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Burek AG, Bumgardner C, Liljestrom T, Porada K, Pan AY, Liegl M, Coon ER, Flynn KE, Ullman AJ, Brousseau DC. Use of central venous access devices outside of the pediatric intensive care units. Pediatr Res 2024:10.1038/s41390-024-03337-7. [PMID: 38937641 DOI: 10.1038/s41390-024-03337-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 05/23/2024] [Accepted: 06/04/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Central venous access devices (CVAD) are associated with central line associated bloodstream infection (CLABSI) and venous thromboembolism (VTE). We identified trends in non-intensive care unit (ICU) CVAD utilization, described complication rates, and compared resources between low and high CVAD sites. METHODS We combined data from the Pediatric Health Information System (PHIS) database and surveys from included hospitals. We analyzed 10-year trends in CVAD encounters for non-ICU children between 01/2012-12/2021 and described variation and complication rates between 01/2017-12/2021. Using Fisher's exact test, we compared resources between low and high CVAD users. RESULTS CVAD use decreased from 6.3% to 3.8% of hospitalizations over 10 years. From 2017-2021, 67,830 encounters with CVAD were identified. Median age was 7 (IQR 2-13) years; 46% were female. Significant variation in CVAD utilization exists (range 1.4-16.9%). Rates of CLABSI and VTE were 4.0% and 3.4%, respectively. Survey responses from 33/41 (80%) hospitals showed 91% had vascular access teams, 30% used vascular access selection guides, and 70% used midline/long peripheral catheters. Low CVAD users were more likely to have a team guiding device selection (100% vs 43%, p = 0.026). CONCLUSIONS CVAD utilization decreased over time. Significant variation in CVAD use remains and may be associated with hospital resources. IMPACT Central venous access device (CVAD) use outside of the ICU is trending down; however, significant variation exists between institutions. Children with CVADs hospitalized on the acute care units had a CLABSI rate of 4% and VTE rate of 3.4%. 91% of surveyed institutions have a vascular access team; however, the services provided vary between institutions. Even though 70% of the surveyed institutions have the ability to place midline/long peripheral catheters, the majority use these catheters less than a few times per month. Institutions with low CVAD use are more likely to have a vascular access team that guides device selection.
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Affiliation(s)
- Alina G Burek
- Children's Wisconsin, 8915 W Connell Ct, Milwaukee, WI, USA.
- Department of Pediatrics, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, USA.
| | | | - Tracey Liljestrom
- Children's Wisconsin, 8915 W Connell Ct, Milwaukee, WI, USA
- Department of Pediatrics, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, USA
| | - Kelsey Porada
- Department of Pediatrics, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, USA
| | - Amy Y Pan
- Department of Pediatrics, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, USA
| | - Melodee Liegl
- Department of Pediatrics, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, USA
| | - Eric R Coon
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Kathryn E Flynn
- Department of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, USA
| | - Amanda J Ullman
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, QLD, Australia
- Children's Health Queensland Hospital and Health Service, Brisbane, QLD, Australia
| | - David C Brousseau
- Department of Pediatrics, Nemours Children's Health Delaware and the Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, DE, USA
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2
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Burek AG, Davis MB, Pechous B, Shaughnessy EE, Meier KA, Mooney S, Woodruff D, Bruner M, Piper L, Liegl M, Pan A, Brousseau DC, Ullman AJ. Inappropriate Use of Peripherally Inserted Central Catheters in Pediatrics: A Multisite Study. Hosp Pediatr 2024; 14:180-188. [PMID: 38404202 PMCID: PMC10896745 DOI: 10.1542/hpeds.2023-007518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2023] [Indexed: 02/27/2024]
Abstract
OBJECTIVES This study aimed to describe how the current practice of peripherally inserted central catheter (PICC) use in hospitalized children aligns with the Michigan Appropriateness Guide for Intravenous Catheters (miniMAGIC) in Children recommendations, explore variation across sites, and describe the population of children who do not receive appropriate PICCs. METHODS A retrospective study was conducted at 4 children's hospitals in the United States. Children with PICCs placed January 2019 to December 2021 were included. Patients in the NICU were excluded. PICCs were categorized using the miniMAGIC in Children classification as inappropriate, uncertain appropriateness and appropriate. RESULTS Of the 6051 PICCs identified, 9% (n = 550) were categorized as inappropriate, 9% (n = 550) as uncertain appropriateness, and 82% (n = 4951) as appropriate. The number of PICCs trended down over time, but up to 20% of PICCs each year were not appropriate, with significant variation between sites. Within inappropriate or uncertain appropriateness PICCs (n = 1100 PICC in 1079 children), median (interquartile range) patient age was 4 (0-11) years, 54% were male, and the main reason for PICC placement was prolonged antibiotic course (56%, n = 611). The most common admitting services requesting the inappropriate/uncertain appropriateness PICCs were critical care 24%, general pediatrics 22%, and pulmonary 20%. Complications resulting in PICC removal were identified in 6% (n = 70) of inappropriate/uncertain PICCs. The most common complications were dislodgement (3%) and occlusion (2%), with infection and thrombosis rates of 1% (n = 10 and n = 13, respectively). CONCLUSIONS Although the majority of PICCs met appropriateness criteria, a substantial proportion of PICCs were deemed inappropriate or of uncertain appropriateness, illustrating an opportunity for quality improvement.
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Affiliation(s)
- Alina G. Burek
- Children’s Wisconsin, Milwaukee, Wisconsin
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mary Beth Davis
- University of Iowa Stead Family Childrens Hospital, Iowa City, Iowa
- University of Iowa College of Nursing, Iowa City, Iowa
| | - Brittany Pechous
- University of Iowa Stead Family Childrens Hospital, Iowa City, Iowa
| | - Erin E. Shaughnessy
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Katie A. Meier
- Department of Pediatrics, University of Cincinnati College of Medicine, and Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Sarah Mooney
- Children’s Wisconsin, Milwaukee, Wisconsin
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Dana Woodruff
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Meaghan Bruner
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Laura Piper
- Department of Pediatrics, University of Cincinnati College of Medicine, and Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Melodee Liegl
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Amy Pan
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David C. Brousseau
- Department of Pediatrics, Nemours Children’s Health Delaware and the Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Amanda J. Ullman
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, Queensland, Australia
- Children’s Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
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Lyren A, Haines E, Fanta M, Gutzeit M, Staubach K, Chundi P, Ward V, Srinivasan L, Mackey M, Vonderhaar M, Sisson P, Sheffield-Bradshaw U, Fryzlewicz B, Coffey M, Cowden JD. Racial and ethnic disparities in common inpatient safety outcomes in a children's hospital cohort. BMJ Qual Saf 2024; 33:86-97. [PMID: 37460119 DOI: 10.1136/bmjqs-2022-015786] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 06/11/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Emerging evidence has shown racial and ethnic disparities in rates of harm for hospitalised children. Previous work has also demonstrated how highly heterogeneous approaches to collection of race and ethnicity data pose challenges to population-level analyses. This work aims to both create an approach to aggregating safety data from multiple hospitals by race and ethnicity and apply the approach to the examination of potential disparities in high-frequency harm conditions. METHODS In this cross-sectional, multicentre study, a cohort of hospitals from the Solutions for Patient Safety network with varying race and ethnicity data collection systems submitted validated central line-associated bloodstream infection (CLABSI) and unplanned extubation (UE) data stratified by patient race and ethnicity categories. Data were submitted using a crosswalk created by the study team that reconciled varying approaches to race and ethnicity data collection by participating hospitals. Harm rates for race and ethnicity categories were compared with reference values reflective of the cohort and broader children's hospital population. RESULTS Racial and ethnic disparities were identified in both harm types. Multiracial Hispanic, Combined Hispanic and Native Hawaiian or other Pacific Islander patients had CLABSI rates of 2.6-3.6 SD above reference values. For Black or African American patients, UE rates were 3.2-4.4 SD higher. Rates of both events in White patients were significantly lower than reference values. CONCLUSIONS The combination of harm data across hospitals with varying race and ethnicity collection systems was accomplished through iterative development of a race and ethnicity category framework. We identified racial and ethnic disparities in CLABSI and UE that can be addressed in future improvement work by identifying and modifying care delivery factors that contribute to safety disparities.
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Affiliation(s)
- Anne Lyren
- Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- UH Rainbow Babies & Children's, Cleveland, Ohio, USA
| | - Elizabeth Haines
- Pediatrics and Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA
- Hassenfeld Children's Hospital at NYU Langone, New York, New York, USA
| | - Meghan Fanta
- Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Katherine Staubach
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Pavan Chundi
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Valerie Ward
- Boston Children's Hospital, Boston, Massachusetts, USA
- Radiology, Harvard Medical School, Boston, Massachusetts, USA
| | - Lakshmi Srinivasan
- Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Megan Mackey
- Special Education and Interventions, Central Connecticut State University, New Britain, Connecticut, USA
| | - Michelle Vonderhaar
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Patricia Sisson
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ursula Sheffield-Bradshaw
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Maitreya Coffey
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Paediatrics, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - John D Cowden
- Department of Pediatrics, Children's Mercy Hospital Kansas, Overland Park, Kansas, USA
- University of Missouri-Kansas City School of Medicine, Kansas, Missouri, USA
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Takashima M, Gibson V, Borello E, Galluzzo L, Gill FJ, Kinney S, Newall F, Ullman AJ. Pediatric invasive device utility and harm: a multi-site point prevalence survey. Pediatr Res 2024:10.1038/s41390-023-03014-1. [PMID: 38200324 DOI: 10.1038/s41390-023-03014-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND AND AIMS Invasive devices are widely used in healthcare settings; however, pediatric patients are especially vulnerable to invasive device-associated harm. This study aimed to explore invasive device utility, prevalence, harm, and clinical practice across three Australian pediatric tertiary hospitals. METHODS In 2022-2023, a multi-center, observational, rolling-point-prevalence survey was conducted. Fifty-per-cent of inpatients were systemically sampled by random allocation. Patients with devices were then followed for up to 3-days for device-related complications/failures and management/removal characteristics. RESULTS Of the 285 patients audited, 78.2% had an invasive device (n = 412 devices), with a median of 1 device-per-patient (interquartile range 1-2), with a maximum of 13 devices-per-patient. Over half of devices were vascular access devices (n = 223; 54.1%), followed by gastrointestinal devices (n = 112; 27.2%). The point-prevalence of all device complications on Day 0 was 10.7% (44/412 devices) and period-prevalence throughout the audit period was 27.7% (114/412 devices). The period-prevalence of device failure was 13.4% (55/412 devices). CONCLUSIONS The study highlighted a high prevalence of invasive devices among hospitalized patients. One-in-ten devices failed during the audit period. These findings underscore the need for vigilant monitoring and improved strategies to minimize complications and enhance the safety of invasive devices in pediatric hospital settings. IMPACT A high prevalence of invasive devices among hospitalized patients was reported. Of the 285 patients audited, almost 80% had an invasive device (total 412 devices), with a median of 1 device-per-patient and a maximum of 13 devices-per-patient. The most common devices used in pediatric healthcare are vascular access devices (n = 223; 54.1%), however, 16% (n = 36) of these devices failed, and one-third had complications. The point prevalence of all device complications at day 0 was 10.7% (44 out of 412 devices), with a period prevalence of 27.7% (114 out of 412 devices) throughout the audit period.
