The bundle "plus": the effect of a multidisciplinary team approach to eradicate central line-associated bloodstream infections

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.

Does letting adolescent and young adult inpatients share decisions in choosing the central-line insertion site reduce central-line-associated bloodstream infections? An empty systematic review

To study whether allowing adolescents and young adults (AYA) with chronic or oncologic diseases admitted to tertiary or intensive care units to share decisions in choosing the insertion site for central-venous catheters (CVC) implanted for intravenous therapies or parenteral nutrition reduces central-line-associated and catheter-related bloodstream infections (CLABSI and CRBSI). Following the PRISMA guidelines, we systematically reviewed the literature by searching MEDLINE, Embase, CINAHL, CENTRAL, SCOPUS, Cochrane Library, and Web of Science up to December 2019. According to our aims, the review identified no study that could be included. This empty systematic review on healthcare teams allowing AYA with chronic or oncologic diseases admitted in tertiary or intensive care units to share decisions in choosing the site for implanting CVC prompts further research on clinical pathways on this hot-topic. By considering purportedly risk-taking behaviors in youngsters thus reducing CLABSI and CRBSI, healthcare teams should test specific strategies by engaging AYA empathetically in sharing decisions on the site for implanting CVC to improve quality in health care bundles.

Cost-effectiveness Analysis of Peripherally Inserted Central Catheters Versus Central Venous Catheters for in-Hospital Parenteral Nutrition

OBJECTIVE

Our objective was to evaluate the cost-effectiveness of the use of peripherally inserted central venous catheters (PICCs) by a vascular access team (VAT) versus central venous catheters (CVCs) for in-hospital total parenteral nutrition (TPN).

METHODS

The study used a cost-effectiveness analysis based on observational data retrospectively obtained from electronic medical records from 2018 to 2019 in a teaching hospital. We included all interventional procedures requiring PICCs or CVCs with the indication of TPN. We recorded the costs of insertion, maintenance, removal, and complications. The main outcome measure was the incidence rate of catheter-associated bacteremia per 1000 catheter days. Cost-effectiveness analysis was performed from the hospital perspective within the context of the publicly funded Spanish health system. Confidence intervals for costs and effectiveness differences were calculated using bootstrap methods.

RESULTS

We analyzed 233 CVCs and 292 PICCs from patients receiving TPN. Average duration was longer for PICC (13 versus 9.4 days, P < 0.001). The main reason for complications in both groups was suspected infection (9.77% CVC versus 5.18% PICC). Complication rates due to bacteremia were 2.44% for CVC and 1.15% for PICC. The difference in the incidence of bacteremia per 1000 catheter days was 1.29 (95% confidence interval, -0.89 to 3.90). Overall, costs were lower for PICCs than for CVCs: the difference in mean overall costs was -€559.9 (95% confidence interval, -€919.9 to -€225.4). Uncertainty analysis showed 86.37% of results with lower costs and higher effectiveness for PICC versus CVC.

CONCLUSIONS

Placement of PICC by VAT compared with CVC for TPN reduces costs and may decrease the rate of bacteremia.

I-DECIDED®-a decision tool for assessment and management of invasive devices in the hospital setting

Indwelling medical devices, including vascular access and urinary catheters, pose a risk for infection, and therefore daily assessment and consideration of their continued need is a patient safety priority. The I-DECIDED® device assessment and decision tool is an evidence-based checklist, designed to improve the assessment, care and timely removal of invasive devices in acute hospitalized patients. This paper explains each step of the tool, with rationale for inclusion.

Incidence of Monomicrobial Staphylococcus aureus Bacteremia: A Population-Based Study in Olmsted County, Minnesota – 2006 to 2020

Background

Population-based studies of Staphylococcus aureus bacteremia (SAB) in the United States are limited. We provide a contemporary evaluation of SAB incidence in Olmsted County, Minnesota, from 2006 to 2020.

Methods

This was a retrospective population-based study of all adult patients with SAB residing in Olmsted County from 1 January 2006 through 31 December 2020. Initial episodes of SAB were identified using the microbiology laboratory databases at both Olmsted Medical Center and Mayo Clinic Rochester.

