Efficacy of introducing a checklist to reduce central venous line associated bloodstream infections in the ICU caring for adult patients

Vascular catheter-related infections: an endemic disease in healthcare institutions. An opinion paper of the Spanish Society of Cardiovascular Infections (SEICAV)

Catheter-related infections (CRI) are a serious healthcare problem due to their potential to cause serious complications, including bacteraemia or infective endocarditis, and to increase patient morbidity and mortality. In addition, these in fections significantly prolong hospital stay and cost. Preventing CRI is crucial and is considered a criterion for quality and safety in healthcare. For these reasons, the Spanish Society of Cardiovascular Infections (SEICAV) has considered it pertinent to review this topic, with experts in different areas including clinical microbiologists, infectious disease specialists, surgeons and nurses. The data were presented at a session held at the Ramón Areces Foundation, which was organised in the form of specific questions grouped into three round tables. The first panel analysed the scale of the problem including epidemiological, clinical and diagnostic aspects; the second panel addressed advances in the treatment of CRI; and the third panel reviewed developments in the prevention of CRI. The recorded session is available on the Areces Foundation website and we believe it maybe of interest not only to health professionals, but also to any non-expert citizen interested in the subject.

ICU outcomes following a Central Line Associated Blood Stream Infections (CLABSI) reduction quality improvement project

BACKGROUND

Central Line Associated Blood Stream Infections (CLABSI) are significant complications for hospitalized patients. Several different approaches have been used to reduce CLABSI.

OBJECTIVE

This study aimed to (1) describe a systematic approach used to analyze and reduce CLABSI rates in a surgical ICU (SICU) at a quaternary care medical facility (CLABSI reduction bundle) and (2) examine the association of the bundle on CLABSI rates in the SICU, compared to six unexposed health system ICUs.

METHODS

Retrospective analysis of 14,022 adult patients with > 0 central line days within a single health system in the southeastern United States. The CLABSI intervention bundle was created and implemented in July 2021. Single and multiple interrupted time series analyses were performed to assess the impact of the CLABSI bundle on CLABSI rate in SICU (compared to control ICUs) pre- and post-intervention. Secondary analyses examined the association of the bundle with ICU mortality and length of stay.

RESULTS

The CLABSI bundle was associated with a significant immediate effect in reducing the CLABSI rate in the SICU compared with control ICUs. There was no significant change in the slope of CLABSI rate post-intervention, compared to control ICUs. There was no significant association of the CLABSI reduction bundle on ICU length of stay or mortality in the SICU.

CONCLUSION

The CLABSI bundle was associated with an immediate reduction in CLABSI incidence in the SICU compared to unexposed ICUs. A simple, bundled intervention can be effective in reducing CLABSI incidence in a surgical ICU population.

Device associated complications in the intensive care unit

Invasive devices are routinely used in the care of critically ill patients. Although they are often essential components of patient care, devices such as intravascular catheters, endotracheal tubes, and ventilators are a common source of complications in the intensive care unit. Critical care practitioners who use these devices need to use strategies for risk reduction and understand approaches to management when adverse events occur. This review discusses the identification, prevention, and management of complications of vascular, airway, and mechanical support devices commonly used in the intensive care unit.

Medical Device-Associated Biofilm Infections and Multidrug-Resistant Pathogens

Medical devices such as venous catheters (VCs) and urinary catheters (UCs) are widely used in the hospital setting. However, the implantation of these devices is often accompanied by complications. About 60 to 70% of nosocomial infections (NIs) are linked to biofilms. The main complication is the ability of microorganisms to adhere to surfaces and form biofilms which protect them and help them to persist in the host. Indeed, by crossing the skin barrier, the insertion of VC inevitably allows skin flora or accidental environmental contaminants to access the underlying tissues and cause fatal complications like bloodstream infections (BSIs). In fact, 80,000 central venous catheters-BSIs (CVC-BSIs)-mainly occur in intensive care units (ICUs) with a death rate of 12 to 25%. Similarly, catheter-associated urinary tract infections (CA-UTIs) are the most commonlyhospital-acquired infections (HAIs) worldwide.These infections represent up to 40% of NIs.In this review, we present a summary of biofilm formation steps. We provide an overview of two main and important infections in clinical settings linked to medical devices, namely the catheter-asociated bloodstream infections (CA-BSIs) and catheter-associated urinary tract infections (CA-UTIs), and highlight also the most multidrug resistant bacteria implicated in these infections. Furthermore, we draw attention toseveral useful prevention strategies, and advanced antimicrobial and antifouling approaches developed to reduce bacterial colonization on catheter surfaces and the incidence of the catheter-related infections.