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Affiliation(s)
- Mari Takashima
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, QLD, Australia.
- Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, South Brisbane, QLD, Australia.
| | - Victoria Gibson
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, QLD, Australia
- Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, South Brisbane, QLD, Australia
| | - Eloise Borello
- Nursing Research Department, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Lily Galluzzo
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, QLD, Australia
| | - Fenella J Gill
- Perth Children's Hospital, Child and Adolescent Health Service, Perth, WA, Australia
- School of Nursing, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
| | - Sharon Kinney
- Nursing Research Department, Royal Children's Hospital, Melbourne, VIC, Australia
- Department of Nursing and Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Fiona Newall
- Nursing Research Department, Royal Children's Hospital, Melbourne, VIC, Australia
- Department of Nursing and Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Amanda J Ullman
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, QLD, Australia
- Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, South Brisbane, QLD, Australia
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Trembath HE, Caruso DM, McLean SE, Akinkuotu AC, Hayes Dixon AA, Phillips MR. Central Line-Associated Bloodstream Infection Risk Factors in a Pediatric Population. Am Surg 2024; 90:69-74. [PMID: 37571962 DOI: 10.1177/00031348231192070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Abstract
BACKGROUND Central venous line (CVL) placement in children is often necessary for treatment and may be complicated by central line-associated bloodstream infection (CLABSI). We hypothesize that line type and clinical and demographic factors at line placement impact CLABSI rates. METHODS This is a single-institution case-control study of pediatric patients (≤18 years old) admitted between January 1, 2015, and December 31, 2019. Case patients had a documented CLABSI. Control patients had a CVL placed during the study period and were matched by sex and age in a 2:1 ratio. Bivariate and multivariate logistic regression analysis was performed. RESULTS We identified 78 patients with a CLABSI and 140 patients without a CLABSI. After controlling for pertinent covariates, patients undergoing tunneled or non-tunneled CVL had higher odds of CLABSI than those undergoing PICC (OR 2.51, CI 1.12-5.64 and OR 3.88, CI 1.06-14.20 respectively), and patients undergoing port placement had decreased odds of CLABSI compared to PICC (OR .05, CI 0.01-.51). There were lower odds of CLABSI when lines were placed for intravenous medications compared to those placed for solid tumor malignancy (OR .15, CI .03-.79). Race and age were not statistically significant risk factors. DISCUSSION Central lines placed for medication administration compared to solid tumors, PICC compared to tunneled and non-tunneled central lines, and ports compared to PICC were associated with lower odds of CLABSI. Future improvement efforts should focus on PICC and port placement in appropriate patients to decrease CLABSI rates.
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Affiliation(s)
- Hannah E Trembath
- Department of Surgery, University of North Carolina Hospitals at Chapel Hill, Chapel Hill, NC, USA
| | - Deanna M Caruso
- Department of Surgery, University of North Carolina Hospitals at Chapel Hill, Chapel Hill, NC, USA
| | - Sean E McLean
- Division of Pediatric Surgery, Department of Surgery, University of North Carolina Hospitals at Chapel Hill, Chapel Hill, NC, USA
| | - Adesola C Akinkuotu
- Division of Pediatric Surgery, Department of Surgery, University of North Carolina Hospitals at Chapel Hill, Chapel Hill, NC, USA
| | - Andrea A Hayes Dixon
- Division of Pediatric Surgery, Department of Surgery, University of North Carolina Hospitals at Chapel Hill, Chapel Hill, NC, USA
| | - Michael R Phillips
- Division of Pediatric Surgery, Department of Surgery, University of North Carolina Hospitals at Chapel Hill, Chapel Hill, NC, USA
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Hong LS, Garcia-Albeniz X, Friesen D, Foskett N, Beau-Lejdstrom R. Use of clinical classifications software to address ICD coding transition in large healthcare databases analyzed via high-dimensional propensity scores. Pharmacoepidemiol Drug Saf 2024; 33:e5702. [PMID: 37749072 DOI: 10.1002/pds.5702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 08/03/2023] [Accepted: 09/13/2023] [Indexed: 09/27/2023]
Abstract
PURPOSE The EUPAS26595 study characterized the rate of acute renal failure (ARF) in patients exposed to levetiracetam versus other antiepileptic drugs using healthcare claims data and a high-dimensional propensity score (hd-PS) for confounding adjustment. The data contained several coding systems by design and an update in International Classification of Diseases (ICD) coding dictionary. Such coding heterogeneity can affect the performance of hd-PS, and manually coding harmonization is not feasible. Our objective was to explore the impact of code aggregation via Clinical Classifications Software (CCS) on the analysis of a large claims-based database using hd-PS. METHODS Patients with epilepsy, who were new-users of an antiepileptic drug, were identified from the IBM® MarketScan® Research Databases. We used CCS categories to harmonize coding and compared the results with other alternatives. Incidence rate ratios (IRRs) were computed using modified Poisson regression model with a robust variance estimator. RESULTS For January 2008-October 2015 (before ICD update), 34 833 eligible patients initiated levetiracetam and 52 649 initiated a comparator drug; IRR (95% CI) for ARF for the hd-PS analysis was 1.34 (0.72-2.50) without CCS categories and 1.30 (0.71-2.39) with CCS categories. For January 2008-December 2017 (including ICD coding change), 45 672 eligible patients initiated levetiracetam and 64 664 initiated a comparator drug; IRR (95% CI) for the hd-PS analysis was 1.34 (0.78-2.29) without CCS categories and 1.37 (0.80-2.34) with CCS categories. CONCLUSIONS Using single-level CCS categories to overcome differences in coding provides consistent results and can be used in studies that use large claims data and hd-PS for adjustment.
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Doellman D. Guarding the central venous access device: a new solution for an old problem. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:S20-S25. [PMID: 37883307 DOI: 10.12968/bjon.2023.32.19.s20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
HIGHLIGHTS CLABSIs are a major concern in both the adult and pediatric patient population. Contamination of catheter hubs is a common cause of CLABSI. A novel, transparent line guard protects CVAD hubs from gross contamination. Central line-associated blood stream infections (CLABSIs) are a serious and potentially deadly complication in patients with a central venous access device (CVAD). CVADs play an essential role in modern medicine, serving as lifelines for many patients. To maintain safe and stable venous access, infection prevention bundles are used to help protect patients from complications such as CLABSI. Despite most CLABSIs being preventable, rates have been on the rise, often disproportionately impacting critically ill children. New solutions are needed to strengthen infection prevention bundles and protect CVADs from pathogen entry at catheter hubs and line connections. A novel, Food and Drug Administration-listed device has become available recently to guard CVADs from sources of gross contamination, addressing this apparent gap in infection prevention technology and practice.
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Devrim İ, Sandal OS, Çelebi MY, Hepduman P, Gönüllü A, Atakul G, Kara AA, Oruç Y, Gülfidan G, Bayram N, Ağın H. The impact of central line bundles on the timing of catheter-associated bloodstream infections and their microbiological distribution in critically ill children. Eur J Pediatr 2023; 182:4625-4632. [PMID: 37555974 DOI: 10.1007/s00431-023-05141-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/20/2023] [Accepted: 07/29/2023] [Indexed: 08/10/2023]
Abstract
Catheter-associated bloodstream infection, also known as CLABSI, is the most serious consequence of central venous access devices. These infections increase the risk of mortality and morbidity. The use of central line bundles in clinical settings is increasing worldwide with the purpose of lowering the risk of catheter-associated bloodstream infections. In this study, we investigated the effect of implementing a central line bundle for the prevention of CLABSIs, the distribution of pathogens, and the duration of time it took for CLABSIs to develop in patients who had subclavian-inserted central venous catheters. This research project was a cross-sectional study investigation carried out in a pediatric tertiary teaching hospital. Participants consisted of children who had been admitted to the pediatric critical care unit with subclavian catheters during a period of 13 years. We compared the prebundle period with the bundle period for CLABSI specifically focusing on the time to infection, the number of polymicrobial infections, the proportion of Candida parapsilosis, and the percentage of Coagulase-negative staphylococci (CoNS). The "prebundle period" included the period from May 2007 to May 2013, and the "bundle period" included the period from June 2013 to June 2020. Throughout the course of the study, a total of 286 cases of CLABSI were documented. Among these patients, 141 (49.3%) had CLABSIs associated with subclavian catheters. During the prebundle period, 55 CLABSIs were diagnosed in 5235 central line days, with an overall rate of 10.5 CLABSIs per 1000 central line days; after the implementation of central line bundle, 86 CLABSIs were diagnosed in 12,450 CL days, with an overall rate of 3.6 CLABSIs per 1000 CL days. This showed a statistically significantly lower rate in the bundle period (p = 0.0126). In the prebundle period, the mean time to develop CLABSI was 15 days, whereas during the bundle period, the mean time to develop CLABSI was 27.9 days, a significantly longer time to onset (p = 0.001). While the percentage of other microorganisms was not statistically different between the prebundle and bundle periods (p > 0.05), the percentage of C. parapsilosis was significantly higher in the prebundle period (p = 0.001). Conclusion: The results of this study imply that the use of central line bundles not only reduces the incidence of CLABSI but also delays the time to which CLABSI patients acquire an infection. In addition, as a direct consequence of the CLB, the number of CLABSIs caused by gram-positive cocci did not increase, while the proportion of CLABSIs caused by C. parapsilosis decreased. What is Known: • The most significant negative consequence of central venous access devices is catheter-associated bloodstream infections. • "Care bundles" for CLABSI prevention have been reported to reduce the CLABSI rate. What is New: • Consider what would happen if the "Care bundle" failed to prevent CLABSI. • The findings of this study imply that using central line bundles not only reduces the risk of CLABSI but also extends the time it takes for patients to develop CLABSI. While the number of CLABSIs caused by gram-positive cocci did not increase as a direct result of CLB, the rate of CLABSIs caused by C. parapsilosis, which has recently become a major problem, has decreased.
