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Antiseptic barrier caps to prevent central line-associated bloodstream infections: a systematic review and meta-analysis. Am J Infect Control 2022:S0196-6553(22)00672-1. [PMID: 36116679 DOI: 10.1016/j.ajic.2022.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/01/2022] [Accepted: 09/07/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Reliable and safe venous access is crucial for patients using central venous catheters (CVC). However, such CVCs carry a risk for central line-associated bloodstream infections (CLABSIs). Antiseptic barrier caps (ABCs) are a novel tool in the armamentarium for CVC disinfection. Our aim was to review the efficacy and safety of ABCs. METHOD A literature search was conducted using PubMed, EMBASE, Cochrane library, and CINAHL. Primary aim was to compare CLABSI rates in patients using ABCs versus standard care. Secondary aims included efficacy of ABCs in relevant subgroups (age, ABC brand, clinical setting), safety, compliance, and costs. Fifteen studies were included in the meta-analysis. RESULTS In total, 391 CLABSIs in 273,993 catheter days occurred in the intervention group versus 620 CLABSIs in 284,912 days in the standard care group, resulting in a risk ratio of 0.65 (95%CI 0.55-0.76; P<0.00001). Subgroup analyses showed similar effects, except for non-intensive care unit. In general, ABCs were safe, highly appreciated by patients and caregivers, and cost-effective, while compliance was easy to monitor. In most studies, a substantial risk of bias was observed. CONCLUSION In conclusion, while available evidence suggests that ABCs are effective, safe, easy in use, and cost-effective. However, due to the poor methodological quality of most available studies, more robust data should justify their use at this point.
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2
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Jasionowska S, Shabbir M, Brunckhorst O, Khan MS, Manzoor H, Dasgupta P, Anderson P, Barbagli G, Ahmed K. Development and content validation of the Urethroplasty Training and Assessment Tool (UTAT) for dorsal onlay buccal mucosa graft urethroplasty. BJU Int 2020; 125:725-731. [PMID: 31131961 DOI: 10.1111/bju.14830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To develop and validate the Urethroplasty Training and Assessment Tool (UTAT) using Healthcare Failure Mode and Effect Analysis (HFMEA) for training and assessment of urology trainees learning this urethral reconstruction technique, as urethroplasty is the 'gold standard' treatment for long and recurrent urethral strictures and with a variety of techniques and a lack of standardised reconstructive curricula, there is a need for procedure-specific training tools to improve surgeon training and patient safety. MATERIALS AND METHODS This international observational study was performed over an 11-month period. The HFMEA was used to identify and evaluate hazardous stages of urethroplasty to develop the UTAT. Hazard scores were calculated for the included steps of urethroplasty. Content validation was performed by 12 expert surgeons and multidisciplinary teams from international tertiary centres. RESULTS The HFMEA process resulted in an internationally validated UTAT. Hazard scores ≥4 and single point weaknesses were included to implement actions and outcome measures. Content validation was achieved by circulating the process map, hazard analysis table, and developed tools. Changes were implemented based on the feedback received from expert surgeons. The content validated dorsal onlay buccal mucosa graft bulbar UTAT contained five phases, 10 processes and 23 sub-processes. CONCLUSIONS The modular UTAT offers a comprehensive validated training tool developed via a detailed HFMEA protocol. This may be utilised to standardise the training and assessment of urology trainees.