A Quality Improvement Initiative to Decrease Central Line-Associated Bloodstream Infections During the COVID-19 Pandemic: A "Zero Harm" Approach

INTRODUCTION

Central line-associated bloodstream infections (CLABSIs) are associated with significant patient harm and health care costs. Central line-associated bloodstream infections are preventable through quality improvement initiatives. The COVID-19 pandemic has caused many challenges to these initiatives. Our community health system in Ontario, Canada, had a baseline rate of 4.62 per 1000 line days during the baseline period.

OBJECTIVES

Our aim was to reduce CLABSIs by 25% by 2023.

METHODS

An interprofessional quality aim committee performed a root cause analysis to identify areas for improvement. Change ideas included improving governance and accountability, education and training, standardizing insertion and maintenance processes, updating equipment, improving data and reporting, and creating a culture of safety. Interventions occurred over 4 Plan-Do-Study-Act cycles. The outcome was CLABSI rate per 1000 central lines: process measures were rate of central line insertion checklists used and central line capped lumens used, and balancing measure was the number of CLABSI readmissions to the critical care unit within 30 days.

RESULTS

Central line-associated bloodstream infections decreased over 4 Plan-Do-Study-Act cycles from a baseline rate of 4.62 (July 2019-February 2020) to 2.34 (December 2021-May 2022) per 1000 line days (51%). The rate of central line insertion checklists used increased from 22.8% to 56.9%, and central line capped lumens used increased from 72% to 94.3%. Mean CLABSI readmissions within 30 days decreased from 1.49 to 0.1798.

CONCLUSIONS

Our multidisciplinary quality improvement interventions reduced CLABSIs by 51% across a health system during the COVID-19 pandemic.

Implementation Strategies for Preventing Healthcare-Associated Infections across the Surgical Pathway: An Italian Multisociety Document

Healthcare-associated infections (HAIs) result in significant patient morbidity and can prolong the duration of the hospital stay, causing high supplementary costs in addition to those already sustained due to the patient’s underlying disease. Moreover, bacteria are becoming increasingly resistant to antibiotics, making HAI prevention even more important nowadays. The public health consequences of antimicrobial resistance should be constrained by prevention and control actions, which must be a priority for all health systems of the world at all levels of care. As many HAIs are preventable, they may be considered an important indicator of the quality of patient care and represent an important patient safety issue in healthcare. To share implementation strategies for preventing HAIs in the surgical setting and in all healthcare facilities, an Italian multi-society document was published online in November 2022. This article represents an evidence-based summary of the document.

Surveillance of hemodialysis related infections: a prospective multicenter study

As in many countries, there is neither a surveillance system nor a study to reveal the hemodialysis (HD) related infection rates in Turkey. We aimed to investigate the infection rate among HD outpatients and implement CDC's surveillance system. A multicenter prospective surveillance study is performed to investigate the infection rate among HD patients. CDC National Healthcare Safety Network (NHSN) dialysis event (DE) protocol is adopted for definitions and reporting. During April 2016-April 2018, 9 centers reported data. A total of 199 DEs reported in 10,035 patient-months, and the overall DE rate was 1.98 per 100 patient-months. Risk of blood culture positivity is found to be 17.6 times higher when hemodialysis was through a tunneled catheter than through an arteriovenous fistula. DE rate was significantly lower in patients educated about the care of their vascular access site. Staphylococcus aureus was the most causative microorganism among mortal patients. Outcomes of DEs were hospitalization (73%), loss of vascular access (18.2%), and death (7.7%). This first surveillance study revealed the baseline status of HD related infections in Turkey and showed that CDC National Healthcare Safety Network (NHSN) DE surveillance system can be easily implemented even in a high workload dialysis unit and be adopted as a nationwide DE surveillance program.