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Affiliation(s)
- İlker Devrim
- Department of Pediatric Infectious Diseases, Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir Faculty of Medicine, University of Health Sciences, İsmet Kaptan Mah, Sezer Doğan Sok, No:11, Konak, Izmir, Turkey.
| | - Ozlem Sarac Sandal
- Department of Pediatric Intensive Care, Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir Faculty of Medicine, University of Health Sciences, Izmir, Turkey
| | - Miray Yılmaz Çelebi
- Department of Pediatric Infectious Diseases, Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir Faculty of Medicine, University of Health Sciences, İsmet Kaptan Mah, Sezer Doğan Sok, No:11, Konak, Izmir, Turkey
| | - Pınar Hepduman
- Department of Pediatric Intensive Care, Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir Faculty of Medicine, University of Health Sciences, Izmir, Turkey
| | - Ahmet Gönüllü
- Department of Pediatrics, Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir Faculty of Medicine, University of Health Sciences, Izmir, Turkey
| | - Gülhan Atakul
- Department of Pediatric Intensive Care, Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir Faculty of Medicine, University of Health Sciences, Izmir, Turkey
| | - Aybüke Akaslan Kara
- Department of Pediatric Infectious Diseases, Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir Faculty of Medicine, University of Health Sciences, İsmet Kaptan Mah, Sezer Doğan Sok, No:11, Konak, Izmir, Turkey
| | - Yeliz Oruç
- Infection Control Committee, Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital, İzmir, Turkey
| | - Gamze Gülfidan
- Department of Microbiology and Clinical Microbiology, Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital, İzmir, Turkey
| | - Nuri Bayram
- Department of Pediatric Infectious Diseases, Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir Faculty of Medicine, University of Health Sciences, İsmet Kaptan Mah, Sezer Doğan Sok, No:11, Konak, Izmir, Turkey
| | - Hasan Ağın
- Department of Pediatric Intensive Care, Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir Faculty of Medicine, University of Health Sciences, Izmir, Turkey
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Milliren CE, Denhoff ER, Hahn PD, Ozonoff A. Incidence of Hospital-Acquired Conditions During Pediatric Clinical Research Inpatient Hospitalizations: A Matched Cohort Study. J Patient Saf 2023; 19:469-477. [PMID: 37678187 DOI: 10.1097/pts.0000000000001159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVES In this matched cohort study using data from pediatric hospitals, we compared the incidence of hospital-acquired conditions (HACs) during clinical research hospitalizations to nonresearch hospitalizations. METHODS Using Pediatric Health Information System data for inpatient discharges January 2017-June 2022, we matched research hospitalizations (identified by International Classification of Diseases, Tenth Revision, diagnosis code) to nonresearch hospitalizations within hospital on age (±3 y), sex, discharge year (±2), and All Patients Refined Diagnosis Related Groups classification, severity of illness (±1), and risk of mortality (±1). We calculated the incidence (per 1000 discharges) and incidence rate (per 10,000 patient days) of HAC identified by International Classification of Diseases, Tenth Revision, codes and compare research versus nonresearch using logistic and Poisson regression, accounting for matching using generalized estimating equations and adjusting for sociodemographic factors and hospital utilization. RESULTS We matched 7000 research hospitalizations to 26,447 nonresearch from 28 hospitals. Median age was 6.0 years (interquartile range, 10.6 y). Median length of stay was 4.0 days (interquartile range, 11.0 days) with longer stays among research hospitalizations ( P < 0.001). Incidence of HAC among research hospitalizations was 13.1 versus 7.2 per 1000 for nonresearch ( P < 0.001) and incidence rate 6.7 versus 4.5 per 10,000 patient days. Adjusting for sociodemographic and clinical factors, research stays had 1.65 times the odds of any HAC (95% confidence interval, 1.27-2.16; P < 0.001) and 1.38 times the incidence rate (95% confidence interval, 1.09-1.75; P = 0.009). CONCLUSIONS Our findings indicate that pediatric research hospitalizations are more likely to experience HACs compared with nonresearch hospitalizations. These findings have important safety implications for pediatric inpatient clinical research that warrant further study.
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Affiliation(s)
- Carly E Milliren
- From the Institutional Centers for Clinical and Translational Research
| | - Erica R Denhoff
- From the Institutional Centers for Clinical and Translational Research
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10
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Saleh NY, Aboelghar HM, Abdelaty NB, Garib MI, Mahmoud AA. Timing of parenteral nutrition initiation in critically ill children: a randomized clinical trial. Clin Exp Pediatr 2023; 66:403-411. [PMID: 37321580 PMCID: PMC10475857 DOI: 10.3345/cep.2023.00178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/27/2023] [Accepted: 05/18/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND The optimal timing of parenteral nutrition (PN) initiation in critically ill children remains controversial. PURPOSE To identify the optimal timing of PN initiation in critically ill children. METHODS This randomized clinical trial was conducted in the pediatric intensive care unit (PICU) of Menoufia University Hospital. A total of 140 patients were randomized to receive early or late PN. The early PN group consisted of 71 well-nourished and malnourished patients who received PN on the first day of PICU admission. Malnourished (42%) and well-nourished children randomized to the late PN group (42%) started PN on the fourth versus seventh day after admission, respectively. Mechanical ventilation (MV) was the primary outcome, while PICU length of stay and mortality were secondary outcomes. RESULTS Patients who received early PN started enteral feeding significantly earlier (median, 6 days; interquartile range, 2-20 days) than those not provided early PN (median, 12 days; interquartile range, 3-30 days; P<0.001) and had a significantly lower risk of feeding intolerance (5.6% vs.18.8%, P=0.035). The median time required to obtain full calories enterally was shorter in the early versus late PN group (P=0.004). Furthermore, patients in the early versus late PN group had a significantly shorter median PICU stay (P<0.001) and were less likely to require MV (P=0.018). CONCLUSION Patients who received early PN had a lower MV need and duration than those who received later PN and had more favorable clinical outcomes in terms of morbidity.
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Affiliation(s)
- Nagwan Y. Saleh
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Hesham M. Aboelghar
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Nehad B. Abdelaty
- Department of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Mohamed I. Garib
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Asmaa A. Mahmoud
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
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11
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Tripathi S, McGarvey J, Lee K, Staubach K, Gehring E, Sisson P, McCaskey M, Mack E, Hord J, Pallotto EK, Lyren A, Coffey M. Compliance With Central Line Maintenance Bundle and Infection Rates. Pediatrics 2023; 152:e2022059688. [PMID: 37539480 DOI: 10.1542/peds.2022-059688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Reliable bundle performance is the mainstay of central line-associated bloodstream infections (CLABSI) prevention despite an unclear relationship between bundle reliability and outcomes. Our primary objective was to evaluate the correlation between reported bundle compliance and CLABSI rate in the Solutions for Patient Safety network. The secondary objective was to identify which hospital and process factors impact this correlation. METHODS We examined data on bundle compliance and monthly CLABSI rates from January 11 to December 21 in 159 hospitals. The correlation (adjusting for temporal trend) between CLABSI rates and bundle compliance was done at the network level. Negative binomial regression was done to detect the impact of hospital type, central line audit rate, and adoption of a comprehensive safety culture program on the association between bundle compliance and CLABSI rates. RESULTS During the study, hospitals reported 27 196 CLABSI on 20 274 565 line days (1.34 CLABSI/1000 line days). Out of 2 460 133 observed bundle opportunities, 2 085 700 (84%) were compliant. There was a negative correlation between the monthly bundle reliability and monthly CLABSI rate (-0.35, P <.001). After adjusting for the temporal trend, the partial correlation was -0.25 (P = .004). On negative binomial regression, significant positive interaction was only noted for the hospital type, with Hospital Within Hospital (but not freestanding children's hospitals) revealing a significant association between compliance ≥95% and lower CLABSI rates. CONCLUSIONS Adherence to best practice guidelines is associated with a reduction in CLABSI rate. Hospital-level factors (hospitals within hospitals vs freestanding), but not process-related (central line audit rate and safety culture training), impact this association.
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Affiliation(s)
- Sandeep Tripathi
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois/University of Illinois College of Medicine at Peoria, Illinois
| | | | - Kejin Lee
- Pusan National University (Department of Education), Busan, South Korea
| | - Katherine Staubach
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Emily Gehring
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Patricia Sisson
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Elizabeth Mack
- Pediatric Critical Care Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Jeffrey Hord
- Department of Pediatrics, Pediatric Hematology-Oncology, Akron Children's Hospital, Akron, Ohio
| | - Eugenia K Pallotto
- Neonatal-Perinatal Medicine, Department of Pediatrics, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Anne Lyren
- Case Western Reserve University School of Medicine, UH Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Maitreya Coffey
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
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Gao S, Albu E, Tuand K, Cossey V, Rademakers F, Van Calster B, Wynants L. Systematic review finds risk of bias and applicability concerns for models predicting central line-associated bloodstream infection. J Clin Epidemiol 2023; 161:127-139. [PMID: 37536503 DOI: 10.1016/j.jclinepi.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVES To systematically review the risk of bias and applicability of published prediction models for risk of central line-associated bloodstream infection (CLA-BSI) in hospitalized patients. STUDY DESIGN AND SETTING Systematic review of literature in PubMed, Embase, Web of Science Core Collection, and Scopus up to July 10, 2023. Two authors independently appraised risk models using CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS) and assessed their risk of bias and applicability using Prediction model Risk Of Bias ASsessment Tool (PROBAST). RESULTS Sixteen studies were included, describing 37 models. When studies presented multiple algorithms, we focused on the model that was selected as the best by the study authors. Eventually we appraised 19 models, among which 15 were regression models and four machine learning models. All models were at a high risk of bias, primarily due to inappropriate proxy outcomes, predictors that are unavailable at prediction time in clinical practice, inadequate sample size, negligence of missing data, lack of model validation, and absence of calibration assessment. 18 out of 19 models had a high concern for applicability, one model had unclear concern for applicability due to incomplete reporting. CONCLUSION We did not identify a prediction model of potential clinical use. There is a pressing need to develop an applicable model for CLA-BSI.
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Affiliation(s)
- Shan Gao
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Elena Albu
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Krizia Tuand
- 2Bergen - Learning Centre Désiré Collen, KU Leuven Libraries, KU Leuven, Leuven, Belgium
| | - Veerle Cossey
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Infection Control and Prevention, University Hospitals Leuven, Leuven, Belgium
| | | | - Ben Van Calster
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands; EPI-Center, KU Leuven, Leuven, Belgium.
| | - Laure Wynants
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; EPI-Center, KU Leuven, Leuven, Belgium; Care & Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
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Dhaliwal M, Daneman N. Utility of Differential Time to Positivity in Diagnosing Central Line-Associated Bloodstream Infections: A Systematic Review and Meta-Analysis. Clin Infect Dis 2023; 77:428-437. [PMID: 37062596 DOI: 10.1093/cid/ciad225] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/06/2023] [Accepted: 04/11/2023] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND Differential time to positivity (DTP), defined as pathogen growth at least 2 hours earlier from catheter versus paired peripheral blood cultures, is sometimes used to diagnose central line-associated bloodstream infections (CLABSIs). Previous studies assessing DTP, however, have been small, provided conflicting results, and did not assess heterogeneity across important subgroups. METHODS We systematically reviewed the diagnostic characteristics of DTP for CLABSI using MEDLINE, Embase, WoS, CINAHL, LILACS, AMED, and the Cochrane database. Studies were included if they reported sensitivities, specificities, predictive values, likelihood ratios, or 2 × 2 tables of DTP for diagnosing CLABSI. Extracted data were analyzed by using forest plots, bivariate model meta-analysis, and QUADAS-2 quality assessment. RESULTS We identified 274 records, of which 23 met the criteria for meta-analysis. Among 2526 suspected CLABSIs, DTP demonstrated a summary sensitivity of 81.3% (95% confidence interval [CI]: 72.8%-87.7%), specificity of 91.8% (95% CI: 84.5%-95.8%), positive likelihood ratio of 9.89 (95% CI: 5.14-19.00), and negative likelihood ratio of 0.20 (95% CI: .14-.30). Covariate analysis based on catheter duration, study design, and patient immune status demonstrated no significant differences. However, DTP performed worse for Staphylococcus aureus (low sensitivity but high specificity) and Candida (high sensitivity but low specificity) compared to other organisms. CONCLUSIONS DTP performs well in ruling CLABSIs in or out. Obtaining paired catheter and peripheral blood cultures for DTP when the infectious source is unclear may prevent unnecessary line removal and diagnostic tests. However, this must be balanced against higher contamination rates from catheter cultures.