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Affiliation(s)
- Sara Jasionowska
- MRC Centre for Transplantation, King's College London, London, UK.,Department of Urology, King's College Hospital, London, UK
| | | | - Oliver Brunckhorst
- MRC Centre for Transplantation, King's College London, London, UK.,Department of Urology, King's College Hospital, London, UK
| | - Muhammad Shamim Khan
- MRC Centre for Transplantation, King's College London, London, UK.,Department of Urology, Guy's Hospital, London, UK
| | - Hussain Manzoor
- Sindh Insitute of Urology and Transplantation, Karachi, Pakistan
| | - Prokar Dasgupta
- MRC Centre for Transplantation, King's College London, London, UK.,Department of Urology, Guy's Hospital, London, UK
| | - Paul Anderson
- Department of Urology, The Dudley Group NHS Foundation Trust, Dudley, UK
| | - Guido Barbagli
- Centro Chirurgico Toscano, Center for Reconstructive Urethral Surgery, Arezzo, Italy
| | - Kamran Ahmed
- MRC Centre for Transplantation, King's College London, London, UK.,Department of Urology, King's College Hospital, London, UK
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Helder OK, van Rosmalen J, van Dalen A, Schafthuizen L, Vos MC, Flint RB, Wildschut E, Kornelisse RF, Ista E. Effect of the use of an antiseptic barrier cap on the rates of central line-associated bloodstream infections in neonatal and pediatric intensive care. Am J Infect Control 2020; 48:1171-1178. [PMID: 31948717 DOI: 10.1016/j.ajic.2019.11.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/19/2019] [Accepted: 11/20/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND The use of antiseptic barrier caps reduced the occurrence of central line-associated bloodstream infections (CLABSI) in adult intensive care settings. We assessed the effect of the use of antiseptic barrier caps on the incidence of CLABSI in infants and children and evaluated the implementation process. METHODS We performed a mixed-method, prospective, observational before-after study. The CLABSI rate was documented during the "scrub the hub method" and the antiseptic barrier cap phase. Main outcomes were the number of CLABSIs per 1,000 catheter days (assessed with a Poisson regression analysis) and nurses' adherence to antiseptic barrier cap protocol. RESULTS In total, 2,248 patients were included. The rate of CLABSIs per 1,000 catheter days declined from 3.15 to 2.35, resulting in an overall incidence reduction of 22% (95% confidence interval, -34%, 55%; P = .368). Nurses' adherence to the antiseptic barrier cap protocol was 95.2% and 89.0% for the neonatal intensive care unit and pediatric intensive care unit, respectively. DISCUSSION The CLABSI reducing effect of the antiseptic barrier caps seems to be more prominent in the neonatal intensive care unit population compared with the pediatric intensive care unit population. CONCLUSIONS The antiseptic barrier cap did not significantly reduce the CLABSI rates in this study.
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Affiliation(s)
- Onno K Helder
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands; Erasmus MC Create4Care, Erasmus MC, Rotterdam, the Netherlands.
| | | | - Anneke van Dalen
- Department of Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Laura Schafthuizen
- Department of Internal Medicine, Section of Nursing Science, Erasmus MC, Rotterdam, the Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands
| | - Robert B Flint
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Pharmacy, Erasmus MC, Rotterdam, the Netherlands
| | - Enno Wildschut
- Department of Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - René F Kornelisse
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Erwin Ista
- Department of Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Internal Medicine, Section of Nursing Science, Erasmus MC, Rotterdam, the Netherlands
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4
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Fuchs I, Rosenbaum D, Klein I, Einhorn M, Pinsk V, Shelef Y, Sherf A, Press Y, Yerushalmi B. A Pilot Study to Reduce Central Line-Associated Bloodstream Infections in Children From Extremely Low-Income Settings With Intestinal Failure-Meeting the Challenge. J Pediatric Infect Dis Soc 2020; 9:188-193. [PMID: 30864666 DOI: 10.1093/jpids/piz006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 01/23/2019] [Indexed: 11/13/2022]
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSIs) are major sources of morbidity, death, and healthcare costs in patients who receive home parenteral nutrition (HPN). The majority of HPN-dependent children in southern Israel reside in poor communities with substandard living conditions, which creates significant challenges for the safe provision of HPN. We developed a pilot intervention that aimed to reduce the rates of CLABSI and central venous catheter (CVC) replacements in this vulnerable population in our region. METHODS Between 2012 and 2014, all HPN-dependent children with intestinal failure who were treated in our center, received HPN through a Hickman catheter, and experienced at least 1 previous CLABSI episode participated in the intervention. The intervention included home visits to assess the caregivers' CVC-handling technique, instillation of prophylactic ethanol lock solution, and the convening of regular multidisciplinary staff debriefings. We calculated CLABSI and CVC-replacement rates before and after the intervention. RESULTS Eight patients who served as their own historical controls were included in the intervention (total of 2544 catheter-days during the intervention period). The mean CLABSI rate decreased from 9.62 to 0.79 CLABSI episodes per 1000 catheter-days; the CVC-replacement rate decreased from 2.5 to 1.2 replacements per 1000 catheter-days in the preintervention and intervention periods respectively. The median hospital length of stay and individual monthly cost of medical care decreased compared to those found in the preintervention period. CONCLUSIONS The results of this study offer a proof of concept for a strategy to reduce CLABSI rates in pediatric patients who reside in remote and low-resource environments and are undergoing HPN.