Analyzing central-line associated bloodstream infection prevention bundles in 22 countries: The results of ID-IRI survey

BACKGROUND

Because central line-associated bloodstream infections (CLABSIs) are a significant complication of central venous access, it is critical to prevent CLABSIs through the use of central line bundles. The purpose of this study was to take a snapshot of central venous access bundles in various countries.

METHODS

The participants in intensive care units (ICUs) completed a questionnaire that included information about the health center, infection control procedures, and central line maintenance. The countries were divided into 2 groups: those with a low or low-middle income and those with an upper-middle or high income.

RESULTS

Forty-three participants from 22 countries (46 hospitals, 85 ICUs) responded to the survey. Eight (17.4%) hospitals had no surveillance system for CLABSI. Approximately 7.1 % (n = 6) ICUs had no CLABSI bundle. Twenty ICUs (23.5%) had no dedicated checklist. The percentage of using ultrasonography during catheter insertion, transparent semi-permeable dressings, needleless connectors and single-use sterile pre-filled ready to use 0.9% NaCl were significantly higher in countries with higher and middle-higher income (P < .05).

CONCLUSIONS

Our study demonstrated that there are significant differences in the central line bundles between low/low-middle income countries and upper-middle/high-income countries. Additional measures should be taken to address inequity in the management of vascular access in resource-limited countries.

Epidemiology of ICU-Onset Bloodstream Infection: Prevalence, Pathogens, and Risk Factors Among 150,948 ICU Patients at 85 U.S. Hospitals

OBJECTIVES

Bloodstream infections (BSIs) acquired in the ICU represent a detrimental yet potentially preventable condition. We determined the prevalence of BSI acquired in the ICU (ICU-onset BSI), pathogen profile, and associated risk factors.

DESIGN

Retrospective cohort study.

DATA SOURCES

Eighty-five U.S. hospitals in the Cerner Healthfacts Database.

PATIENT SELECTION

Adult hospitalizations between January 2009 and December 2015 including a (≥ 3 d) ICU stay.

DATA EXTRACTION AND DATA SYNTHESIS

Prevalence of ICU-onset BSI (between ICU Day 3 and ICU discharge) and associated pathogen and antibiotic resistance distributions were compared with BSI present on (ICU) admission (ICU-BSI POA ); and BSI present on ICU admission day or Day 2. Cox models identified risk factors for ICU-onset BSI among host, care setting, and treatment-related factors. Among 150,948 ICU patients, 5,600 (3.7%) had ICU-BSI POA and 1,306 (0.9%) had ICU-onset BSI. Of those with ICU-BSI POA , 4,359 (77.8%) were admitted to ICU at hospital admission day. Patients with ICU-onset BSI (vs ICU-BSI POA ) displayed higher crude mortality of 37.9% (vs 20.4%) ( p < 0.001) and longer median (interquartile range) length of stay of 13 days (8-23 d) (vs 5 d [3-8 d]) ( p < 0.001) (considering all ICU stay). Compared with ICU-BSI POA , ICU-onset BSI displayed more Pseudomonas , Acinetobacter , Enterococcus, Candida , and Coagulase-negative Staphylococcus species, and more methicillin-resistant staphylococci, vancomycin-resistant enterococci, ceftriaxone-resistant Enterobacter , and carbapenem-resistant Enterobacterales and Acinetobacter species, respectively. Being younger, male, Black, Hispanic, having greater comorbidity burden, sepsis, trauma, acute pulmonary or gastrointestinal presentations, and pre-ICU exposure to antibacterial and antifungal agents was associated with greater ICU-onset BSI risk after adjusted analysis. Mixed ICUs (vs medical or surgical ICUs) and urban and small/medium rural hospitals were also associated with greater ICU-onset BSI risk. The associated risk of acquiring ICU-onset BSI manifested with any duration of mechanical ventilation and 7 days after insertion of central venous or arterial catheters.

CONCLUSIONS

ICU-onset BSI is a serious condition that displays a unique pathogen and resistance profile compared with ICU-BSI POA . Further scrutiny of modifiable risk factors for ICU-onset BSI may inform control strategies.

Chlorhexidine (di)gluconate locking device for central line infection prevention in intensive care unit patients: a multi-unit, pilot randomized controlled trial

PURPOSE

Intensive care unit (ICU) patients are at risk for central line-associated bloodstream infection (CLABSI) with significant attributable mortality and increased hospital length of stay, readmissions, and costs. Chlorhexidine (di)gluconate (CHG) is used as a disinfectant for central line insertion; however, the feasibility and efficacy of using CHG as a locking solution is unknown.