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Affiliation(s)
- Manreet Dhaliwal
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nick Daneman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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McGrath CL, Bettinger B, Stimpson M, Bell SL, Coker TR, Kronman MP, Zerr DM. Identifying and Mitigating Disparities in Central Line-Associated Bloodstream Infections in Minoritized Racial, Ethnic, and Language Groups. JAMA Pediatr 2023; 177:700-709. [PMID: 37252746 PMCID: PMC10230370 DOI: 10.1001/jamapediatrics.2023.1379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 04/02/2023] [Indexed: 05/31/2023]
Abstract
Importance Although inequitable care due to racism and bias is well documented in health care, the impact on health care-associated infections is less understood. Objective To determine whether disparities in first central catheter-associated bloodstream infection (CLABSI) rates existed for pediatric patients of minoritized racial, ethnic, and language groups and to evaluate the outcomes associated with quality improvement initiatives for addressing these disparities. Design, Setting, and Participants This cohort study retrospectively examined outcomes of 8269 hospitalized patients with central catheters from October 1, 2012, to September 30, 2019, at a freestanding quaternary care children's hospital. Subsequent quality improvement interventions and follow-up were studied, excluding catheter days occurring after the outcome and episodes with catheters of indeterminate age through September 2022. Exposures Patient self-reported (or parent/guardian-reported) race, ethnicity, and language for care as collected for hospital demographic purposes. Main Outcomes and Measures Central catheter-associated bloodstream infection events identified by infection prevention surveillance according to National Healthcare Safety Network criteria were reported as events per 1000 central catheter days. Cox proportional hazards regression was used to analyze patient and central catheter characteristics, and interrupted time series was used to analyze quality improvement outcomes. Results Unadjusted infection rates were higher for Black patients (2.8 per 1000 central catheter days) and patients who spoke a language other than English (LOE; 2.1 per 1000 central catheter days) compared with the overall population (1.5 per 1000 central catheter days). Proportional hazard regression included 225 674 catheter days with 316 infections and represented 8269 patients. A total of 282 patients (3.4%) experienced a CLABSI (mean [IQR] age, 1.34 [0.07-8.83] years; female, 122 [43.3%]; male, 160 [56.7%]; English-speaking, 236 [83.7%]; LOE, 46 [16.3%]; American Indian or Alaska Native, 3 [1.1%]; Asian, 14 [5.0%]; Black, 26 [9.2%]; Hispanic, 61 [21.6%]; Native Hawaiian or Other Pacific Islander, 4 [1.4%]; White, 139 [49.3%]; ≥2 races, 14 [5.0%]; unknown race and ethnicity or refused to answer, 15 [5.3%]). In the adjusted model, a higher hazard ratio (HR) was observed for Black patients (adjusted HR, 1.8; 95% CI, 1.2-2.6; P = .002) and patients who spoke an LOE (adjusted HR, 1.6; 95% CI, 1.1-2.3; P = .01). Following quality improvement interventions, infection rates in both subgroups showed statistically significant level changes (Black patients: -1.77; 95% CI, -3.39 to -0.15; patients speaking an LOE: -1.25; 95% CI, -2.23 to -0.27). Conclusions and Relevance The study's findings show disparities in CLABSI rates for Black patients and patients who speak an LOE that persisted after adjusting for known risk factors, suggesting that systemic racism and bias may play a role in inequitable hospital care for hospital-acquired infections. Stratifying outcomes to assess for disparities prior to quality improvement efforts may inform targeted interventions to improve equity.
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Affiliation(s)
- Caitlin L. McGrath
- University of Washington, Seattle, Washington
- Seattle Children’s Research Institute, Seattle, Washington
| | | | | | - Shaquita L. Bell
- University of Washington, Seattle, Washington
- Seattle Children’s Hospital, Seattle, Washington
| | - Tumaini R. Coker
- University of Washington, Seattle, Washington
- Seattle Children’s Research Institute, Seattle, Washington
| | - Matthew P. Kronman
- University of Washington, Seattle, Washington
- Seattle Children’s Research Institute, Seattle, Washington
| | - Danielle M. Zerr
- University of Washington, Seattle, Washington
- Seattle Children’s Research Institute, Seattle, Washington
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Zhou Y, Zhou S, Peng J, Min L, Chen Q, Ke J. Bacterial distribution and drug resistance in blood samples of children in Jiangxi Region, 2017-2021. Front Cell Infect Microbiol 2023; 13:1163312. [PMID: 37424793 PMCID: PMC10324674 DOI: 10.3389/fcimb.2023.1163312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/31/2023] [Indexed: 07/11/2023] Open
Abstract
Objective This study aims to investigate the distribution and drug resistance of bacteria in clinical blood culture specimens from children in Jiangxi province in recent years and to provide a foundation for preventing and treating bloodstream infection diseases in children. Methods The study involved a statistical analysis of the isolation and drug resistance of bacterial strains obtained from blood culture specimens of children in Jiangxi province between 2017 and 2021. The analysis was performed using the WHONET 5.6 software. Results A total of 7,977 bacterial strains were isolated from the blood samples of children between 2017 and 2021. Of these, 2,334 strains (29.3%) were identified as Gram-negative bacteria, and 5,643 strains (70.7%) were identified as Gram-positive bacteria. The most commonly isolated pathogens were coagulase-negative Staphylococcus, Escherichia coli, and Staphylococcus aureus. Among the Gram-negative bacteria, Escherichia coli (840 strains, 36.0%), Klebsiella pneumoniae (385 strains), Salmonella (283 strains), Acinetobacter baumannii (137 strains), and Pseudomonas aeruginosa (109 strains) were the most prevalent. Among the Gram-positive bacteria, coagulase-negative Staphylococcus (3,424 strains, 60.7%), Staphylococcus aureus (679 strains), Streptococcus pneumoniae (432 strains), Enterococcus sp. (292 strains), and Streptococcus agalactiae (192 strains) were the most common. Resistance to third-generation cephalosporins (cefotaxime/ceftriaxone) was observed in 45.9% and 56.0% of Escherichia coli and Klebsiella pneumoniae strains, respectively, while resistance to carbapenems was observed in 4.6% and 20.3% of these strains, respectively. Resistance to third-generation cephalosporins (cefotaxime/ceftriaxone) was observed in 15.5% of Salmonella strains, while resistance to imipenem was absent. Carbapenem resistance was observed in 17.1% (20/117) and 13% (14/108) of Acinetobacter baumannii and Pseudomonas aeruginosa strains, respectively. Methicillin-resistant Staphylococcus aureus (MRSA) was detected in 32.7% of the strains, while methicillin-resistant coagulase-negative Staphylococcus was detected in 64.3% of the coagulase-negative Staphylococcus strains. No Staphylococcus bacteria resistant to vancomycin were detected. Four strains of vancomycin-resistant Enterococcus faecium were detected over the 5-year period, and one strain of linezolid-resistant Enterococcus faecalis was detected. Conclusion Gram-positive cocci were the most commonly isolated clinical pathogens in blood specimens from children in Jiangxi province. The composition of the pathogen species showed a slight change over the years. The detection ratios of pathogens varied with age group and season. Although the isolation rate of common carbapenem-resistant Enterobacter bacteria has decreased, it remains high. It is necessary to monitor the antimicrobial resistance of pathogens causing bloodstream infections in children more closely, and antimicrobial agents should be used with caution.
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Affiliation(s)
- Yan Zhou
- Department of Clinical Laboratory, Jiangxi Provincial Children’s Hospital, Nanchang, Jiangxi, China
- Department of Clinical Laboratory, The Affiliated Children’s Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Shuping Zhou
- Department of Clinical Laboratory, Jiangxi Provincial Children’s Hospital, Nanchang, Jiangxi, China
- Department of Clinical Laboratory, The Affiliated Children’s Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Jun Peng
- Department of Clinical Laboratory, Jiangxi Provincial Children’s Hospital, Nanchang, Jiangxi, China
- Department of Clinical Laboratory, The Affiliated Children’s Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Liang Min
- Department of Clinical Laboratory, Jiangxi Provincial Children’s Hospital, Nanchang, Jiangxi, China
- Department of Clinical Laboratory, The Affiliated Children’s Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Qiang Chen
- Department of Clinical Laboratory, Jiangxi Provincial Children’s Hospital, Nanchang, Jiangxi, China
- Department of Clinical Laboratory, The Affiliated Children’s Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Jiangwei Ke
- Department of Clinical Laboratory, Jiangxi Provincial Children’s Hospital, Nanchang, Jiangxi, China
- Department of Clinical Laboratory, The Affiliated Children’s Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
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16
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Zhang Y, Wang Y, Sheng Z, Wang Q, Shi D, Xu S, Ai Y, Chen E, Xu Y. Incidence Rate, Pathogens and Economic Burden of Catheter-Related Bloodstream Infection: A Single-Center, Retrospective Case-Control Study. Infect Drug Resist 2023; 16:3551-3560. [PMID: 37305736 PMCID: PMC10256568 DOI: 10.2147/idr.s406681] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/25/2023] [Indexed: 06/13/2023] Open
Abstract
Purpose Indwelling central venous catheters (CVCs) can cause catheter related bloodstream infection (CRBSI). CRBSI occurring in intensive care unit (ICU) patients may lead to the worse outcomes and extra medical costs. The present study aimed to assess the incidence and incidence density, pathogens and economic burden of CRBSI in ICU patients. Patients and Methods A case-control study was retrospectively carried out in six ICUs of one hospital between July 2013 and June 2018. The Department of Infection Control performed routinely surveillance for CRBSI on these different ICUs. Data of the clinical and microbiological characteristics of patients with CRBSI, the incidence and incidence density of CRBSI in ICUs, the attributable length of stay (LOS), and the costs among patients with CRBSI in ICU were collected and assessed. Results A total of 82 ICU patients with CRBSI were included into the study. The CRBSI incidence density was 1.27 per 1000 CVC-days in all ICUs, in which the highest was 3.52 per 1000 CVC-days in hematology ICU and the lowest was 0.14 per 1000 CVC-days in Special Procurement ICU. The most common pathogen causing CRBSI was Klebsiella pneumoniae (15/82, 16.67%), in which 12 (80%) were carbapenem resistant. Fifty-one patients were successfully matched with control patients. The average costs in the CRBSI group were $ 67,923, which were significantly higher (P < 0.001) than the average costs in the control group. The total average costs attributable to CRBSI were $33, 696. Conclusion The medical costs of ICU patients were closely related to the incidence of CRBSI. Imperative measures are needed to reduce CRBSI in ICU patients.