Results

Overall, 541 incident SAB cases were identified with a median age of 66.8 (interquartile range, 54.4–78.5) years, and 60.4% were male. Among these cases, 298 (56.2%) were due to methicillin-susceptible S aureus (MSSA) and 232 (43.8%) cases of methicillin-resistant S aureus (MRSA). The overall age- and sex-adjusted SAB incidence rate (IR) was 33.9 (95% confidence interval [CI], 31.0–36.8) cases/100 000 person-years (PY). Males had a higher age-adjusted IR of 46.0 (95% CI, 41.0–51.0) cases/100 000 PY compared to females (IR, 24.4 [95% CI, 21.1–27.7] cases/100 000 PY). Age- and sex-adjusted SAB IRs due to MSSA and MRSA were 18.7 and 14.6 cases/100 000 PY, respectively, and the percentage of incident SAB cases due to MRSA fluctuated across the study period. There was no apparent temporal trend in SAB incidence over the study period (P = .093).

Conclusions

Our investigation represents the only contemporary population-based study in the United States. Despite the impression that SAB incidence may have increased based on Centers for Disease Control and Prevention surveillance data, our finding of no change in SAB incidence was somewhat unanticipated.

Prevention of Central Line-Associated Bloodstream Infections Through Educational Interventions in Adult Intensive Care Units: A Systematic Review

Central line-associated bloodstream infections (CLABSIs) represent a severe systemic threat to patients admitted in ICUs and contribute to increased mortality, prolonged length of stay in ICUs, and increased costs. The majority of CLABSIs are preventable. The current systematic review aimed to investigate the effectiveness of educational methods on CLABSI rates in adult ICUs. A systematic literature search was conducted using the electronic databases of Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, and Cochrane Database of Systematic Reviews for studies published from the beginning of 1995 to March 2020. The terms used for the search were as follows: central venous catheters, infection, central line-associated bloodstream infections, intensive care unit, and education intervention in all possible combinations and using the word 'and' between them. Data were extracted independently and crosschecked by two authors using a standard data collection form. The quality of the studies included in the review was assessed using the Methodological Index for Non-randomized Studies (MINORS). The current systematic review included 27 interventional studies of central line insertion or maintenance or both in adult ICU settings with documentation of the CLABSI incidence expressed per 1,000 catheter days. A large deviation between the length of time and type of educational interventions was found. Statistical significance was found in all studies (except one) in terms of CLABSI reduction despite the large variation of the length or the type of the educational intervention. Continuing education on infection prevention may be necessary to maintain the post-intervention results and improve clinical outcomes.

Longitudinal evaluation of risk factors and outcomes of blood stream infections due to Staphylococcus species in persons with HIV: An observational cohort study

BACKGROUND

Staphylococcal blood stream infections (SBSI) are a significant cause of morbidity and mortality, however there is little data on such infections in persons with HIV (PWH) in the combination antiretroviral therapy era, particularly when divided by species; methicillin-sensitive (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative Staphylococcus (CoNS).

METHODS

Using linked longitudinal clinical and microbiologic databases, all cases of SBSI in PWH accessing care at Southern Alberta Clinic were identified and demographic features and outcomes characterized. We compared participants with SBSI to those with no SBSI and determined the 1-year all-cause mortality following SBSI and longitudinally over the study period.

FINDINGS

From 2000 to 2018, 130 SBSI occurred in 95 PWH over 21,526 patient-years follow-up. MSSA caused 38.4%, MRSA 26.1% and CoNS 35.3% of SBSI. Highest risks for SSBI were in Hepatitis C coinfection, low CD4 nadir, Indigenous/Metis ethnicity and in persons who use injection drugs (PWID). During follow-up, 423 deaths occurred in all PWH. Mortality rates for PWH with SBSI was 74.9/1000 patient-years (95% CI 59.2-94.9) compared with no SBSI 16.0/1000 patient-years (95% CI 14.4-17.7). The mortality Hazard Ratio was 2.61(95% CI 1.95-3.49, P= <0.001) for SBSI compared to no SBSI, following adjusting for confounding. Seventy deaths occurred in persons with SBSI with 40% in the first year. Higher 1-year mortality rates occurred in hospital-acquired infections.

INTERPRETATION

Incidence rates of SBSI are high in PWH, with identified characteristics that further increase this risk. PWH who experience SBSI have a significant mortality risk within the first year of follow-up, however they also have greater long-term all-cause mortality compared to those with no SBSI. Further investigation is needed in PWH evaluating host, environment and pathogen differences that lead to differing rates of SBSI and mortality seen here.

FUNDING

No funding was received for this work.

Guidelines of the Italian Association of Pediatric Hematology and Oncology for the management of the central venous access devices in pediatric patients with onco-hematological disease

INTRODUCTION

Central venous accesses devices (CVADs) have a fundamental importance for diagnostic and therapeutic purposes in pediatric onco-hematological patients. The treatment of pediatric onco-hematological diseases is complex and requires the use of integrated multimodal therapies. Long-lasting and safe central venous access is therefore a cornerstone for any successful treatment.