METHODS

Patients with a central venous access device (CVAD) in situ were randomized to standard care or a CHG lock solution (CHGLS) within 72 hours of ICU admission. The CHG solution was instilled in the lumen of venous catheters not actively infusing. CVAD blood cultures were taken at baseline and every 48 hours. The primary outcome was feasibility including recruitment rate, consent rate, protocol adherence, and staff uptake. Secondary outcomes included CVAD colonization, bacteraemia, and clinical endpoints.

RESULTS

Of 3,848 patients screened, 122 were eligible for the study and consent was obtained from 82.0% of the patients or substitute decision makers approached. Fifty participants were allocated to each group. Tracking logs indicated that the CHGLS was used per protocol 408 times. Most nurses felt comfortable using the CHGLS. The proportion of central line colonization was significantly higher in the standard care group with 40 (29%) versus 26 (18.7%) in the CHGLS group (P=0.009).

CONCLUSIONS

Using a device that delivers CHG into CVADs was feasible in the ICU. Findings from this trial will inform a full-scale randomized controlled trial and provide preliminary data on the effectiveness of CHGLS.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03309137, registered on October 13, 2017.

The Effectiveness of Bundle Applications in the Prevention of Central Line-associated Bloodstream Infections: Nine Years of Observation

Objective

This study aimed to assess the effectiveness of chlorhexidine-impregnated dressing in a bundle of interventions to reduce the rate of central line-associated bloodstream infections (CLABSIs).

Materials and Methods

We performed a bundle of interventions to reduce the CLABSIs from 2012. As one bundle component, we started using the chlorhexidine impregnated catheter dressing. We used a document describing applying central venous catheters for the practicing physicians and nurses, and we organized several educational meetings. An interrupted time-series analysis was performed.

Results

Seventy-six CLABSI events were detected in total between January 1, 2011, and December 31, 2019. Twenty-six cases were detected in the pre-intervention period (January 1, 2011, to December 31, 2011), and 50 patients were seen in the post-intervention term (January 1, 2012, to December 31, 2019). The annual CLABSI rate was 2.60/1000 catheter days in the pre-intervention period and 0.46/1000 catheter days (p=0.0328) in the post-intervention period. The CLABSI rate among hematology-oncology inpatients decreased from 3.39 to 0.71 (p=0.0101) in the same term.

Conclusion

By using bundle form including chlorhexidine impregnated dressing, the rate of CLABSIs decreased significantly. This effect has been observed consistently for nine years, and the clinical pathway use has become the standard care protocol.

The impact on obstetric and perinatal outcomes in term infants following the introduction of a colour-coded, hierarchical cardiotocography classification system: A retrospective non-inferiority study

BACKGROUND

Queensland introduced a colour-coded cardiotocograph (CTG) classification system (green, blue, yellow and red) to complement the Royal Australian and New Zealand College of Obstetricians and Gynaecologists prose-based classification system of 'low, unlikely, maybe or likely' fetal compromise.

AIMS

The aim of the study was to determine the clinical impact of the introduction of the colour-coded CTG classification system compared to the prose-based system. We hypothesised there would be no change in the rate of operative delivery for intrapartum fetal compromise (OD-IFC).

MATERIALS AND METHODS

This retrospective non-inferiority study from November 2014 to May 2018 used routinely collected data from the Mater Mother's Hospital. Non-insured women with a singleton, non-anomalous, cephalic fetus at term, attempting a vaginal birth with continuous intrapartum CTG were included. The primary outcome was OD-IFC. Secondary outcomes included various obstetric and perinatal outcomes. Non-inferiority analysis was performed with a pre-specified non-inferiority margin of 2% risk difference.

RESULTS

Eleven thousand seven hundred and twenty-seven participants were included. The OD-IFC rate was similar across the study groups (prose-based 15.1% vs colour-coded 15.3%, adjusted odds ratio (aOR) 1.02, 95% CI 0.93-1.13) with the adjusted risk difference of 0.29% (95% CI -0.98 to 1.56), which did not exceed the inferiority margin. There were more spontaneous (aOR 1.11, 95% CI 1.04-1.19) and fewer instrumental (aOR 0.87, 95% CI 0.80-0.95) vaginal births in the colour-coded cohort. There were no differences in neonatal outcomes.