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Affiliation(s)
- Yibo Zhang
- Department of Hospital Infection Management, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Yichen Wang
- Department of Hospital Infection Management, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Zike Sheng
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Qun Wang
- Department of Hospital Infection Management, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Dake Shi
- Department of Hospital Infection Management, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Shirui Xu
- Department of Clinical Laboratory Medicine, Shanghai Fenglin Clinical Laboratory Co. Ltd, Shanghai, People’s Republic of China
| | - Yaping Ai
- Health Economics and Outcome Research, Becton & Dickinson Medical Device (Shanghai) Ltd, Shanghai, People’s Republic of China
| | - Erzhen Chen
- Department of Emergency Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Yumin Xu
- Department of Hospital Infection Management, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
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King B, Patel RM. Using Quality Improvement to Improve Value and Reduce Waste. Clin Perinatol 2023; 50:489-506. [PMID: 37201993 DOI: 10.1016/j.clp.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Value is defined as health outcomes achieved per dollar spent. Addressing value in quality improvement (QI) efforts can help optimize patient outcomes while reducing unnecessary spending. In this article, we discuss how QI focused on reducing morbidities frequently reduces costs, and how proper cost accounting can help demonstrate improvements in value. We provide examples of high-yield opportunities for value improvement in neonatology and review the literature associated with these topics. Opportunities include reducing neonatal intensive care admissions for low-acuity infants, sepsis evaluations in low-risk infants, unnecessary total parental nutrition use, and utilization of laboratory and imaging.
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Affiliation(s)
- Brian King
- Department of Pediatrics, University of Pittsburg School of Medicine.
| | - Ravi M Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive, NE, Atlanta, GA 30322, USA
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A tale of two intensive care units (ICUs): Baseline Staphylococcus aureus colonization and mupirocin susceptibility in neonatal and pediatric patients requiring intensive care. Infect Control Hosp Epidemiol 2023; 44:447-452. [PMID: 35450544 PMCID: PMC10015265 DOI: 10.1017/ice.2022.96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To assess the incidence rate of S. aureus colonization at baseline along with the mupirocin susceptibility (or resistance) rate in patients in a neonatal intensive care unit (NICU) and a pediatric intensive care unit (PICU) in conjunction with the implementation of universal decolonization as the standard of care. DESIGN Prospective cohort study. SETTING Children's Hospital of Michigan (CHM) inpatient intensive care units (ICUs). PARTICIPANTS Newly admitted pediatric patients to the CHM NICU or PICU aged between 1 day and ≤21 years. INTERVENTIONS Baseline and follow-up S. aureus screening cultures were obtained before patients underwent universal decolonization with mupirocin 2% antibiotic ointment (intranasal and umbilical) and chlorhexidine baths as standard of care to reduce CLABSI rates. RESULTS Baseline S. aureus colonization rates of new admissions to the CHM NICU and PICU were high at 32% and 29%, respectively. Baseline mupirocin susceptibility to any S. aureus growth was 98.4%. All baseline culture isolates whether positive for MRSA or MSSA, with one exception, had minimum inhibitory concentrations (MICs) of ≤0.19 µg/mL. All follow-up study cultures after universal decolonization at 7 days or beyond with any S. aureus growth had mupirocin MICs of ≤0.125 µg/mL. CONCLUSIONS Baseline S. aureus colonization rates of new admissions to the CHM ICUs were high as was baseline mupirocin susceptibility. Follow-up cultures, albeit limited in number, did not detect increasing mupirocin MICs over 1 year, despite broad mupirocin exposure due to the implementation of universal decolonization.
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McKinney A, Steanson K, Lebar K. A Standardized Training Program in Ultrasound-Guided Intravenous Line Placement: Improving Nurses' Confidence and Success. Adv Neonatal Care 2023; 23:17-22. [PMID: 35170498 DOI: 10.1097/anc.0000000000000969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ultrasound-guided imagery to obtain peripheral intravenous (USGIV) access is a technique that can be used to increase successful peripheral intravenous catheter insertion rates. Improving rates of USGIV use will subsequently decrease central venous catheter use and thus decrease the time to treatment initiation, reduce costs, and improve patient satisfaction. PURPOSE Current available programs teach nurses USGIV use for the adult population, mainly with a focus on the emergency department. To address this gap in knowledge, a USGIV program aimed at the specific needs of the neonatal intensive care unit (NICU) nurse was developed and implemented. METHOD Twelve NICU nurses were trained in USGIV access during a 4-hour combination didactic and simulation-based program. Participants took a pretest survey assessing baseline knowledge and confidence levels related to USGIV access. After didactic lecture, participants worked at stations focused on USGIV access. An 80% benchmark for each participant was set for successful USGIV attempts during simulation. Participants' knowledge and confidence levels were reassessed at the end of the program. RESULTS Posttest scores increased by an average of 25%, demonstrating increased knowledge. The pre- to posttest confidence scores increased by a minimum of 1.6 points (based on a 5-point Likert scale). All participants (n = 12) successfully demonstrated proficiency by achieving at least 80% of attempted USGIV access on a mannequin. IMPLICATIONS FOR PRACTICE AND RESEARCH This project demonstrated that USGIV catheter can be employed in neonatal patients by training NICU nurses in USGIV techniques.
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Affiliation(s)
- Amanda McKinney
- Dell Children's Medical Center, Austin, Texas (Dr McKinney); Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee (Dr Steanson); and Jefferson Health Systems, Philadelphia, Pennsylvania (Dr Lebar)
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20
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Burek AG, Shaughnessy EE. Raising the bar for vascular access research. J Hosp Med 2023; 18:107-108. [PMID: 36445007 DOI: 10.1002/jhm.13017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 11/15/2022] [Accepted: 11/18/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Alina G Burek
- Children's Wisconsin, Milwaukee, Wisconsin, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Erin E Shaughnessy
- Department of Pediatrics, University of Alabama at Birmingham and Children's of Alabama, Birmingham, Alabama, USA
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21
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Hightower HB, Young JA, Thomas J, Smith JJ, Hobby-Noland D, Palombo G, McCaskey M, Benton B, Hutto C, Coghill C, McCullough B, Hayes L, Martin C, Chewning JH. Reduction of Central-line-Associated Bloodstream Infections in a Tertiary Neonatal Intensive Care Unit through Simulation Education. Pediatr Qual Saf 2022; 7:e610. [PMID: 38585503 PMCID: PMC10997285 DOI: 10.1097/pq9.0000000000000610] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 09/08/2022] [Indexed: 11/07/2022] Open
Abstract
Introduction Critically ill neonates and those with complex medical conditions frequently require the use of central venous lines. Unfortunately, central line-associated bloodstream infections (CLABSIs) result in significant morbidity and mortality, and the cost and increased length of stay burden the healthcare system. Previous studies have demonstrated that standardized care bundles can decrease CLABSI rates, but achieving sustained improvement has proven difficult. Methods All patients admitted to the Neonatal Intensive Care Unit between 2014 and 2020 who had a CVL were included in this study. First, we recorded all CLABSI events and total CVL days according to defined criteria. Then, in late 2016, we instituted simulation-based nursing training for CVL care. Results Job Instruction Sheets were initially introduced to Neonatal Intensive Care Unit nursing staff simultaneously with one-on-one teaching sessions between instructors and bedside nurses. Intermittent performance audits and re-education for identified deficiencies did not improve the CLABSI rate per 1000 line days. After instituting simulation-based CVL training in 2016, there was a decreased rate of CLABSI events per 1000 line days sustained over time (x = 0.692). Conclusions Standardized care bundles and Hospital-acquired Condition interactor audits were insufficient to reduce the CLABSI rate. However, combining care bundles and education with simulation-based training significantly decreased CLABSI rates. One-on-one intensive training and continued ongoing monitoring were critical to producing a sustained reduction. This experience demonstrates that supervised, interactive education combined with simulation can significantly impact patient outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Cecelia Hutto
- From the University of Alabama at Birmingham, Birmingham, Ala
| | - Carl Coghill
- From the University of Alabama at Birmingham, Birmingham, Ala
| | | | - Leslie Hayes
- From the University of Alabama at Birmingham, Birmingham, Ala
| | - Colin Martin
- From the University of Alabama at Birmingham, Birmingham, Ala
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22
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Adekunle MO, Davidson A, Hendricks M. Risk factors and predictors of adverse outcomes of in paediatric febrile neutropenia. SOUTH AFRICAN JOURNAL OF ONCOLOGY 2022. [DOI: 10.4102/sajo.v6i0.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Haldar R, Mandelia A, Mishra P, Mishra A, Siddiqui Y. Central Venous Catheter-Related Infectious Complications in Pediatric Surgical Patients: A Single-Center Experience. J Pediatr Intensive Care 2022; 11:240-246. [DOI: 10.1055/s-0041-1723946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/03/2021] [Indexed: 10/22/2022] Open
Abstract
AbstractThe purpose of this study was to estimate the rate of central venous catheter (CVC) colonization and catheter-related bloodstream infections (CRBSIs) in pediatric surgical patients at our institute and to determine the various risk factors for their occurrence. The electronic medical records of 260 children undergoing surgery with simultaneous CVC insertion were retrospectively reviewed. Data on demographics, primary organ system involved, site of CVC, CVC dwell time, CVC colonization, CRBSI, and organisms isolated on culture were collated, categorized, and analyzed. The rate of CVC colonization and CRBSI was 32.8 per 1,000 catheter days (19.6%) and 17.4 per 1,000 catheter days (10.4%), respectively. Patients with CVC colonization and CRBSI had a significantly higher proportion of patients younger than 1 year of age (p = 0.014). The CVC dwell time was significantly higher in both CVC colonization (7 [5–8] days) and CRBSI (6 [5–9] days) patients (p = 0.005). The frequency of femoral catheterization was significantly higher in patients with CRBSI and CVC colonization (p < 0.001). Coagulase negative staphylococcus was the commonest isolate in CVC infections. Age (adjusted odds ratio [OR] = 0.87; p = 0.009), CVC dwell time (adjusted OR = 1.28; p = 0.003), and femoral CVC (adjusted OR = 9.61; p < 0.001) were independent risk factors for CRBSI. Conclusion: This study reveals important observations regarding the infectious complications of CVC in pediatric surgical patients. The rates of CVC colonization and CRBSI in this study were found to be higher as compared with previously reported rates in Western literature. However, these findings are significant in view of paucity of existing literature in pediatric surgical patients. In our study, higher risk of CRBSI was associated with younger age, increasing CVC dwell time, and femoral venous catheterization. We recommend strict compliance with CVC insertion and maintenance practices and adherence to CVC care bundles to minimize these serious complications.
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Affiliation(s)
- Rudrashish Haldar
- Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ankur Mandelia
- Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prabhaker Mishra
- Department of Biostatistics & Health Informatics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ashwani Mishra
- Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Yousuf Siddiqui
- Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Willer BL, Tobias JD, Suttle ML, Nafiu OO, Mpody C. Trends of Racial/Ethnic Disparities in Pediatric Central Line-Associated Bloodstream Infections. Pediatrics 2022; 150:188786. [PMID: 35979730 DOI: 10.1542/peds.2021-054955] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Central line-associated bloodstream infections (CLABSIs), eminently preventable nosocomial infections, are a substantial source of morbidity, mortality, and increased resource utilization in pediatric care. Racial or ethnic disparities in health outcomes have been demonstrated across an array of medical specialties and practices in pediatric patients. However, it is unknown whether disparities exist in the rate of CLABSIs. Our objective was to evaluate the trends in racial and ethnic disparities of CLABSIs over the past 5 years. METHODS This is a retrospective cohort study using data from Pediatric Health Information System database collected from tertiary children's hospitals in the United States. Participants included 226 802 children (<18 years) admitted to the emergency department or inpatient ward between 2016 and 2021 who required central venous catheter placement. The primary outcome was risk-adjusted rate of CLABSI, occurring during the same admission, across race and ethnicity. RESULTS Of the 226 802 children, 121 156 (53.4%) were White, 40 589 (17.9%) were Black, and 43 374 (19.1%) were Hispanic. CLABSI rate decreased in all racial/ethnic groups over the study period, with the rates being consistently higher in Black (relative risk [RR], 1.27; 95% confidence interval [CI], 1.17-1.37; P < .01) and Hispanic children (RR, 1.16; 95% CI, 1.08-1.26; P < .01) than in White children. There was no statistically significant evidence that gaps in CLABSI rate between racial/ethnic groups narrowed over time. CONCLUSIONS CLABSI rate was persistently higher among Black and Hispanic children than their White peers. These findings emphasize the need for future exploration of the causes of persistent racial and ethnic disparities in pediatric patients.