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Affiliation(s)
- Inbal Fuchs
- Medical School for International Health, Beer Sheva, Israel.,Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Dov Rosenbaum
- Medical School for International Health, Beer Sheva, Israel
| | - Ilana Klein
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Menachem Einhorn
- Home Care Unit, Clalit Health Services, Southern District, Beer Sheva, Israel.,Financial Department, Clalit Health Services, Southern District, Beer Sheva, Israel
| | - Vered Pinsk
- Pediatric Infectious Diseases Unit, Soroka University Medical Center, Beer-Sheva, Israel
| | - Yonat Shelef
- Pediatric Infectious Diseases Unit, Soroka University Medical Center, Beer-Sheva, Israel
| | - Amir Sherf
- Pediatric Gastroenterology Unit, Soroka University Medical Center, Beer-Sheva, Israel
| | - Yan Press
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Baruch Yerushalmi
- Pediatric Infectious Diseases Unit, Soroka University Medical Center, Beer-Sheva, Israel
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Marofi M, Bijani N, Abdeyazdan Z, Barekatain B. The Impact of an Educational Program Regarding Total Parenteral Nutrition on Infection Indicators in Neonates Admitted to the Neonatal Intensive Care Unit. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2017; 22:486-489. [PMID: 29184590 PMCID: PMC5684799 DOI: 10.4103/ijnmr.ijnmr_53_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: One of the basic care measures for preterm infants is providing nutrition through total parenteral nutrition (TPN) and one of the most important complications of it is infection. Because prevention of nosocomial infections is an important issue for neonate's safety, this study aimed to determine the effects of a continuing medical education (CME) course on TPN for neonatal intensive care unit (NICU) nurses on indicators of infection in newborns. Materials and Methods: This quasi-experimental study was conducted on 127 neonates who fulfilled the inclusion criteria. They were selected through simple convenience sampling method at two stages of before and after the CME program. The inclusion criteria were prescription of TPN by the physician and lack of clinical evidences for infection in newborns before the beginning of TPN. Death of the infant during each stage of the study was considered as the exclusion criteria. The data gathering tool was a data record sheet including clinical signs of infection in the infants and their demographic characteristics. Data were analyzed using Chi-square test, Fisher's exact test, and student's t-test in SPSS software. Results: The results showed the frequency of clinical markers for infection in newborns at the pre-intervention stage (n = 41; 65.10%) was significantly less than at the post-intervention stage (n = 30; 46.90%) (p = 0.04). Conclusions: Nursing educational programs on TPN reduce infection rates among neonates in NICUs.
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Affiliation(s)
- Maryam Marofi
- Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nahid Bijani
- Student Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Abdeyazdan
- Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Behzad Barekatain
- Division of Neonatology, Department of Pediatrics, Isfahan University of Medical Sciences, Isfahan, Iran
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Asgari Dastjerdi H, Khorasani E, Yarmohammadian MH, Ahmadzade MS. Evaluating the application of failure mode and effects analysis technique in hospital wards: a systematic review. J Inj Violence Res 2017; 9:794. [PMID: 28039688 PMCID: PMC5279992 DOI: 10.5249/jivr.v9i1.794] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 12/19/2016] [Indexed: 11/06/2022] Open
Abstract
Background: Medical errors are one of the greatest problems in any healthcare systems. The best way to prevent such problems is errors identification and their roots. Failure Mode and Effects Analysis (FMEA) technique is a prospective risk analysis method. This study is a review of risk analysis using FMEA technique in different hospital wards and departments. Methods: This paper has systematically investigated the available databases. After selecting inclusion and exclusion criteria, the related studies were found. This selection was made in two steps. First, the abstracts and titles were investigated by the researchers and, after omitting papers which did not meet the inclusion criteria, 22 papers were finally selected and the text was thoroughly examined. At the end, the results were obtained. Results: The examined papers had focused mostly on the process and had been conducted in the pediatric wards and radiology departments, and most participants were nursing staffs. Many of these papers attempted to express almost all the steps of model implementation; and after implementing the strategies and interventions, the Risk Priority Number (RPN) was calculated to determine the degree of the technique’s effect. However, these papers have paid less attention to the identification of risk effects. Conclusions: The study revealed that a small number of studies had failed to show the FMEA technique effects. In general, however, most of the studies recommended this technique and had considered it a useful and efficient method in reducing the number of risks and improving service quality.