CONCLUSIONS

Reassuringly, the colour-coded CTG classification system was non-inferior to the prose-based system, did not influence OD-IFC but was associated with more spontaneous vaginal deliveries.

Implementation of an Electronic Catheter Checklist in Outpatient Hemodialysis Facilities: Results of a Pilot Quality Improvement Project

Background

Performing catheter-care observations in outpatient hemodialysis facilities are one of the CDC's core interventions, which have been proven to reduce bloodstream infections. However, staff have many competing responsibilities. Efforts to increase and streamline the process of performing observations are needed. We developed an electronic catheter checklist, formatted for easy access with a mobile device, and conducted a pilot project to determine the feasibility of implementing it in outpatient dialysis facilities.

Methods

The tool contained the following content: (1) patient education videos; (2) catheter-care checklists (connection, disconnection, and exit-site care); (3) prepilot and postpilot surveys; and (4) a pilot implementation guide. Participating hemodialysis facilities performed catheter-care observations on either a weekly or monthly schedule and provided feedback on implementation of the tool.

Results

The pilot data were collected from January 6 through March 12, 2020, at seven participating facilities. A total of 954 individual observations were performed. The catheter-connection, disconnection, and exit-site steps were performed correctly for most individual steps; however, areas for improvement were (1) allowing for appropriate antiseptic dry time, (2) avoiding contact after antisepsis, and (3) applying antibiotic ointment to the exit site. Postpilot feedback from staff was mostly favorable. Use of the electronic checklists facilitated patient engagement with staff and was preferred over paper checklists, because data are easily downloaded and available for use in facility Quality Assurance and Performance Improvement (QAPI) meetings. The educational video content was a unique learning opportunity for both patients and staff.

Conclusions

Converting the CDC's existing catheter checklists to electronic forms reduced paperwork and improved the ease of collating data for use during QAPI meetings. An additional benefit was the educational content provided on the tablet, which was readily available for viewing by patients and staff while in the hemodialysis facility.

Intubation Checklist for COVID-19 Patients: A Practical Tool for Bedside Practitioners

BACKGROUND

The high frequency of aerosolizing procedures in the ICU, including endotracheal intubation, places clinical staff at elevated risk of contracting the 2019 coronavirus (COVID-19). Use of an intubation checklist can reduce exposure risk and thus acts as a potential safeguard. Specific, step-by-step guidance to perform safe endotracheal intubation in the setting of COVID-19 are limited. This article outlines the development and refinement of a COVID-19 intubation checklist and operational protocol for ICU staff at a single center in the United States.

METHODS

A standard pre-intubation checklist was adapted and refined by consensus using a multidisciplinary and iterative process, then distributed to local staff for clinical use. Subsequent mock intubation training sessions were held using the new checklist to ensure proficiency. Planned debriefing sessions helped identify several previously unanticipated issues, allowing for further refinement of the intubation checklist and inclusion of all stakeholders.

RESULTS

A COVID-19 intubation checklist helped optimize safety during a high-risk situation by minimizing aerosolization of secretions, the number of staff required in the room, the time spent in the room, and the frequency of donning/doffing personal protective equipment.

CONCLUSIONS

We present a checklist for use during high-risk intubations of COVID-19 patients, which serves as a pragmatic bedside tool for clinicians. The process of checklist development may also serve as a model for facilities preparing their own pandemic protocols.

How Frequently Is Asthma Objectively Demonstrated before Starting a Biologic? Quality Assessment of a Group Practice of Allergists and Immunologists