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Affiliation(s)
- Brittany L Willer
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Markita L Suttle
- Division of Critical Care Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
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Soto C, Dixon-Woods M, Tarrant C. Families' experiences of central-line infection in children: a qualitative study. Arch Dis Child 2022; 107:archdischild-2022-324186. [PMID: 35863869 PMCID: PMC9606494 DOI: 10.1136/archdischild-2022-324186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/29/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Central venous access devices (CVADs), often known as central lines, are important for delivering medically complex care in children, and are increasingly used for children living at home. Central line-associated bloodstream infection (CLABSI) is a serious, life-threatening complication. Although the physical consequences of CLABSIs are well documented, families' views and experiences of CLABSI are poorly understood. DESIGN Qualitative study using semistructured interviews with participants from 11 families of a child living at home with a CVAD. PARTICIPANTS Parents of children aged 4-12 years living at home with a CVAD. Four fathers and nine mothers participated in interviews. RESULTS The risk of CLABSI is a constant fear for families of a child with a CVAD. Though avoiding infection is a key priority for families, it is not the only one: maintaining a sense of 'normal life' is another goal. Infection prevention and control require much work and expertise on the part of families, contributing significantly to families' physical and emotional workload. CONCLUSIONS Living with the risk of CLABSI poses additional burdens that impact on the physical and emotional well-being of families. Services to better support families to manage these burdens are needed.
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Affiliation(s)
- Carmen Soto
- Paediatric Oncology, University College London Hospitals NHS Foundation Trust, London, UK
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Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:553-569. [PMID: 35437133 PMCID: PMC9096710 DOI: 10.1017/ice.2022.87] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Severyn CJ, Siranosian BA, Kong STJ, Moreno A, Li MM, Chen N, Duncan CN, Margossian SP, Lehmann LE, Sun S, Andermann TM, Birbrayer O, Silverstein S, Reynolds CG, Kim S, Banaei N, Ritz J, Fodor AA, London WB, Bhatt AS, Whangbo JS. Microbiota dynamics in a randomized trial of gut decontamination during allogeneic hematopoietic cell transplantation. JCI Insight 2022; 7:e154344. [PMID: 35239511 PMCID: PMC9057614 DOI: 10.1172/jci.insight.154344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/02/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUNDGut decontamination (GD) can decrease the incidence and severity of acute graft-versus-host disease (aGVHD) in murine models of allogeneic hematopoietic cell transplantation (HCT). In this pilot study, we examined the impact of GD on gut microbiome composition and the incidence of aGVHD in HCT patients.METHODSWe randomized 20 patients undergoing allogeneic HCT to receive (GD) or not receive (no-GD) oral vancomycin-polymyxin B from day -5 through neutrophil engraftment. We evaluated shotgun metagenomic sequencing of serial stool samples to compare the composition and diversity of the gut microbiome between study arms. We assessed clinical outcomes in the 2 arms and performed strain-specific analyses of pathogens that caused bloodstream infections (BSI).RESULTSThe 2 arms did not differ in the predefined primary outcome of Shannon diversity of the gut microbiome at 2 weeks post-HCT (genus, P = 0.8; species, P = 0.44) or aGVHD incidence (P = 0.58). Immune reconstitution of T cell and B cell subsets was similar between groups. Five patients in the no-GD arm had 8 BSI episodes versus 1 episode in the GD arm (P = 0.09). The BSI-causing pathogens were traceable to the gut in 7 of 8 BSI episodes in the no-GD arm, including Staphylococcus species.CONCLUSIONWhile GD did not differentially affect Shannon diversity or clinical outcomes, our findings suggest that GD may protect against gut-derived BSI in HCT patients by decreasing the prevalence or abundance of gut pathogens.TRIAL REGISTRATIONClinicalTrials.gov NCT02641236.FUNDINGNIH, Damon Runyon Cancer Research Foundation, V Foundation, Sloan Foundation, Emerson Collective, and Stanford Maternal & Child Health Research Institute.
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Affiliation(s)
- Christopher J. Severyn
- Department of Pediatrics, Division of Pediatric Hematology/Oncology and Division of Pediatric Stem Cell Transplant and Regenerative Medicine
| | | | | | - Angel Moreno
- Department of Pathology, Stanford University, Palo Alto, California, USA
| | - Michelle M. Li
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Nan Chen
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Christine N. Duncan
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Steven P. Margossian
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Leslie E. Lehmann
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Shan Sun
- Department of Bioinformatics and Genomics, College of Computing and Informatics, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
| | - Tessa M. Andermann
- Department of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Olga Birbrayer
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Carol G. Reynolds
- Harvard Medical School, Boston, Massachusetts, USA
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Soomin Kim
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Niaz Banaei
- Department of Pathology, Stanford University, Palo Alto, California, USA
- Department of Medicine, Division of Infectious Diseases, Stanford University, Palo Alto, California, USA
| | - Jerome Ritz
- Harvard Medical School, Boston, Massachusetts, USA
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Anthony A. Fodor
- Department of Bioinformatics and Genomics, College of Computing and Informatics, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
| | - Wendy B. London
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Ami S. Bhatt
- Departments of Genetics and Medicine, Division of Hematology
| | - Jennifer S. Whangbo
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Lv Y, Huang X, Lan Y, Xia Q, Chen F, Wu J, Li W, Cao H, Xie C, Li L, Han H, Wang H, Xiang Q. Peripherally inserted central catheters have a protective role and the effect of fluctuation curve feature in the risk of bloodstream infection compared with central venous catheters: a propensity-adjusted analysis. BMC Infect Dis 2022; 22:289. [PMID: 35346073 PMCID: PMC8961920 DOI: 10.1186/s12879-022-07265-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 03/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background The prevention of peripherally inserted central catheters (PICC)-associated BSI and central venous catheters (CVC)-associated BSI have been a topic of national importance in China. Therefore, we aimed to explore the epidemiological characteristics of central line-associated bloodstream infection (CLABSI), and to evaluate whether PICCs were associated with a protective effect for CLABSI. Methods A retrospective cohort study was conducted in teaching hospital in Western China. All adult patients received a CVC or PICC during their hospital stay were included from January 2017 to December 2020. Primary endpoint was CLABSI up to 30 days after CVC or PICC placement. Propensity scores with a 2:1 match was used to account for potential confounders, and restricted cubic spline was used to visualize the risk of CLABSI at different time points during the catheterization. Results A total of 224687 devices (180522 PICCs and 45965 CVCs) in 24879 patients were included. The overall incidence was 1.8 CLABSIs per 1000 catheter-days. The odds ratio (OR) value increased day by day after PICC insertion, reached a relatively high point on the 4th day, and decreased from days 5 through 8. From the 9th day of intubation the OR value began to gradually increase day by day again. After covariate adjustment using propensity scores, CVCs were associated with higher risk of CLABSI (adjHR = 3.27, 95% CI 2.38–4.49) compared with PICCs. Conclusions PICCs have a protective role and the effect of fluctuation curve feature in CLABSI when compared to CVCs, and the first 8 calendar days after CVC insertion are the acute stage of CVC-associated BSI. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07265-x.
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Vernon-Roberts A, Lopez RN, Frampton CM, Day AS. Meta-analysis of the efficacy of taurolidine in reducing catheter-related bloodstream infections for patients receiving parenteral nutrition. JPEN J Parenter Enteral Nutr 2022; 46:1535-1552. [PMID: 35233792 PMCID: PMC9541343 DOI: 10.1002/jpen.2363] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/07/2022] [Accepted: 02/28/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Parenteral nutrition administered via central venous catheter is an established treatment option for people with intestinal failure. A serious complication of central venous catheters is the high risk of catheter-related blood stream infections (CRBSI). Catheter locking solutions are one strategy for CRBSI prevention, with the solution taurolidine showing beneficial effects. The aim of this meta-analysis was to identify and synthesize evidence to assess taurolidine efficacy against comparators for the prevention of CRBSI for people with intestinal failure on parenteral nutrition. METHODS Six health literature databases were searched for efficacy data of rate of CRBSI for taurolidine versus control among our study population, no study design limits were applied. Individual study data were presented for the number of CRBSI and catheter days, and rate ratio. Overall data were synthesized as a pooled risk ratio, with sub-group analysis by study design, control type, and taurolidine solution. RESULTS Thirty-four studies were included in the final analysis. At the individual level all studies showed superior efficacy of taurolidine versus control for prevention of CRBSI. When the data were synthesized, the pooled risk ratio was 0.49 (95% CI 0.46 to 0.53, p=<0.0001), indicating a 51% decreased risk of CRBSI through the use of taurolidine. Sub-group analysis showed no difference depending on study design (p=0.23), or control type (p=0.37), and a significant difference for taurolidine type (p=0.0005). CONCLUSION Taurolidine showed superior efficacy over controls regardless of study design or comparator group. The results show that taurolidine provides effective CRBSI reduction for people with intestinal failure on parenteral nutrition. This article is protected by copyright. All rights reserved.
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A Quality Improvement Initiative to Increase Central Line Maintenance Bundle Compliance through Nursing-led Rounds. Pediatr Qual Saf 2022; 7:e515. [PMID: 35071956 PMCID: PMC8782106 DOI: 10.1097/pq9.0000000000000515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/08/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction: Improvements in maintenance bundle compliance around central line-associated bloodstream infections (CLABSIs) lack standardization. The objective was to implement a formalized nursing-led rounding process, Rounds for Influence, with a goal of 12 rounds/wk on each inpatient unit and Ambulatory Infusion Center, achieving > 90% maintenance bundle compliance. Methods: Nurses served as peer “influencers” to perform rounds. The CLABSI prevention team created three comprehensive rounding tools (line access, dressing change/port needle insertion, and cap change) on a digital platform. The team designed these tools to assess clinical competence for maintenance bundle components and implemented nine plan-do-study-act cycles throughout the study period. Results: Influencers completed 191 rounds after the first month of implementation, resulting in a 264.2% increase from the baseline of 52.5 rounds per month. Over the 2.5 years postimplementation, rounds resulted in 7836 total observations. Maintenance bundle compliance decreased from 86.9% (centerline value from November 2017 to September 2018) to 40.8% after the first month of implementation. Compliance increased iteratively (two separate centerline shifts) to a current centerline value of 87.1%. The CLABSI 12-month cumulative standardized infection ratio (SIR) was 0.9 in November 2017 and dropped to 0.53 in June 2021. Conclusion: Implementing a formalized nursing-led rounding process led to increased maintenance bundle compliance, decreased CLABSI SIR, and is an integral part of nursing practice. Given this success, there is interest from other hospital-acquired condition improvement teams in applying this rounding practice to their improvement work.