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Affiliation(s)
| | - Elahe Khorasani
- School of Pharmacy, Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran.
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Sauron C, Jouvet P, Pinard G, Goudreault D, Martin B, Rival B, Moussa A. Using isopropyl alcohol impregnated disinfection caps in the neonatal intensive care unit can cause isopropyl alcohol toxicity. Acta Paediatr 2015; 104:e489-93. [PMID: 26109465 DOI: 10.1111/apa.13099] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 06/18/2015] [Indexed: 11/29/2022]
Abstract
AIM The safety of SwabCap alcohol impregnated disinfection caps was questioned in our unit because of malfunctions in luer access valves. We examined whether SwabCaps affected the integrity of two luer access valves and were associated with alcohol injected into the lines. METHODS Our bench test study included seven circuits using SmartSite or CARESITE valves exposed to two environmental temperatures. Passive circuits consisted of a 96-hour contact system using SwabCap without other interventions. Active circuits consisted of nine sham injections during a 24-hour period, with the SwabCap replaced after each injection. The active control circuit used isopropyl alcohol impregnated pads to disinfect valves. Isopropyl alcohol was measured at the extremity of all active circuits by gas chromatography. RESULTS The visual appearance of all SmartSite valves and 67% of the CARESITE valves was changed by SwabCap use. The mean isopropyl alcohol dosages were 52 mmol/L in the SmartSite and 8 mmol/L in the CARESITE at room temperature and 73 and 7 mmol/L, respectively, at 35°C. No alcohol was found in the control circuit. CONCLUSION The SwabCap altered the valves' appearance and allowed significant amounts of isopropyl alcohol to be injected. It should not be used for neonates without further research.
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Affiliation(s)
- Charlotte Sauron
- Neonatology; CHU Sainte-Justine; University of Montreal; Montreal QC Canada
- Neonatology; Hôpital Femme-Mère-Enfant; Hospices Civils de Lyon; Bron France
| | - Philippe Jouvet
- Pediatric Intensive Care; CHU Sainte-Justine; Montreal QC Canada
| | - Geneviève Pinard
- Quality, Security and Risk Counsel; CHU Sainte-Justine; Montreal QC Canada
| | | | | | - Bastien Rival
- Specialized Biochemistry Laboratory; CHU Sainte-Justine; Montreal QC Canada
| | - Ahmed Moussa
- Neonatology; CHU Sainte-Justine; University of Montreal; Montreal QC Canada
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8
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Fujioka WK, Cowles RA. Infectious complications following serial transverse enteroplasty in infants and children with short bowel syndrome. J Pediatr Surg 2015; 50:428-30. [PMID: 25746702 DOI: 10.1016/j.jpedsurg.2014.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 06/19/2014] [Accepted: 07/19/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Serial transverse enteroplasty (STEP) lengthens and tapers dilated small bowel in patients with short bowel syndrome (SBS). Previous reports document encouraging outcomes with regard to tolerance for enteral nutrition (EN) and complications appear related to the re-operative nature of many cases and to the presence of multiple staple lines. However, infectious complications following STEP have not been examined. Since infections, especially catheter-related blood stream infections (CRBSI), are considered detrimental in infants and children with SBS, we sought to define the frequency and outcomes of peri-operative infections associated with STEP. METHODS All children with SBS who underwent a STEP between 2004 and 2012 were indentified and their medical records were reviewed. Patients were considered candidates for a STEP if they had dilated small bowel and failure to advance enteral nutrition. For the purpose of this study, infections occurring within a 14-day period after STEP were considered procedure-related and were the focus of the study. RESULTS A total of 18 patients underwent 23 STEP procedures. Primary diagnoses included intestinal atresia, gastroschisis, necrotizing enterocolitis, and midgut volvulus. After the STEP, eight patients (35%) developed CRBSI, three developed wound infections, and two had urinary tract infections. Organisms isolated from either blood, wound or urine cultures included gram-positive cocci, gram-negative rods, and yeast. Perioperative antibiotics were administered in all cases with cefoxitin (43%) and piperacillin/tazobactam (30%) being most common. Neither antibiotic appeared superior in reducing the incidence of CRBSI. In three patients with persistent bacteremia despite adequate antibiotic therapy, a 74% ethanol lock resulted in negative blood cultures in all cases. Only one central venous catheter required replacement acutely for persistent fungemia. CONCLUSION STEP can improve enteral tolerance. In this fragile patient population, however, STEP carries a documented infectious burden. The optimal antibiotic prophylaxis and the role of ethanol locking in patients undergoing STEP require further study.