Worldwide, asthma-related healthcare cost remains a major burden. Individuals with severe asthma account for 50% of that cost. Although they are expensive, biologics such as anti-IL5 and anti-IgE agents promise cost-effectiveness when judiciously used to decrease asthma-related hospitalization and the debilitating side effects of systemic corticosteroids. Before considering biologics to treat patients with asthma, current guidelines recommend confirmation of asthma and control of comorbid diseases. Diagnostic confirmation of asthma can be challenging among individuals with severe asthma. In this quality assessment study, we determined the frequency of objective asthma confirmation and addressing of comorbidities prior to starting biologics at a group practice of allergists and immunologists. We surveyed our specialty providers to understand habit(s) leading to the observed results. We identified 40 adult patients who started on biologic modifiers for asthma over the past 5 years. Only 58% of these patients had a proper diagnosis of asthma. Providers underutilized several diagnostic methods that may prove useful in confirming asthma diagnosis in this patient population. The factors contributing to poor asthma control were rarely addressed. A sense of urgency to initiate biologics was the primary reason for the observed results. Further interventions are needed to improve asthma diagnosis and management prior to the initiation of biologic therapeutics.

Central venous catheter insertion: Review of recent evidence

Guidelines for prevention of catheter-related bloodstream infection (CR-BSI) describe a series of recommendations for correct insertion and handling of central venous catheters (CVCs). Since their implementation, quality programs such as "Zero bacteremia" have achieved a reduction in CR-BSI rates, but there is still room for further improvement. New evidence is emerging regarding, e.g., antiseptic-antimicrobial impregnated catheters or the use of passive disinfection of closed connectors. These examples of new tools among others might help to further decrease infection rates. This article aims to review new evidence-based strategies to reduce catheter insertion-related infection.

Central venous catheter insertion and maintenance: Evidence-based clinical recommendations

OBJECTIVE

To share with clinicians supporting evidence of the safest and the most effective processes for central venous catheter insertion and maintenance as a strategy to prevent catheter-associated bloodstream infections.

METHODS

A literature search was conducted in the Medline via PubMed, Embase Central and Lilacs databases based on a set of clinical questions aimed at improving safety and effectiveness at key moments in the process of central venous catheter insertion and maintenance. The rapid literature review methodology was used. The studies identified were assessed from the quality point of view, using the Joanna Briggs Institute (JBI) tools for qualitative and quantitative studies and for systematic reviews. Clinical practice guidelines were assessed using the AGREE II tool. The evidence is presented in the form of evidence-based clinical recommendations, which were graded in accordance with the JBI methodology.

RESULTS

Twelve clinical evidence summaries containing evidence related to the safe and effective use of central venous catheters are presented, including the following topics: central venous catheter insertion (CVC), peripherally inserted central catheters (PICC), preoperative assessment, the use of analgesia, field preparation, choice between CVC or PICC, CVC care and maintenance, prevention of complications, and general considerations pertaining to the use of central venous catheters in oncologic patients and in parenteral nutrition.

CONCLUSIONS

Recommendations on the safe and effective use of central venous access catheters in relation to CVC insertion and maintenance processes are presented in the evidence-based summary model. It is necessary to evaluate their implementation in health outcomes in the institutions where they are developed.

Effectiveness of a bundle of measures for reducing central line-associated bloodstream infections

INTRODUCTION

Catheter-associated infections are the main cause of nosocomial bacteremia. The main objective of this study was to demonstrate a possible decrease in CLABSI rates in perioperative environment after the implementation of a bundle of measures. Secondary objective was to determine which factors were associated with an increased risk of CLABSI, after the implementation of the bundle.

METHODS

Insertion bundle consisted of: subclavian vein as access of choice, disinfection with alcoholic 2% chlorhexidine, central-line full body drapes, sterile ultrasound probe-cable covers and insertion check-list. Cumulative Incidence (CI) and Incidence Density Rate (IR) of CLABSIs were compared before and after the intervention. Associations between patient or CVC characteristic and CLABSI were summarized with odds ratios and 95% confidence interval, obtained from multiple logistic regression, adjusting for age, sex, comorbidities and days with CVC.

RESULTS

Before implementing the bundle, from January to November 2016, CI of CLABSI was 5.05% and IR was 5.17 ‰. In the same period of 2018, CI of CLABSI was 2.28% and IR was 2.27 ‰, which means a reduction of 54.8% in CI (P=.072) and of 56% in IR (P=.068) In multivariable analyses, replacement of CVC was associated with a higher risk of CLABSI (OR 11.01, 95%CI 2.03-59.60, P=.005), as well as 2 or more catheterizations (OR 10.05, 95%CI 1.77-57.16, P=.009), and parenteral nutrition (OR 23.37, 95%CI 4.37-124.91, P<.001).