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Pediatric central venous access devices: practice, performance, and costs. Pediatr Res 2022; 92:1381-1390. [PMID: 35136199 PMCID: PMC9700519 DOI: 10.1038/s41390-022-01977-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 01/10/2022] [Accepted: 01/23/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Healthcare delivery is reliant on a functional central venous access device (CVAD), but the knowledge surrounding the burden of pediatric CVAD-associated harm is limited. METHODS A prospective cohort study at a tertiary-referral pediatric hospital in Australia. Children <18 years undergoing insertion of a CVAD were screened from the operating theatre and intensive care unit records, then assessed bi-weekly for up to 3 months. Outcomes were CVAD failure and complications, and associated healthcare costs (cost of complications). RESULTS 163 patients with 200 CVADs were recruited and followed for 6993 catheter days, with peripherally inserted central catheters most common (n = 119; 60%). CVAD failure occurred in 20% of devices (n = 30; 95% CI: 15-26), at an incidence rate (IR) of 5.72 per 1000 catheter days (95% CI: 4.09-7.78). CVAD complications were evident in 43% of all CVADs (n = 86; 95% CI: 36-50), at a rate of 12.29 per 1000 catheter days (95% CI: 9.84-15.16). CVAD failure costs were A$826 per episode, and A$165,372 per 1000 CVADs. Comparisons between current and recommended practice revealed inconsistent use of ultrasound guidance for insertion, sub-optimal tip-positioning, and appropriate device selection. CONCLUSIONS CVAD complications and failures represent substantial burdens to children and healthcare. Future efforts need to focus on the inconsistent use of best practices. IMPACT Current surveillance of central venous access device (CVAD) performance is likely under-estimating actual burden on pediatric patients and the healthcare system. CVAD failure due to complication was evident in 20% of CVADs. Costs associated with CVAD complications average at $2327 (AUD, 2020) per episode. Further investment in key diverse practice areas, including new CVAD types, CVAD pathology-based occlusion and dislodgment strategies, the appropriate use of device types, and tip-positioning technologies, will likely lead to extensive benefit.
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Stewardship Intervention to Optimize Central Venous Catheter Utilization in Critically Ill Children. Pediatr Qual Saf 2021; 6:e389. [PMID: 34963999 PMCID: PMC8701869 DOI: 10.1097/pq9.0000000000000389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 09/27/2020] [Indexed: 11/26/2022] Open
Abstract
We aimed to describe utilization and indication(s) for long-term central venous catheters (CVCs) in a pediatric intensive care unit (PICU) and identify potential strategies to decrease CVC utilization.
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Inhofer J, Bertasi A, Gangidine M, Repas SJ, Holmes J, Harris M, Stull M, Marco C. Incidence of central line associated bloodstream infection following central venous catheter placement in the emergency department. Am J Emerg Med 2021; 51:338-341. [PMID: 34808455 DOI: 10.1016/j.ajem.2021.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 10/24/2021] [Accepted: 11/12/2021] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Central line-associated bloodstream infections (CLABSI) are costly and can be lifethreatening. Many efforts have been taken to minimize the rates of infection, including sterile technique, pre-packaged sterile kits, site selection, and replacing infected or potentially infected lines. This study aims to identify the incidence of CLABSI following catheter placement in the ED, and to compare rates of CLABSI among ED and ICU placed catheters. METHODS This retrospective chart review was conducted at a Level 1 Trauma Center. Eligibility criteria included patients who had CVC placed in the ED or ICU from January 1st, 2018, through July 31st, 2019 who were 18 years or older. RESULTS Among 1810 patients with central lines, 1254 met eligibility criteria. There was no significant difference in infection rates when comparing lines placed in the ED (2.5 per 1000 catheter days, 95% confidence interval [CI] 0.8 to 5.8) compared to those placed in the ICU (4.6 per 1000 catheter days, 95% CI 3.0 to 6.8). The odds of CLABSI was not associated with age, sex, indication, site, location nor which type of health care professional (HCP) placed the line. CONCLUSIONS In this study, the incidence of infection was no different between lines placed in the ED compared to the ICU.
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Affiliation(s)
- Joseph Inhofer
- Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH, United States of America.
| | - Anthony Bertasi
- 81st Medical Group, Keesler AFB, MS (July 2020 onward), Biloxi, MS, United States of America; Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH, (through June 2020), United States of America
| | - Matthew Gangidine
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, (July 2020 onward), United States of America; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, (July 2020 onward), United States of America; Air Force Institute of Technology, Wright-Patterson AFB, OH, (July 2020 onward), United States of America; Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH, (through June 2020), United States of America
| | - Steven J Repas
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States of America
| | - Jasmine Holmes
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States of America
| | - Micah Harris
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States of America
| | - Madeline Stull
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States of America
| | - Catherine Marco
- Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH, United States of America
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Enlisting Parents to Decrease Hospital-Acquired Central Line-Associated Infections in the Pediatric Intensive Care Unit. Crit Care Nurs Clin North Am 2021; 33:431-440. [PMID: 34742499 DOI: 10.1016/j.cnc.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Hospital-acquired central line-associated bloodstream infections (CLABSIs) are the leading cause of infections in the pediatric intensive care unit. Bacteria responsible for CLABSIs are spread by health care workers, parents, and families and mitigated by scrupulous attention to hand hygiene and safety prevention strategies. Maintenance bundles are grouped elements, such as hand hygiene, standardized dressing and tubing changes, and aseptic technique for entering a central line, effective in preventing CLABSIs. Nurses can decrease the incidence of CLABSIs by using maintenance bundles and including parents and families in safety prevention strategies."
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Hao R, Qi X, Xia X, Wang L, Li X. Temporal trend of comorbidity and increasing impacts on mortality, length of stay, and hospital costs of first stroke in Tianjin, North of China. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:63. [PMID: 34583749 PMCID: PMC8477574 DOI: 10.1186/s12962-021-00316-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stroke patients have a high incidence of comorbidity. Previous studies have shown that comorbidity can impact on the short-term and long-term mortality after stroke. METHODS Our study aimed to explore the trend of comorbidity among patients with first stroke from 2010 to 2020, and the influence of comorbidity on admission mortality, length of stay and hospitalization costs. 5988 eligible patients were enrolled in our study, and divided into 4 comorbidity burden groups according to Charlson comorbidity index (CCI): none, moderate, severe, very severe. Survival analysis was expressed by Kaplan-Meier curve. Cox regression model was used to analyze the effect of comorbidity on 7-day and in-hospital mortality. Generalized linear model (GLM) was used to analyze the association between comorbidity and hospitalization days and cost. RESULTS Compared to patients without comorbidity, those with very severe comorbidity were more likely to be male (342, 57.7%), suffer from ischemic stroke (565, 95.3%), afford higher expense (Midian, 19339.3RMB, IQR13020.7-27485.9RMB), and have a higher in-hospital mortality (60, 10.1%). From 2010 to 2020, proportion of patients with severe and very severe comorbidity increased 12.9%. The heaviest comorbidity burden increased the risk of 7-day mortality (adjusted hazard ratio, 3.51, 95% CI 2.22-5.53) and in-hospital mortality (adjusted hazard ratio, 3.83, 95% CI 2.70-5.45). Patients with very severe comorbidity had a 12% longer LOS and extra 27% expense than those without comorbidity. CONCLUSIONS Comorbidity burden showed an increasing trend year in past eleven years. The heavy comorbidity burden increased in-hospital mortality, LOS, and hospitalization cost, especially in patients aged 55 years or more. The findings also provide some reference on improvement of health care reform policies and allocation of resources.
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Affiliation(s)
- Ruixiao Hao
- Department of Neurology, The Second Hospital of Tianjin Medical University, 23 Pingjiang Road, Tianjin, 300211, China
| | - Xuemei Qi
- Department of Neurology, The Second Hospital of Tianjin Medical University, 23 Pingjiang Road, Tianjin, 300211, China
| | - Xiaoshuang Xia
- Department of Neurology, The Second Hospital of Tianjin Medical University, 23 Pingjiang Road, Tianjin, 300211, China
| | - Lin Wang
- Department of Geriatrics, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xin Li
- Department of Neurology, The Second Hospital of Tianjin Medical University, 23 Pingjiang Road, Tianjin, 300211, China.
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Goldman J, Rotteau L, Shojania KG, Baker GR, Rowland P, Christianson MK, Vogus TJ, Cameron C, Coffey M. Implementation of a central-line bundle: a qualitative study of three clinical units. Implement Sci Commun 2021; 2:105. [PMID: 34530918 PMCID: PMC8447632 DOI: 10.1186/s43058-021-00204-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 08/25/2021] [Indexed: 11/24/2022] Open
Abstract
Background Evidence for the central line-associated bloodstream infection (CLABSI) bundle effectiveness remains mixed, possibly reflecting implementation challenges and persistent ambiguities in how CLABSIs are counted and bundle adherence measured. In the context of a tertiary pediatric hospital that had reduced CLABSI by 30% as part of an international safety program, we aimed to examine unit-based socio-cultural factors influencing bundle practices and measurement, and how they come to be recognized and attended to by safety leaders over time in an organization-wide bundle implementation effort. Methods We used an interpretivist qualitative research approach, based on 74 interviews, approximately 50 h of observations, and documents. Data collection focused on hospital executives and safety leadership, and three clinical units: a medical specialty unit, an intensive care unit, and a surgical unit. We used thematic analysis and constant comparison methods for data analysis. Results Participants had variable beliefs about the central-line bundle as a quality improvement priority based on their professional roles and experiences and unit setting, which influenced their responses. Nursing leaders were particularly concerned about CLABSI being one of an overwhelming number of QI targets for which they were responsible. Bundle implementation strategies were initially reliant on unit-based nurse education. Over time there was recognition of the need for centralized education and reinforcement tactics. However, these interventions achieved limited impact given the influence of competing unit workflow demands and professional roles, interactions, and routines, which were variably targeted in the safety program. The auditing process, initially a responsibility of units, was performed in different ways based on individuals’ approaches to the process. Given concerns about auditing reliability, a centralized approach was implemented, which continued to have its own variability. Conclusions Our findings report on a contextualized, dynamic implementation approach that required movement between centralized and unit-based approaches and from a focus on standardization to some recognition of a role for customization. However, some factors related to bundle compliance and measurement remain unaddressed, including harder to change socio-cultural factors likely important to sustainability of the CLABSI reductions and fostering further improvements across a broader safety agenda.
