atomic force microscopy and scanning electron microscopy as alternative methods of early identification of pathogens causing catheter-related bloodstream infections of patients in ICU

Introduction

Vascular catheters are an indispensable element of the therapy of patients in intensive care. Their use is associated with the possibility of complications, including infectious. According to various sources, the incidence of catheter-related bloodstream infections (CRBSIs) ranges from 0.1 to 22.7 per 1,000 catheter days.

Materials and Methods

The central venous catheter tip culture samples were collected from 24 patients with suspected catheter-related bloodstream infection, from three intensive care units (ICUs). The results of microscopic examinations: atomic force microscope (AFM) and scanning electron microscope (SEM) were compared with the results of microbiological analysis of the central venous catheter tip and blood collected from the catheter.

Results

The microscopic examination and microbiological analysis of both the blood and central venous catheter samples confirmed the presence of microorganisms in 16 cases (double positive result). Our study was conducted in a short period of time (up to 6 hours) and it gave an initial answer to the question about the type of microorganisms colonising the central venous catheter. In one patient the infection was not caused by removal of the central venous catheter. However, not all results were fully consistent within the two diagnostic methods. The colonisation of the central venous catheter with Pseudomonas aeruginosa and Staphylococcus epidermidis was microbiologically confirmed, but it was not confirmed by the microscopic examination of the sample collected from patient No. 20. However, the examination enabled preliminary assessment of the microorganism colonising the catheter, which may have caused the blood infection. It cannot be ruled out that Pseudomonas aeruginosa bacilli were grown on the catheter that came into contact with blood from another source of infection, e.g. the respiratory, nervous or urinary systems. Information on the presence of cocci-shaped bacteria forming characteristic clusters or rods may enable initial diagnosis of catheter-related bloodstream infection if it is accompanied by typical clinical symptoms. Alternative diagnostics also provides valuable information on the presence of biofilm, which is a factor hindering the body’s response to infection and penetration of antibiotics.

Conclusions

Our pilot study presents new diagnostic possibilities of microscopic imaging with the atomic force microscope (AFM) and scanning electron microscope (SEM) to identify pathogens on routinely used disposable medical devices, such as the central venous catheter. On the other hand, this range of diagnostics reveals the potential to constantly improve medical materials which come into direct contact with patients’ tissues. It is important to create a database of microscopic images, which would be a repeatable diagnostic pattern and fully correlated with the results of microbiological analysis, because it would facilitate initial quick diagnosis of a potential CRBSI.

Multifaceted intervention to reduce haemodialysis catheter related bloodstream infections: REDUCCTION stepped wedge, cluster randomised trial

OBJECTIVE

To identify whether multifaceted interventions, or care bundles, reduce catheter related bloodstream infections (CRBSIs) from central venous catheters used for haemodialysis.

DESIGN

Stepped wedge, cluster randomised design.

SETTING

37 renal services across Australia.

PARTICIPANTS

All adults (age ≥18 years) under the care of a renal service who required insertion of a new haemodialysis catheter.

INTERVENTIONS

After a baseline observational phase, a service-wide, multifaceted intervention bundle that included elements of catheter care (insertion, maintenance, and removal) was implemented at one of three randomly assigned time points (12 at the first time point, 12 at the second, and 13 at the third) between 20 December 2016 and 31 March 2020.

MAIN OUTCOMES MEASURE

The primary endpoint was the rate of CRBSI in the baseline phase compared with intervention phase at the renal service level using the intention-to-treat principle.

RESULTS

1.14 million haemodialysis catheter days of use were monitored across 6364 patients. Patient characteristics were similar across baseline and intervention phases. 315 CRBSIs occurred (158 in the baseline phase and 157 in the intervention phase), with a rate of 0.21 per 1000 days of catheter use in the baseline phase and 0.29 per 1000 days in the intervention phase, giving an incidence rate ratio of 1.37 (95% confidence interval 0.85 to 2.21; P=0.20). This translates to one in 10 patients who undergo dialysis for a year with a catheter experiencing an episode of CRBSI.

CONCLUSIONS

Among patients who require a haemodialysis catheter, the implementation of a multifaceted intervention did not reduce the rate of CRBSI. Multifaceted interventions to prevent CRBSI might not be effective in clinical practice settings.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry ACTRN12616000830493.