METHODS

The aim of this work is to define pediatric guidelines about the management of CVADs in onco-hematology. A panel of experts belonging to the working groups on Infections and Supportive Therapy, Surgery and Nursing of the Italian Pediatric Hematology Oncology Association (AIEOP) revised the scientific literature systematically, scored the level of evidence and prepared these guidelines. The content of the following guidelines was approved by the Scientific Board of AIEOP.

RESULTS AND CONCLUSIONS

Important innovations have been developed recently in the field of CVADs, leading to new insertion methods, new materials and new strategy in the overall management of the device, especially in the adult population. These guidelines recommend how to apply these innovations in the pediatric population, and are directed to all physicians, nurses and health personnel active in the daily management of CVADs. Their aim is to update the knowledge on CVAD and improve the standard of care in pediatric patients with malignancies.

Central Line-Associated Bloodstream Infections in Children With Hematologic and Oncologic Diseases: First Prevalence Results From a University Hospital

Central line-associated bloodstream infections (CLABSIs) are still a major cause of morbidity and mortality in pediatric hematology-oncology patients in many countries. This cross-sectional study was a retrospective review of CLABSI in inpatient pediatric hematology-oncology cases with long-term central venous catheter at the Pediatric Hematology Department from January 2013 to June 2014. Characteristics of CLABSI events in pediatric patients with hematologic malignancies and related nonmalignant hematologic conditions are documented. CLABSI developed in 61.8% (n = 21) of the 34 hospitalized patients included in the study. The CLABSI rate was 7.8 per 1,000 inpatient central venous catheter days. Coagulase-negative staphylococci was the predominant pathogen in 47.6% of the patients with CLABSI. The high rate of CLABSI requires prevention strategies to reduce CLABSI immediately. This study provides guidance in prioritizing strategies for reducing rates of infection.

Impact of MaxZero™ needle-free connector on the incidence of central venous catheter-related infections in surgical intensive care unit

BACKGROUND

Central venous catheter-related infections (CRIs) are a complication of central venous catheters in intensive care unit (ICU). Some needle-free connectors have been designed to decrease CRI, but there is a lack of data concerning their impact on infection.

OBJECTIVES

The objective was to explore the impact of MaxZero™ connectors (BD; Franklin Lakes, US) on CRI in ICU.

METHODS

Observational, pre-post design study (2011-2013 and 2014-2016) conducted in the surgical ICU of a tertiary care hospital (18 beds). Patients with a central venous catheter and a length of stay ≥48 h were included. The connectors replaced all disposable caps used on infusion stopcocks and ramps. The primary parameter was to compare the incidence of CRI between the "before" period and the "after" period.

RESULTS

A total of 1633 patients were included (789 "before" and 844 "after"). There was no difference between groups concerning the global duration of catheterisation (12.5 ± 11.5 days vs. 12.1 ± 10.9 days). There were 61 CRIs before and 28 CRIs after the introduction of connectors; the incidence of CRI in the "before" group was 20.33 CRI/year (6.18 CRI per 1000 catheter-days) vs. 9.33 CRI/year (2.73 CRI per 1000 catheter-days) in the "after" group (incidence rate ratio = 0.44; 95% confidence interval = 0.28-0.68, p < 0.001). However, after a global analysis of the 6-year period, when adjusting for seasonal effect and pre-existing linear trend, the effect was no longer significant (adjusted incidence rate ratio = 0.57; 95% confidence interval = 0.24-1.35, p = 0.20).

CONCLUSIONS

Our results do not allow us to conclude to a potential beneficial effect of MaxZero™ on CRI but are compatible with its prolonged and safe use in ICU. Only future prospective works will be able to confirm the value of these connectors for CRI prevention.

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

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

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

Objective:

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

Method:

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

Results:

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

Conclusion:

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

Golden hour of neonatal life: Need of the hour

"Golden Hour" of neonatal life is defined as the first hour of post-natal life in both preterm and term neonates. This concept in neonatology has been adopted from adult trauma where the initial first hour of trauma management is considered as golden hour. The "Golden hour" concept includes practicing all the evidence based intervention for term and preterm neonates, in the initial sixty minutes of postnatal life for better long-term outcome. Although the current evidence supports the concept of golden hour in preterm and still there is no evidence seeking the benefit of golden hour approach in term neonates, but neonatologist around the globe feel the importance of golden hour concept equally in both preterm and term neonates. Initial first hour of neonatal life includes neonatal resuscitation, post-resuscitation care, transportation of sick newborn to neonatal intensive care unit, respiratory and cardiovascular support and initial course in nursery. The studies that evaluated the concept of golden hour in preterm neonates showed marked reduction in hypothermia, hypoglycemia, intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP). In this review article, we will discuss various components of neonatal care that are included in "Golden hour" of preterm and term neonatal care.

