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Reynolds H, Gowardman J, Woods C. Care bundles and peripheral arterial catheters. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2024; 33:S34-S41. [PMID: 38271041 DOI: 10.12968/bjon.2024.33.2.s34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
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.
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Affiliation(s)
- Heather Reynolds
- Department of Anaesthesia & Perioperative Medicine, Royal Brisbane & Women's Hospital, Herston, Queensland, Australia, The University of Queensland, St Lucia, Queensland, Australia, Alliance for Vascular Access Teaching & Research, Griffith University, Nathan, Queensland, Australia
| | - John Gowardman
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Herston, Queensland, Australia, The University of Queensland, St Lucia, Queensland, Australia
| | - Christine Woods
- Department of Anaesthesia & Perioperative Medicine, Royal Brisbane & Women's Hospital, Herston, Queensland, Australia, The University of Queensland, St Lucia, Queensland, Australia
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Lazarus B, Bongetti E, Ling J, Gallagher M, Kotwal S, Polkinghorne KR. Multifaceted Quality Improvement Interventions to Prevent Hemodialysis Catheter-Related Bloodstream Infections: A Systematic Review. Am J Kidney Dis 2023; 82:429-442.e1. [PMID: 37178814 DOI: 10.1053/j.ajkd.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 02/06/2023] [Indexed: 05/15/2023]
Abstract
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.
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Affiliation(s)
- Benjamin Lazarus
- Department of Medicine, Monash University, Melbourne; Department of Nephrology, Monash Medical Centre, Monash Health, Melbourne; George Institute of Global Health, Sydney.
| | - Elisa Bongetti
- Department of Medicine, Monash University, Melbourne; Department of Nephrology, Monash Medical Centre, Monash Health, Melbourne
| | - Jonathan Ling
- Department of Medicine, Monash University, Melbourne; Department of Nephrology, Monash Medical Centre, Monash Health, Melbourne
| | - Martin Gallagher
- George Institute of Global Health, Sydney; South Western Sydney Campus, University of New South Wales, Sydney
| | - Sradha Kotwal
- George Institute of Global Health, Sydney; Prince of Wales Hospital, University of New South Wales, Sydney, Australia
| | - Kevan R Polkinghorne
- Department of Medicine, Monash University, Melbourne; Department of Nephrology, Monash Medical Centre, Monash Health, Melbourne; School of Public Health and Preventive Medicine, Monash University, Melbourne
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Rotter J, Carlstrom LP, Graffeo CS, Nesvick CL, Gunnels M, Hellickson JD, Marcellino C, Atkinson JLD. Streamlining the External Ventricular Drain and Intracranial Pressure Monitor Procedural Setup: A Quality Improvement Initiative. World Neurosurg 2022; 166:e475-e483. [PMID: 35843582 DOI: 10.1016/j.wneu.2022.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Juliana Rotter
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, USA.
| | - Lucas P Carlstrom
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, USA
| | | | - Cody L Nesvick
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, USA
| | - Marshall Gunnels
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, USA
| | - Jodi D Hellickson
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, USA
| | | | - John L D Atkinson
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, USA
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Atomic force microscopy and scanning electron microscopy as alternative methods of early identification of pathogens causing catheter-related bloodstream infections of patients in ICU. POSTEP HIG MED DOSW 2022. [DOI: 10.2478/ahem-2022-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
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.
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Kotwal S, Cass A, Coggan S, Gray NA, Jan S, McDonald S, Polkinghorne KR, Rogers K, Talaulikar G, Di Tanna GL, Gallagher M. Multifaceted intervention to reduce haemodialysis catheter related bloodstream infections: REDUCCTION stepped wedge, cluster randomised trial. BMJ 2022; 377:e069634. [PMID: 35414532 PMCID: PMC9002320 DOI: 10.1136/bmj-2021-069634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Sradha Kotwal
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Prince of Wales Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Sarah Coggan
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Nicholas A Gray
- Sunshine Coast University Hospital, Birtinya, QLD, Australia
- Department of Health and Behavioural Science,University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Stephen Jan
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Stephen McDonald
- ANZDATA Registry, South Australia Health and Medical Research Institute, Adelaide, SA, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Renal Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Kevan R Polkinghorne
- Department of Epidemiology and Preventive Medicine, Monash University, VIC, Australia
- Departments of Nephrology and Medicine, Monash Medical Centre, Monash University, VIC, Australia
| | - Kris Rogers
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
- School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Gian Luca Di Tanna
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Martin Gallagher
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, NSW, Sydney, Australia
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Kovar A, Joiner K, Leonard LD, Cumbler E, Tevis S. Variability in Surgical Site Preparation Technique: An Opportunity for Improvement. AORN J 2022; 115:341-345. [PMID: 35333395 DOI: 10.1002/aorn.13645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 12/29/2020] [Accepted: 02/24/2021] [Indexed: 11/06/2022]
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Incident Reporting Systems: What Will It Take to Make Them Less Frustrating and Achieve Anything Useful? Jt Comm J Qual Patient Saf 2021; 47:755-758. [PMID: 34716115 DOI: 10.1016/j.jcjq.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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8
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Schiff G, Shojania KG. Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. BMJ Qual Saf 2021; 31:148-152. [PMID: 34625484 PMCID: PMC8785050 DOI: 10.1136/bmjqs-2021-014163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/27/2021] [Indexed: 12/20/2022]
Affiliation(s)
- Gordon Schiff
- General Medicine, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Kaveh G Shojania
- Department of Medicine and the Centre for Quality Improvement and Patient Safety, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Goldman J, Rotteau L, Shojania KG, Baker GR, Rowland P, Christianson MK, Vogus TJ, Cameron C, Coffey M. Implementation of a central-line bundle: a qualitative study of three clinical units. Implement Sci Commun 2021; 2:105. [PMID: 34530918 PMCID: PMC8447632 DOI: 10.1186/s43058-021-00204-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 08/25/2021] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Joanne Goldman
- Centre for Quality Improvement and Patient Safety, Temerty Faculty of Medicine, University of Toronto, 630-525 University Ave., Toronto, M5G2L3, Canada. .,Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada. .,Wilson Centre for Research in Education, University of Toronto, 200 Elizabeth St., 1ES-565, Toronto, M5G 2C4, Canada.