Implementation of a central-line bundle: a qualitative study of three clinical units

Background

Evidence for the central line-associated bloodstream infection (CLABSI) bundle effectiveness remains mixed, possibly reflecting implementation challenges and persistent ambiguities in how CLABSIs are counted and bundle adherence measured. In the context of a tertiary pediatric hospital that had reduced CLABSI by 30% as part of an international safety program, we aimed to examine unit-based socio-cultural factors influencing bundle practices and measurement, and how they come to be recognized and attended to by safety leaders over time in an organization-wide bundle implementation effort.

Methods

We used an interpretivist qualitative research approach, based on 74 interviews, approximately 50 h of observations, and documents. Data collection focused on hospital executives and safety leadership, and three clinical units: a medical specialty unit, an intensive care unit, and a surgical unit. We used thematic analysis and constant comparison methods for data analysis.

Results

Participants had variable beliefs about the central-line bundle as a quality improvement priority based on their professional roles and experiences and unit setting, which influenced their responses. Nursing leaders were particularly concerned about CLABSI being one of an overwhelming number of QI targets for which they were responsible. Bundle implementation strategies were initially reliant on unit-based nurse education. Over time there was recognition of the need for centralized education and reinforcement tactics. However, these interventions achieved limited impact given the influence of competing unit workflow demands and professional roles, interactions, and routines, which were variably targeted in the safety program. The auditing process, initially a responsibility of units, was performed in different ways based on individuals’ approaches to the process. Given concerns about auditing reliability, a centralized approach was implemented, which continued to have its own variability.

Conclusions

Our findings report on a contextualized, dynamic implementation approach that required movement between centralized and unit-based approaches and from a focus on standardization to some recognition of a role for customization. However, some factors related to bundle compliance and measurement remain unaddressed, including harder to change socio-cultural factors likely important to sustainability of the CLABSI reductions and fostering further improvements across a broader safety agenda.

Adherence to the central line bundle in intensive care: An integrative review

BACKGROUND

Central line-associated bloodstream infections (CLABSI) occurring in intensive care units are associated with increased morbidity and mortality, increased length of hospitalization, and cost of care associated with treating CLABSIs. The Centers for Disease Control and Prevention guidelines and checklist bundle are intended to provide evidence-based recommendations for the prevention of CLABSIs. Despite the promotion of central line bundle policies, wide variability exists in compliance and infection rates in intensive care units.

OBJECTIVE

To evaluate and synthesize the existing literature on adherence to the central line bundle recommendations for the prevention of CLABSI.

DESIGN

Integrative literature review.

DATA SOURCES

CINHAL, PubMed, and SCOPUS databases were searched.

REVIEW METHODS

Whittmore and Knafl's integrative review method.

RESULTS

A total of 608 articles were identified, 407 articles were screened for topic of interest and adherence to the inclusion criteria, and 19 articles were included in this review. None of the 19 studies addressed adherence to all 14 recommendations of the central line bundle checklist.

CONCLUSION

This integrative review identified gaps in adherence to the central line bundle. Research is needed to determine the actual adherence to each item in the bundle, and to investigate factors that contribute to nonadherence. To achieve complete compliance with all the bundle items creative and innovative technology is needed.

Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prevention and sepsis care

Background

An academic safety-net hospital leveraged the federally funded state Delivery System Reform Incentive Payment programme to implement a hospital-wide initiative to reduce healthcare-associated infections (HAIs) and improve sepsis care.

Methods

The study period was from 2013 to 2017. The setting is a 770-bed urban hospital with six intensive care units and a large emergency department. Key interventions implemented were (1) awareness campaign and clinician engagement, (2) implementation of HAI and sepsis bundles, (3) education of clinical personnel using standardised curriculum on bundles, (4) training of key managers, leaders and personnel in quality improvement methods, and (5) electronic medical record-based clinical decision support. Throughout the 5-year period, staff received frequent, clear, visible and consistent messages from leadership regarding the importance of their participation in this initiative, performing hand hygiene and preventing potential regulatory failures. Several process measures including bundle compliance, hand hygiene and culture of safety were monitored. The primary outcomes were rates of central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI) and sepsis mortality.

Results

From 2013 to 2017, the hospital-wide rates of HAI reduced: CLABSI from 1.6 to 0.8 per 1000 catheter-days (Poisson regression estimate: −0.19; 95% CI −0.29 to −0.09; p=0.0002), CAUTI from 4.7 to 1.3 per 1000 catheter-days (−0.34; −0.43 to −0.26; p<0.0001) and SSI after 18 types of procedures from 3.4% to 1.3% (−0.29; −0.34 to −0.24; p<0.0001). Mortality of patients presenting to emergency department with sepsis reduced from 9.4% to 2.9% (−0.42; −0.49 to −0.36; p<0.0001). Adherence to bundles of care and hand hygiene and the hospital culture of patient safety improved. Results were sustained through 2019.