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Affiliation(s)
- Wendy K Fujioka
- Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, 10032, USA
| | - Robert A Cowles
- Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, 10032, USA; Section of Pediatric Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA.
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Rinke ML, Milstone AM, Chen AR, Mirski K, Bundy DG, Colantuoni E, Pehar M, Herpst C, Miller MR. Ambulatory pediatric oncology CLABSIs: epidemiology and risk factors. Pediatr Blood Cancer 2013; 60:1882-9. [PMID: 23881643 PMCID: PMC4559846 DOI: 10.1002/pbc.24677] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 06/06/2013] [Indexed: 11/12/2022]
Abstract
BACKGROUND To compare the burden of central line-associated bloodstream infections (CLABSIs) in ambulatory versus inpatient pediatric oncology patients, and identify the epidemiology of and risk factors associated with ambulatory CLABSIs. PROCEDURE We prospectively identified infections and retrospectively identified central line days and characteristics associated with CLABSIs from January 2009 to October 2010. A nested case-control design was used to identify characteristics associated with ambulatory CLABSIs. RESULTS We identified 319 patients with central lines. There were 55 ambulatory CLABSIs during 84,705 ambulatory central line days (0.65 CLABSIs per 1,000 central line days (95% CI 0.49, 0.85)), and 19 inpatient CLABSIs during 8,682 inpatient central line days (2.2 CLABSIs per 1,000 central lines days (95% CI 1.3, 3.4)). In patients with ambulatory CLABSIs, 13% were admitted to an intensive care unit and 44% had their central lines removed due to the CLABSI. A secondary analysis with a sub-cohort, suggested children with tunneled, externalized catheters had a greater risk of ambulatory CLABSI than those with totally implantable devices (IRR 20.6, P < 0.001). Other characteristics independently associated with ambulatory CLABSIs included bone marrow transplantation within 100 days (OR 16, 95% CI 1.1, 264), previous bacteremia in any central line (OR 10, 95% CI 2.5, 43) and less than 1 month from central line insertion (OR 4.2, 95% CI 1.0, 17). CONCLUSIONS In pediatric oncology patients, three times more CLABSIs occur in the ambulatory than inpatient setting. Ambulatory CLABSIs carry appreciable morbidity and have identifiable, associated factors that should be addressed in future ambulatory CLABSI prevention efforts.
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Affiliation(s)
- Michael L. Rinke
- Department of Pediatrics, The Children’s Hospital at Montefiore, Bronx, New York,Correspondence to: Michael L. Rinke, The Children’s Hospital at Montefiore, 3415 Bainbridge Avenue, Bronx, NY 10467.
| | - Aaron M. Milstone
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Allen R. Chen
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kara Mirski
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David G. Bundy
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Elizabeth Colantuoni
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Miriana Pehar
- Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
| | - Cynthia Herpst
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marlene R. Miller
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland,Children’s Hospital Association, Alexandria, Virginia
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10
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Rinke ML, Bundy DG, Chen AR, Milstone AM, Colantuoni E, Pehar M, Herpst C, Fratino L, Miller MR. Central line maintenance bundles and CLABSIs in ambulatory oncology patients. Pediatrics 2013; 132:e1403-12. [PMID: 24101764 PMCID: PMC3813391 DOI: 10.1542/peds.2013-0302] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Pediatric oncology patients are frequently managed with central lines as outpatients, and these lines confer significant morbidity in this immune-compromised population. We aimed to investigate whether a multidisciplinary, central line maintenance care bundle reduces central line-associated bloodstream infections (CLABSIs) and bacteremias in ambulatory pediatric oncology patients. METHODS We conducted an interrupted time-series study of a maintenance bundle concerning all areas of central line care. Each of 3 target groups (clinic staff, homecare agency nurses, and patient families) (1) received training on the bundle and its importance, (2) had their practice audited, and (3) were shown CLABSI rates through graphs, in-service training, and bulletin boards. CLABSI and bacteremia person-time incidence rates were collected for 23 months before and 24 months after beginning the intervention and were compared by using a Poisson regression model. RESULTS The mean CLABSI rate decreased by 48% from 0.63 CLABSIs per 1000 central line days at baseline to 0.32 CLABSIs per 1000 central line days during the intervention period (P = .005). The mean bacteremia rate decreased by 54% from 1.27 bacteremias per 1000 central line days at baseline to 0.59 bacteremias per 1000 central line days during the intervention period (P < .001). CONCLUSIONS Implementation of a multidisciplinary, central line maintenance care bundle significantly reduced CLABSI and bacteremia person-time incidence rates in ambulatory pediatric oncology patients with central lines. Further research is needed to determine if maintenance care bundles reduce ambulatory CLABSIs and bacteremia in other adult and pediatric populations.