CONCLUSIONS

CLABSI rates decreased after the implementation of the insertion bundle. CVC replacement, 2 or more catheterizations and parenteral nutrition were associated with CLABSI after bundle implementation.

Chlorhexidine locking device for central line infection prevention in ICU patients: protocol for an open-label pilot and feasibility randomized controlled trial

Background

Critically ill patients in the intensive care unit (ICU) are at risk for central line-associated bloodstream infection (CLABSI) with an incidence up to 6.9 per 1000 catheter days. CLABSI has a significant attributable mortality and increases in-hospital length of stay, readmissions, and costs. Chlorhexidine gluconate (CHG), a broad-spectrum biocide, has been shown to effectively reduce infections including CLABSI; however, few trials have utilized CHG for prevention of central line infections. Our preclinical work has demonstrated a device that diffuses CHG into the intravenous lock solution of central venous catheters and decreases bacterial growth on the catheter lumen. We designed a clinical trial to test the feasibility of using a CHG device in an ICU patient population.

Methods

The proposed pilot trial will be a single centre, open-label, two-arm, parallel group feasibility randomized controlled trial (RCT). Participants will have a central line in situ and will be enrolled within 72 h of admittance to 3 ICUs at a single academic hospital. Exclusion criteria will include suspected infection, chronic indwelling catheters, and CHG allergy. Informed consent will be obtained from eligible participants or their substitute decision maker prior to randomization. Participants will be randomized to receive either usual care or the CHG locking device. Blood cultures will be drawn from all participants every 48 h. The primary objective of this study will be to determine the feasibility of using this protocol to conduct a larger trial. Feasibility will be assessed through the following outcomes: (1) consent rate, (2) recruitment rate, (3) protocol adherence, and (4) comfort level with the device. The secondary objective of this study will be to establish the preliminary efficacy of the device.

Discussion

This study will be the first human RCT to investigate a CHG locking device for the prevention of central line infections. Findings from this trial will inform the feasibility of conducting a large RCT and provide preliminary data on the efficacy of a CHG locking device.

Trial registration

ClinicalTrials.gov, NCT03309137, registered on October 13, 2017.

Patient safety climate from the nursing perspective

ABSTRACT Objective: To analyze the patient safety climate in intensive care units from the nursing perspective. Methods: Cross-sectional study developed with 87 nursing professionals working in three Intensive Care Units of a public hospital for emergency services in Piauí from October to November 2018. The study used a validated Safety Attitudes Questionnaire (SAQ). In the inferential analysis, the Student’s t-test, Mann-Whitney, and Kruskal-Wallis were performed. Results: The total SAQ score obtained a mean of 68.57. In analyzing the scores obtained for each domain in the general SAQ, the Job Satisfaction, and Teamwork Climate domains were those that obtained the highest scores, and the lowest score was for the Perception of Hospital Management domain. Conclusion: The safety attitudes assessed from the perspective of the nursing team proved to be unfavorable.

Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events

BACKGROUND

Unintentionally retained foreign objects remain the sentinel events most frequently reported to The Joint Commission. Many of these objects are guidewires used to facilitate placement of catheters, tubes, and other devices. The purpose of this study was to describe reports of unintentionally retained guidewires in order to make recommendations to improve patient safety.

METHODS

A retrospective review was undertaken of unintentionally retained guidewires voluntarily reported to The Joint Commission from October 2012 through March 2018. Reports included the type of catheter or device, location of insertion, department, contributing factors, discovery period, patient harm, and a narrative description of the event.

RESULTS

A total of 73 reports of retained guidewires or parts of guidewires were reviewed. Retention occurred during insertion of vascular catheters, devices used during surgery, and drainage tubes. A total of 285 contributing factors were identified, most frequently within the categories of human factors, leadership, and communication. In the cases in which the discovery period was known, 39.3% were identified after hospital discharge. In 76.7% of reports, the harm was categorized as unexpected additional care or extended stay. Four patients died as a result of the retained guidewire.

CONCLUSION

Unintentionally retained guidewires remain a significant patient safety issue. This study describes retained guidewires used to insert a variety of vascular catheters and devices, in different departments within hospitals. The large number of contributing factors demonstrates the complexity of care and provides new knowledge that can be used for designing interventions for prevention.