Conclusion

A hospital-wide initiative incentivised by the Delivery System Reform Incentive Payment programme succeeded in reducing HAI and sepsis mortality over 5 years in a sustainable manner.

Infection prevention practices in the Netherlands: results from a National Survey

Objective

To examine the extent to which acute care hospitals in the Netherlands have adopted recommended practices to prevent catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and Clostridioides difficile infection (CDI).

Methods

Between 18 July 2017 and 31 October 2017, we surveyed the infection prevention teams of all acute care hospitals in the Netherlands. The survey instrument was based on the 'Translating Healthcare-Associated Infection Prevention Research into Practice' (TRIP) questionnaire and adapted to the Dutch context. Descriptive statistics were used to examine the reported regular use of CAUTI, CLABSI, VAP, and CDI prevention practices as well as the hospital characteristics.

Results

Out of 72 eligible hospitals, 47 (65.3%) responded. Surveillance systems for monitoring CAUTI, CLABSI, VAP, and CDI were present in 17.8, 95.4, 26.2, and 77.3% of hospitals, respectively. Antimicrobial stewardship programs have been established in 91.5% of participating hospitals. For CAUTI, the majority of hospitals regularly used aseptic technique during catheter insertion (95%) and portable bladder ultrasound scanners (86.1%). Intermittent catheterization and catheter stop-orders were regularly used by 65.8 and 62.2% of hospitals. For CLABSI, all hospitals regularly used maximum sterile barrier precautions and chlorhexidine gluconate for insertion site antisepsis. Avoidance of the femoral site for central line insertions was regularly used by 65.9% of hospitals. Urinary catheters and central-lines impregnated with antibiotics or antiseptics were rarely used (≤ 5%). Selective decontamination strategies for preventing VAP were used in 84% of hospitals. With the exception of disposable thermometers (31.8%), all prevention practices to prevent CDI were regularly used by more than 80% of hospitals.

Conclusions

Most Dutch hospitals report regular use of recommended practices for preventing CLABSI and CDI. Several specific practices to prevent CAUTI and VAP were less frequently used, however, providing an opportunity for improvement.

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

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

Peripherally Inserted Central Catheters in the ICU: A Retrospective Study of Adult Medical Patients in 52 Hospitals

OBJECTIVES

To quantify variation in use and complications from peripherally inserted central catheters placed in the ICU versus peripherally inserted central catheters placed on the general ward.

DESIGN

Retrospective cohort study.

SETTING

Fifty-two hospital Michigan quality collaborative.

PATIENTS

Twenty-seven-thousand two-hundred eighty-nine patients with peripherally inserted central catheters placed during hospitalization.

MEASUREMENTS AND MAIN RESULTS

Descriptive statistics were used to summarize patient, provider, and device characteristics. Bivariate tests were used to assess differences between peripherally inserted central catheters placed in the ICU versus peripherally inserted central catheters placed on the ward. Multilevel mixed-effects generalized linear models adjusting for patient and device factors with a logit link clustered by hospital were used to examine the association between peripherally inserted central catheter complications and location of peripherally inserted central catheter placement. Variation in ICU peripherally inserted central catheter use, rates of complications, and appropriateness of use across hospitals was also examined. Eight-thousand two-hundred eighty patients (30.3%) received peripherally inserted central catheters in the ICU versus 19,009 (69.7%) on the general ward. The commonest indication for peripherally inserted central catheter use in the ICU was difficult IV access (35.1%) versus antibiotic therapy (53.3%) on wards. Compared with peripherally inserted central catheters placed in wards, peripherally inserted central catheters placed in the ICU were more often multilumen (59.5% vs 39.3; p < 0.001) and more often associated with a complication (odds ratio, 1.30; 95% CI, 1.18-1.43; p < 0.001). Substantial variation in ICU peripherally inserted central catheter use and outcomes across hospitals was observed, with median peripherally inserted central catheter dwell time ranging from 3 to 38.5 days (p < 0.001) and complications from 0% to 40.2% (p < 0.001). Importantly, 87% (n = 45) of ICUs reported median peripherally inserted central catheter dwell times less than or equal to 14 days, a duration where traditional central venous catheters, not peripherally inserted central catheters, are considered appropriate by published criteria.

CONCLUSIONS

Peripherally inserted central catheter use in the ICU is highly variable, associated with complications and often not appropriate. Further study of vascular access decision-making in the ICU appears necessary.