| | - Leahora Rotteau
- Centre for Quality Improvement and Patient Safety, Temerty Faculty of Medicine, University of Toronto, 630-525 University Ave., Toronto, M5G2L3, Canada
| | - Kaveh G Shojania
- Centre for Quality Improvement and Patient Safety, Temerty Faculty of Medicine, University of Toronto, 630-525 University Ave., Toronto, M5G2L3, Canada.,Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.,Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - G Ross Baker
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College St., Suite 425, Toronto, M5T 3M6, Canada
| | - Paula Rowland
- Wilson Centre for Research in Education, University of Toronto, 200 Elizabeth St., 1ES-565, Toronto, M5G 2C4, Canada.,Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Marlys K Christianson
- Rotman School of Management, University of Toronto, 125 St. George St., Toronto, M5S 2E8, Canada
| | - Timothy J Vogus
- Owen Graduate School of Management, Vanderbilt University, 401 21st Avenue South, Nashville, TN, 37203, USA
| | - Connie Cameron
- The Hospital for Sick Children, 555 University Ave., Toronto, M5G 1X8, Canada
| | - Maitreya Coffey
- The Hospital for Sick Children, 555 University Ave., Toronto, M5G 1X8, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,Children's Hospitals Solutions for Patient Safety, Cincinnati, OH, USA
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A Tracheal Intubation Checklist: Curb Your Enthusiasm. Crit Care Med 2021; 49:358-360. [PMID: 33438974 DOI: 10.1097/ccm.0000000000004757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Adherence to the central line bundle in intensive care: An integrative review. Am J Infect Control 2021; 49:937-956. [PMID: 33221472 DOI: 10.1016/j.ajic.2020.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 11/22/2022]
Abstract
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.
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Sreeramoju P, Voy-Hatter K, White C, Ruggiero R, Girod C, Minei J, Garvey K, Herrington J, Minhajuddin A, Madden C, Haley R, Cerise F. Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prevention and sepsis care. BMJ Open Qual 2021; 10:bmjoq-2020-001189. [PMID: 33547154 PMCID: PMC7871234 DOI: 10.1136/bmjoq-2020-001189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/18/2020] [Accepted: 01/13/2021] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Pranavi Sreeramoju
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA .,Department of Infection Prevention, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Karla Voy-Hatter
- Department of Infection Prevention, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Calvin White
- Department of Infection Prevention, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Rosechelle Ruggiero
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Carlos Girod
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Joseph Minei
- Department of Surgery, Burn and Critical Care, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Karen Garvey
- Department of Patient Safety and Risk, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Judith Herrington
- Division of Nursing, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Abu Minhajuddin
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Christopher Madden
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Robert Haley
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Fred Cerise
- Health System Administration, Parkland Health and Hospital System, Dallas, Texas, USA
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Shojania KG. Beyond CLABSI and CAUTI: broadening our vision of patient safety. BMJ Qual Saf 2020; 29:361-364. [PMID: 32111644 DOI: 10.1136/bmjqs-2019-010498] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Kaveh G Shojania
- Department of Medicine and the Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, ON M4N 3M5, Canada
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14
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Shojania KG, Marang-van de Mheen PJ. Identifying adverse events: reflections on an imperfect gold standard after 20 years of patient safety research. BMJ Qual Saf 2020; 29:265-270. [DOI: 10.1136/bmjqs-2019-009731] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2020] [Indexed: 12/16/2022]
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Huis A, Schouten J, Lescure D, Krein S, Ratz D, Saint S, Hulscher M, Greene MT. Infection prevention practices in the Netherlands: results from a National Survey. Antimicrob Resist Infect Control 2020; 9:7. [PMID: 31921413 PMCID: PMC6945725 DOI: 10.1186/s13756-019-0667-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 12/19/2019] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Anita Huis
- 1Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, PO box 9101 (114), 6500 HB Nijmegen, The Netherlands
| | - Jeroen Schouten
- 1Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, PO box 9101 (114), 6500 HB Nijmegen, The Netherlands
| | - Dominique Lescure
- 2Erasmus MC, University Medical Center Rotterdam, PO box 2040, 3000 CA Rotterdam, The Netherlands
| | - Sarah Krein