A 10-Year Review of Total Hospital-Onset ICU Bloodstream Infections at an Academic Medical Center

BACKGROUND

The rates of central line-associated bloodstream infections (CLABSIs) in U.S. ICUs have decreased significantly, and a parallel reduction in the rates of total hospital-onset bacteremias in these units should also be expected. We report 10-year trends for total hospital-onset ICU-associated bacteremias at a tertiary-care academic medical center.

METHODS

This was a retrospective analysis of all positive-result blood cultures among patients admitted to seven adult ICUs for fiscal year 2005 (FY2005) through FY2014 according to Centers for Disease Control and Prevention National Healthcare Safety Network definitions. The rate of change for primary and secondary hospital-onset BSIs was determined, as was the distribution of organisms responsible for these BSIs. Data from three medical, two general surgical, one combined neurosurgical/trauma, and one cardiac/cardiac surgery adult ICU were analyzed.

RESULTS

Across all ICUs, the rates of primary BSIs progressively fell from 2.11/1,000 patient days in FY2005 to 0.32/1,000 patient days in FY2014; an 85.0% decrease (P < .0001). Secondary BSIs also progressively decreased from 3.56/1,000 to 0.66/1,000 patient days; an 81.4% decrease (P < .0001). The decrease in BSI rates remained significant after controlling for the number of blood cultures obtained and patient acuity.

CONCLUSIONS

An increased focus on reducing hospital-onset infections at the academic medical center since 2005, including multimodal multidisciplinary efforts to prevent central line-associated BSIs, pneumonia, Clostridium difficile disease, surgical site infections, and urinary tract infections, was associated with progressive and sustained decreases for both primary and secondary hospital-onset BSIs.

Golden 60 minutes of newborn's life: Part 1: Preterm neonate

"Golden 60 minutes "or "Golden Hour" is defined as the first hour of the newborn after birth. This hour includes resuscitation care, transport to nursery from place of birth and course in nursery. The concept of "Golden hour" includes evidence based interventions that are done in the first 60 min of postnatal life for the better long term outcome of the preterm newborn especially extreme premature, extreme low birth weight and very low birth weight. The evidence shows that the concept of "Golden 60 minutes" leads to reduction in neonatal complications like hypothermia, hypoglycemia, intraventricular hemorrhage, chronic lung disease and retinopathy of prematurity. In this review, we have covered various interventions included in "Golden hour" for preterm newborn namely delayed cord clamping, prevention of hypothermia, respiratory and cardiovascular system support, prevention of sepsis, nutritional support and communication with family.

Venous Access Devices: Clinical Rounds

Nursing management of venous access devices (VADs) requires knowledge of current evidence, as well as knowledge of when evidence is limited. Do you know which practices we do based on evidence and those that we do based on institutional history or preference? This article will present complex VAD infection and occlusion complications and some of the controversies associated with them. Important strategies for identifying these complications, troubleshooting, and evaluating the evidence related to lack of blood return, malposition, infection, access and maintenance protocols, and scope of practice issues are presented.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

None.

Eliminating Infections in the ICU: CLABSI

Central line-associated bloodstream infections (CLABSI) are one of the leading causes of death in the USA and around the world. As a preventable healthcare-associated infection, they are associated with significant morbidity and excess costs to the healthcare system. Effective and long-term CLABSI prevention requires a multifaceted approach, involving evidence-based best practices coupled with effective implementation strategies. Currently recommended practices are supported by evidence and are simple, such as appropriate hand hygiene, use of full barrier precautions, avoidance of femoral lines, skin antisepsis, and removal of unnecessary lines. The most successful and sustained improvements in CLABSI rates further utilize an adaptive component to align provider behaviors with consistent and reliable use of evidence-based practices. Great success has been achieved in reducing CLABSI rates in the USA and elsewhere over the past decade, but more is needed. This article aims to review the initiatives undertaken to reduce CLABSI and summarizes the sentinel and recent literature regarding CLABSI and its prevention.