Hospital-to-Home Interventions, Use, and Satisfaction: A Meta-analysis

CONTEXT

Hospital-to-home transitions are critical opportunities to promote patient safety and high-quality care. However, such transitions are often fraught with difficulties associated with increased health care use and poor patient satisfaction.

OBJECTIVE

In this review, we determine which pediatric hospital discharge interventions affect subsequent health care use or parental satisfaction compared with usual care.

DATA SOURCES

We searched 7 bibliographic databases and 5 pediatric journals.

STUDY SELECTION

Inclusion criteria were: (1) available in English, (2) focused on children <18 years of age, (3) pediatric data reported separately from adult data, (4) not focused on normal newborns or pregnancy, (5) discharge intervention implemented in the inpatient setting, and (6) outcomes of health care use or caregiver satisfaction. Reviews, case studies, and commentaries were excluded.

DATA EXTRACTION

Two reviewers independently abstracted data using modified Cochrane data collection forms and assessed quality using modified Downs and Black checklists.

RESULTS

Seventy one articles met inclusion criteria. Although most interventions improved satisfaction, interventions variably reduced use. Interventions focused on follow-up care, discharge planning, teach back-based parental education, and contingency planning were associated with reduced use across patient groups. Bundled care coordination and family engagement interventions were associated with lower use in patients with chronic illnesses and neonates.

LIMITATIONS

Variability limited findings and reduced generalizability.

CONCLUSIONS

In this review, we highlight the utility of a pediatric discharge bundle in reducing health care use. Coordinating follow-up, discharge planning, teach back-based parental education, and contingency planning are potential foci for future efforts to improve hospital-to-home transitions.

A state of the art review on optimal practices to prevent, recognize, and manage complications associated with intravascular devices in the critically ill

Intravascular catheters are inserted into almost all critically ill patients. This review provides up-to-date insight into available knowledge on epidemiology and diagnosis of complications of central vein and arterial catheters in ICU. It discusses the optimal therapy of catheter-related infections and thrombosis. Prevention of complications is a multidisciplinary task that combines both improvement of the process of care and introduction of new technologies. We emphasize the main component of the prevention strategies that should be used in critical care and propose areas of future investigation in this field.

Are antimicrobial peripherally inserted central catheters associated with reduction in central line-associated bloodstream infection? A systematic review and meta-analysis

BACKGROUND

Antimicrobial peripherally inserted central catheters (PICCs) may reduce the risk of central line-associated bloodstream infection (CLABSI). However, data regarding efficacy are limited. We aimed to evaluate whether antimicrobial PICCs are associated with CLABSI reduction.

METHODS

MEDLINE, EMBASE, CINHAL, and Web of Science were searched from inception to July 2016; conference proceedings were searched to identify additional studies. Study selection and data extraction were performed independently by 2 authors.

RESULTS

Of 597 citations identified, 8 studies involving 12,879 patients met eligibility criteria. Studies included adult and pediatric patients from intensive care, long-term care, and general ward settings. The incidence of CLABSI in patients with antimicrobial PICCs was 0.2% (95% confidence interval [CI], 0.0%-0.5%), and the incidence among nonantimicrobial catheters was 5.3% (95% CI, 2.6%-8.8%). Compared with noncoated PICCs, antimicrobial PICCs were associated with a significant reduction in CLABSI (relative risk [RR], 0.29; 95% CI, 0.10-0.78). Statistical heterogeneity (I², 71.6%; T2 = 1.07) was resolved by publication type, with peer-reviewed articles showing greater reduction in CLABSI (RR, 0.21; 95% CI, 0.06-0.74). Twenty-six patients (95% CI, 21-75) need to be treated with antimicrobial PICCs to prevent 1 CLABSI. Studies of adults at greater baseline risk of CLABSI experienced greater reduction in CLABSI (RR, 0.20; P = .003).

CONCLUSIONS

Available evidence suggests that antimicrobial PICCs may reduce CLABSI, especially in high-risk subgroups. Randomized trials are needed to assess efficacy across patient populations.

Hospital-Acquired Infections: Current Trends and Prevention

Health care-associated infections (HAIs) are the primary cause of preventable death and disability among hospitalized patients. According to the Centers for Disease Control and Prevention (CDC), complications or infections secondary to either device implantation or surgery are referred to as HAIs. Specifically, the CDC monitors surgical site infections, central-line-associated bloodstream infection, catheter-associated urinary tract infections, and ventilator-associated pneumonias. This article explores HAIs specific to pathophysiology, epidemiology, and prevention, and how nurses can work together with other health care providers to decrease the incidence of these preventable complications.