- 3VA Ann Arbor Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Road, North Campus Research Complex 16, Ann Arbor, MI 48109 USA.,4Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, USA.,VA/UM Patient Safety Enhancement Program, Ann Arbor, USA
| | - David Ratz
- 3VA Ann Arbor Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Road, North Campus Research Complex 16, Ann Arbor, MI 48109 USA.,VA/UM Patient Safety Enhancement Program, Ann Arbor, USA
| | - Sanjay Saint
- 3VA Ann Arbor Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Road, North Campus Research Complex 16, Ann Arbor, MI 48109 USA.,4Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, USA.,VA/UM Patient Safety Enhancement Program, Ann Arbor, USA
| | - Marlies Hulscher
- 1Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, PO box 9101 (114), 6500 HB Nijmegen, The Netherlands
| | - M Todd Greene
- 3VA Ann Arbor Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Road, North Campus Research Complex 16, Ann Arbor, MI 48109 USA.,4Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, USA.,VA/UM Patient Safety Enhancement Program, Ann Arbor, USA
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Chang BH, Hsu YJ, Rosen MA, Gurses AP, Huang S, Xie A, Speck K, Marsteller JA, Thompson DA. Reducing Three Infections Across Cardiac Surgery Programs: A Multisite Cross-Unit Collaboration. Am J Med Qual 2019; 35:37-45. [DOI: 10.1177/1062860619845494] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Shu Huang
- Johns Hopkins University, Baltimore, MD
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17
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Govindan S, Snyder A, Flanders SA, Chopra V. Peripherally Inserted Central Catheters in the ICU: A Retrospective Study of Adult Medical Patients in 52 Hospitals. Crit Care Med 2018; 46:e1136-e1144. [PMID: 30247241 PMCID: PMC6317857 DOI: 10.1097/ccm.0000000000003423] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Sushant Govindan
- Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan Health System
- Patient Safety Enhancement Program, Ann Arbor VA Medical Center all in Ann Arbor, MI
| | - Ashley Snyder
- Division of Hospital Medicine, Department of Medicine, University of Michigan Health System
| | - Scott A. Flanders
- Division of Hospital Medicine, Department of Medicine, University of Michigan Health System
| | - Vineet Chopra
- Division of Hospital Medicine, Department of Medicine, University of Michigan Health System
- Center for Clinical Management Research, Ann Arbor VA Healthcare System
- Patient Safety Enhancement Program, Ann Arbor VA Medical Center all in Ann Arbor, MI
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Hamline MY, Speier RL, Vu PD, Tancredi D, Broman AR, Rasmussen LN, Tullius BP, Shaikh U, Li STT. Hospital-to-Home Interventions, Use, and Satisfaction: A Meta-analysis. Pediatrics 2018; 142:e20180442. [PMID: 30352792 PMCID: PMC6317574 DOI: 10.1542/peds.2018-0442] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2018] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Paul Dai Vu
- School of Aerospace Medicine, Wright-Patterson Air Force Base, United States Air Force, Dayton, Ohio
| | | | - Alia R Broman
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon; and
| | | | - Brian P Tullius
- Department of Pediatric Hematology, Oncology, and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio
| | - Ulfat Shaikh
- Department of Pediatrics
- School of Medicine, University of California, Davis, Sacramento, California
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A state of the art review on optimal practices to prevent, recognize, and manage complications associated with intravascular devices in the critically ill. Intensive Care Med 2018; 44:742-759. [PMID: 29754308 DOI: 10.1007/s00134-018-5212-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/05/2018] [Indexed: 12/14/2022]
Abstract
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.
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20
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Affiliation(s)
- Kevin Hugill
- Director of Nursing, Hamad Medical Corporation, Doha Qatar
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Kramer RD, Rogers MA, Conte M, Mann J, Saint S, Chopra V. Are antimicrobial peripherally inserted central catheters associated with reduction in central line-associated bloodstream infection? A systematic review and meta-analysis. Am J Infect Control 2017; 45:108-114. [PMID: 28341283 DOI: 10.1016/j.ajic.2016.07.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 07/15/2016] [Accepted: 07/15/2016] [Indexed: 10/20/2022]
Abstract
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.
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Abstract
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.
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Affiliation(s)
- Christine Boev
- St. John Fisher College Wegmans School of Nursing, 3690 East Avenue, Rochester, NY 14618, USA.
| | - Elizabeth Kiss
- St. John Fisher College Wegmans School of Nursing, 3690 East Avenue, Rochester, NY 14618, USA
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