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Affiliation(s)
- Michael L. Rinke
- Department of Pediatrics, The Children's Hospital at Montefiore, Bronx, New York
| | - David G. Bundy
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina; Departments of
| | | | - Aaron M. Milstone
- Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; Departments of,Hospital Epidemiology and Infection Control, and
| | - Elizabeth Colantuoni
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; and
| | | | | | - Lisa Fratino
- Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland
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Rinke ML, Bundy DG, Milstone AM, Deuber K, Chen AR, Colantuoni E, Miller MR. Bringing central line-associated bloodstream infection prevention home: CLABSI definitions and prevention policies in home health care agencies. Jt Comm J Qual Patient Saf 2013; 39:361-70. [PMID: 23991509 DOI: 10.1016/s1553-7250(13)39050-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND A study was conducted to investigate health care agency central line-associated bloodstream infection (CLABSI) definitions and prevention policies and pare them to the Joint Commission National Patient Safety Goal (NPSG.07.04.01), the Centers for Disease Control and Prevention (CDC) CLABSI prevention recommendations, and a best-practice central line care bundle for inpatients. METHODS A telephone-based survey was conducted in 2011 of a convenience sample of home health care agencies associated with children's hematology/oncology centers. RESULTS Of the 97 eligible home health care agencies, 57 (59%) completed the survey. No agency reported using all five aspects of the National Healthcare and Safety Network/Association for Professionals in Infection Control and Epidemiology CLABSI definition and adjudication process, and of the 50 agencies that reported tracking CLABSI rates, 20 (40%) reported using none. Only 10 agencies (18%) had policies consistent with all elements of the inpatient-focused NPSG.07.04.01, 10 agencies (18%) were consistent with all elements of the home care targeted CDC CLABSI prevention recommendations, and no agencies were consistent with all elements of the central line care bundle. Only 14 agencies (25%) knew their overall CLABSI rate: mean 0.40 CLABSIs per 1,000 central line days (95% confidence interval [CI], 0.18 to 0.61). Six agencies (11%) knew their agency's pediatric CLABSI rate: mean 0.54 CLABSIs per 1,000 central line days (95% CI, 0.06 to 1.01). CONCLUSIONS The policies of a national sample of home health care agencies varied significantly from national inpatient and home health care agency targeted standards for CLABSI definitions and prevention. Future research should assess strategies for standardizing home health care practices consistent with evidence-based recommendations.
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Affiliation(s)
- Michael L Rinke
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, USA.
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12
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Hover AR, Sistrunk WW, Cavagnol RM, Scarrow A, Finley PJ, Kroencke AD, Walker JL. Effectiveness and Cost of Failure Mode and Effects Analysis Methodology to Reduce Neurosurgical Site Infections. Am J Med Qual 2013; 29:517-21. [DOI: 10.1177/1062860613505680] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Flodgren G, Conterno LO, Mayhew A, Omar O, Pereira CR, Shepperd S. Interventions to improve professional adherence to guidelines for prevention of device-related infections. Cochrane Database Syst Rev 2013:CD006559. [PMID: 23543545 DOI: 10.1002/14651858.cd006559.pub2] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. There are specific risk profiles for each device, but in general, the breakdown of aseptic technique during insertion and care for the device, as well as the duration of device use, are important factors for the development of these serious and costly infections. OBJECTIVES To assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device-related infection rates and measures of adherence. SEARCH METHODS We searched the following electronic databases for primary studies up to June 2012: the Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. We searched reference lists and contacted authors of included studies. We also searched the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews. SELECTION CRITERIA We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies that complied with the Cochrane EPOC Group methodological criteria, and that evaluated interventions to improve professional adherence to guidelines for the prevention of device-related infections. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane EPOC 'Risk of bias' tool. We contacted authors of original papers to obtain missing information. MAIN RESULTS We included 13 studies: one cluster randomised controlled trial (CRCT) and 12 ITS studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards, and more than 3504 patients and 1406 healthcare professionals. Six of the included studies targeted adherence to guidelines to prevent central line-associated blood stream infections (CLABSIs); another six studies targeted adherence to guidelines to prevent ventilator-associated pneumonia (VAP), and one study focused on interventions to improve urinary catheter practices. We judged all included studies to be at moderate or high risk of bias.The largest median effect on rates of VAP was found at nine months follow-up with a decrease of 7.36 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). The one included cluster randomised controlled trial (CRCT) observed, improved urinary catheter practices five weeks after the intervention (absolute difference 12.2 percentage points), however, the statistical significance of this is unknown given a unit of analysis error. It is worth noting that N = 6 interventions that did result in significantly decreased infection rates involved more than one active intervention, which in some cases, was repeatedly administered over time, and further, that one intervention involving specialised oral care personnel showed the largest step change (-22.9 cases per 1000 ventilator days (standard error (SE) 4.0), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002)) among the included studies. We attempted to combine the results for studies targeting the same indwelling medical device (central line catheters or mechanical ventilators) and reporting the same outcomes (CLABSI and VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among included studies (I(2) up to 97%), we did not retain these analyses. Six of the included studies reported post-intervention adherence scores ranging from 14% to 98%. The effect on rates of infection were mixed and the effect sizes were small, with the largest median effect for the change in level (interquartile range (IQR)) for the six CLABSI studies being observed at three months follow-up was a decrease of 0.6 (-2.74 to 0.28) cases per 1000 central line days (six studies and 36 sites). This change was not sustained over longer follow-up times. AUTHORS' CONCLUSIONS The low to very low quality of the evidence of studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions involving more than one active element and that are repeatedly administered over time, and interventions employing specialised personnel, who are focused on an aspect of care that is supported by evidence e.g. dentists/dental auxiliaries performing oral care for VAP prevention.
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Affiliation(s)
- Gerd Flodgren
- Department of Public Health, University of Oxford, Oxford, UK.
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Rinke ML, Chen AR, Bundy DG, Colantuoni E, Fratino L, Drucis KM, Panton SY, Kokoszka M, Budd AP, Milstone AM, Miller MR. Implementation of a central line maintenance care bundle in hospitalized pediatric oncology patients. Pediatrics 2012; 130:e996-e1004. [PMID: 22945408 PMCID: PMC3457619 DOI: 10.1542/peds.2012-0295] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To investigate whether a multidisciplinary, best-practice central line maintenance care bundle reduces central line-associated blood stream infection (CLABSI) rates in hospitalized pediatric oncology patients and to further delineate the epidemiology of CLABSIs in this population. METHODS We performed a prospective, interrupted time series study of a best-practice bundle addressing all areas of central line care: reduction of entries, aseptic entries, and aseptic procedures when changing components. Based on a continuous quality improvement model, targeted interventions were instituted to improve compliance with each of the bundle elements. CLABSI rates and epidemiological data were collected for 10 months before and 24 months after implementation of the bundle and compared in a Poisson regression model. RESULTS CLABSI rates decreased from 2.25 CLABSIs per 1000 central line days at baseline to 1.79 CLABSIs per 1000 central line days during the intervention period (incidence rate ratio [IRR]: 0.80, P = .58). Secondary analyses indicated CLABSI rates were reduced to 0.81 CLABSIs per 1000 central line days in the second 12 months of the intervention (IRR: 0.36, P = .091). Fifty-nine percent of infections resulted from Gram-positive pathogens, 37% of patients with a CLABSI required central line removal, and patients with Hickman catheters were more likely to have a CLABSI than patients with Infusaports (IRR: 4.62, P = .02). CONCLUSIONS A best-practice central line maintenance care bundle can be implemented in hospitalized pediatric oncology patients, although long ramp-up times may be necessary to reap maximal benefits. Further research is needed to determine if this CLABSI rate reduction can be sustained and spread.
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Affiliation(s)
| | - Allen R. Chen
- Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Elizabeth Colantuoni
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Lisa Fratino
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland; and
| | - Kim M. Drucis
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland; and
| | | | - Michelle Kokoszka
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland; and
| | - Alicia P. Budd
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland; and
| | | | - Marlene R. Miller
- Departments of Pediatrics, and,Children’s Hospital Association, Alexandria, Virginia
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