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Affiliation(s)
- Joanne Goldman
- Centre for Quality Improvement and Patient Safety, Temerty Faculty of Medicine, University of Toronto, 630-525 University Ave., Toronto, M5G2L3, Canada. .,Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada. .,Wilson Centre for Research in Education, University of Toronto, 200 Elizabeth St., 1ES-565, Toronto, M5G 2C4, Canada.
| | - Leahora Rotteau
- Centre for Quality Improvement and Patient Safety, Temerty Faculty of Medicine, University of Toronto, 630-525 University Ave., Toronto, M5G2L3, Canada
| | - Kaveh G Shojania
- Centre for Quality Improvement and Patient Safety, Temerty Faculty of Medicine, University of Toronto, 630-525 University Ave., Toronto, M5G2L3, Canada.,Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.,Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - G Ross Baker
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College St., Suite 425, Toronto, M5T 3M6, Canada
| | - Paula Rowland
- Wilson Centre for Research in Education, University of Toronto, 200 Elizabeth St., 1ES-565, Toronto, M5G 2C4, Canada.,Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Marlys K Christianson
- Rotman School of Management, University of Toronto, 125 St. George St., Toronto, M5S 2E8, Canada
| | - Timothy J Vogus
- Owen Graduate School of Management, Vanderbilt University, 401 21st Avenue South, Nashville, TN, 37203, USA
| | - Connie Cameron
- The Hospital for Sick Children, 555 University Ave., Toronto, M5G 1X8, Canada
| | - Maitreya Coffey
- The Hospital for Sick Children, 555 University Ave., Toronto, M5G 1X8, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,Children's Hospitals Solutions for Patient Safety, Cincinnati, OH, USA
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Chamblee TB, Miles DK. A Prospective Study of Family Engagement for Prevention of Central Line-associated Blood Stream Infections. Pediatr Qual Saf 2021; 6:e467. [PMID: 34476318 PMCID: PMC8389930 DOI: 10.1097/pq9.0000000000000467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 04/20/2021] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: We sought to determine if a family-centered care (FCC) handout intervention designed to encourage family engagement (FE) in the prevention of central line-associated bloodstream infections (CLABSIs) would alter parental perceptions of FCC and improve staff compliance with CLABSI bundle components. Methods: A prospective quasiexperimental study of 121 legal guardians of children with a central venous catheter (CVC) admitted to the pediatric intensive care unit (PICU). Baseline (n = 59) and intervention (n = 62) groups of parents completed an 18-question online survey assessing basic CLABSI care practices and FCC principles. The intervention group received an FE handout before completing the survey with information about CLABSI prevention practices designed to encourage active participation in their child’s CVC care. Results: Independent sample t-tests found significant improvements in the intervention parents responses compared to the baseline group (no handout) on survey items assessing CLABSI knowledge (P < 0.001) and on parental perceptions of FCC in the domains of dignity and respect, information sharing, participation, and partnership (all with a P < 0.001). An improvement was observed in staff CLABSI maintenance bundle compliance in the postintervention period, increasing from 89% to 94%. Conclusions: Educating parents on CLABSI prevention strategies and encouraging family participation in CVC care was associated with improved parental perceptions of participation in their child’s care, medical team’s listening, attention, honesty, and explanation of treatment plans and was associated with an increase in staff compliance with CLABSI maintenance bundle practices.
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Affiliation(s)
| | - Darryl K Miles
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Tex
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Low Risk of Central Line-associated Bloodstream Infections in Pediatric Hematology/Oncology Patients. Pediatr Infect Dis J 2021; 40:827-831. [PMID: 33990520 DOI: 10.1097/inf.0000000000003177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Central venous lines (CVLs) are essential for standard care of pediatric hematology/oncology patients providing safe administration of cytotoxic drugs and pain-free blood sampling. Central line-associated bloodstream infections (CLABSIs) cause significant morbidity. This study describes the epidemiology, microbiology, and risk factors for CLABSI in all children with malignancies in Iceland. METHODS All children that were diagnosed with malignancy in Iceland and received a CVL during 2008-2017 were included in the study. Characteristics of CVLs and patients were registered, information on risk factors, and microbiology was collected. International standards were used for CLABSI definition. RESULTS One hundred forty-three CVLs were placed in 94 children. Acute lymphoblastic leukemia was the most common underlying disease (31/94). Median age was 7 years. Implantable ports were the most commonly placed CVLs (82/143, 57%), tunneled lines were 39 (27%). Overall CLABSI rate was 0.24 infections/1000 line-days (14 episodes in 58,830 line-days), with little fluctuations. No CLABSI episodes occurred for 4 consecutive years (2012-2015). Staphylococci (of which 7 Staphylococcus aureus) were the cause of 10/14 episodes. Nine CLABSI episodes led to line removal, but no deaths were linked to CLABSIs. CONCLUSION We report very low CLABSI rates over a 9-year period at our hospital, with 4 consecutive CLABSI-free years. Even with the addition of episodes of possible CLABSI, rates were still very low and lower than most published reports.
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Time-Driven Cost Analysis of Noncuffed Venous Catheter Placement in Infants: Bedside versus IR Suite. J Vasc Interv Radiol 2021; 32:1479-1487. [PMID: 34358685 DOI: 10.1016/j.jvir.2021.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/30/2021] [Accepted: 07/25/2021] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To compare the direct bundled costs of interventional radiology (IR) suite versus bedside placement of noncuffed central venous catheters in infants. METHODS A single-center retrospective review was performed of all noncuffed upper extremity (peripherally inserted central venous catheter [PICC]) and tunneled femoral (tunneled femoral central venous catheter [TCVC]) catheters placed in infants between January 1, 2018, and December 31, 2018. Propensity score matching was performed adjusting for age, birth weight, procedure weight, and catheter days. Process maps for each procedure were created based on location and sedation type. Technical success and complications were recorded for each placement. The total direct bundled cost for each catheter placement was calculated by summing the procedure and complication costs. RESULTS A total of 142 procedures were performed on 126 matched patients with a technical success of 96% at the bedside and 100% in the IR suite (P = .08). The complication rates did not significantly differ between the 2 groups (P = .51). The total direct bundled costs for catheter placement were $1421.3 ± 2213.2 at the bedside and $2256.8 ± 3264.7 in the IR suite (P = .001). CONCLUSIONS The bundled cost of bedside femoral catheter placement is significantly less than that of fluoroscopic TCVC and PICC placement performed in the IR suite, mainly related to differences in sedation costs.
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Development and Implementation of a Real-time Bundle-adherence Dashboard for Central Line-associated Bloodstream Infections. Pediatr Qual Saf 2021; 6:e431. [PMID: 34235355 PMCID: PMC8225377 DOI: 10.1097/pq9.0000000000000431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 01/06/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction: Central line-associated bloodstream infections (CLABSIs) are the most common hospital-acquired infection in pediatric patients. High adherence to the CLABSI bundle mitigates CLABSIs. At our institution, there did not exist a hospital-wide system to measure bundle-adherence. We developed an electronic dashboard to monitor CLABSI bundle-adherence across the hospital and in real time. Methods: Institutional stakeholders and areas of opportunity were identified through interviews and data analyses. We created a data pipeline to pull adherence data from twice-daily bundle checks and populate a dashboard in the electronic health record. The dashboard was developed to allow visualization of overall and individual element bundle-adherence across units. Monthly dashboard accesses and element-level bundle-adherence were recorded, and the nursing staff’s feedback about the dashboard was obtained. Results: Following deployment in September 2018, the dashboard was primarily accessed by quality improvement, clinical effectiveness and analytics, and infection prevention and control. Quality improvement and infection prevention and control specialists presented dashboard data at improvement meetings to inform unit-level accountability initiatives. All-element adherence across the hospital increased from 25% in September 2018 to 44% in December 2019, and average adherence to each bundle element increased between 2018 and 2019. Conclusions: CLABSI bundle-adherence, overall and by element, increased across the hospital following the deployment of a real-time electronic data dashboard. The dashboard enabled population-level surveillance of CLABSI bundle-adherence that informed bundle accountability initiatives. Data transparency enabled by electronic dashboards promises to be a useful tool for infectious disease control.
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Briassoulis P, Briassoulis G, Christakou E, Machaira M, Kassimis A, Barbaressou C, Nikolaou F, Sdougka M, Gikas A, Ilia S. Active Surveillance of Healthcare-associated Infections in Pediatric Intensive Care Units: Multicenter ECDC HAI-net ICU Protocol (v2.2) Implementation, Antimicrobial Resistance and Challenges. Pediatr Infect Dis J 2021; 40:231-237. [PMID: 33565812 DOI: 10.1097/inf.0000000000002960] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Surveillance is essential to all aspects of management of healthcare-associated infections (HAIs) in critically ill children, where data are limited. We conducted an active surveillance study to elucidate epidemiology, resistance, antimicrobial treatment practices and outcomes of pediatric intensive care unit-acquired HAIs in a southern European country. METHODS Four Greek pediatric intensive care unit encounters (153 patients, 2183 patient-days) during a 6-month period participated using the European Centre for Disease Prevention and Control HAI-net ICU (v2.2) protocol. Bloodstream infections and device-associated HAIs were recorded. Clinical severity, isolated pathogens, antimicrobial resistance and antibiotic prescriptions were collected on a daily basis. Mortality and excess length of stay due to HAI were also assessed. RESULTS Overall rate of HAIs was 18.3 per 1000 patient-days. Aggregate rates for device-associated HAI were: catheter-related bloodstream infection 2.32, intubation-associated pneumonia 10.5, and catheter-associated urinary tract infection 4.6 per 1000 device-days. Children with HAI (n = 28, 18.3%) had higher severity of illness (Pediatric Risk Mortality Score 7.5 vs. 4, P < 0.001), longer hospitalization (23 vs. 6 days, P < 0.001), but not higher mortality, compared with those without. Most frequent recovered pathogens were Klebsiella pneumoniae (40%), Pseudomonas aeruginosa (22.5%), Acinetobacter baumannii (12.5%), with respective carbapenem resistance 50%, 44% and 80%, and Staphylococcus aureus (12.5%). Total antibiotic use was 2142 days of treatment per 1000 patient-days. CONCLUSIONS Our study, based on the updated ECDC HAI-net ICU (v2.2) protocol, effectively addresses the significant burden of HAIs in critically ill children in Greece. Using a well-standardized system facilitates inter- and intra-countries reliable recordings and comparative assessments of infection control programs.
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Affiliation(s)
- Panagiotis Briassoulis
- From the PICU, University Hospital, Medical School, University of Crete, Heraklion, Greece
| | - George Briassoulis
- From the PICU, University Hospital, Medical School, University of Crete, Heraklion, Greece
| | | | - Maria Machaira
- PICU, Panagiotis and Aglaia Kyriakou Children's Hospital, Athens, Greece
| | | | | | - Filippia Nikolaou
- PICU, Panagiotis and Aglaia Kyriakou Children's Hospital, Athens, Greece
| | - Maria Sdougka
- PICU, Ippokrateio General Hospital, Thessaloniki, Greece
| | - Achilleas Gikas
- Infection Control Committee, University Hospital, Medical School, University of Crete, Heraklion, Greece
| | - Stavroula Ilia
- From the PICU, University Hospital, Medical School, University of Crete, Heraklion, Greece
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Woods-Hill CZ, Papili K, Nelson E, Lipinski K, Shea J, Beidas R, Lane-Fall M. Harnessing implementation science to optimize harm prevention in critically ill children: A pilot study of bedside nurse CLABSI bundle performance in the pediatric intensive care unit. Am J Infect Control 2021; 49:345-351. [PMID: 32818579 DOI: 10.1016/j.ajic.2020.08.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Central-line associated bloodstream infection (CLABSI) is associated with increased mortality, morbidity, and cost in hospitalized children. An evidence-based bundle of care can decrease CLABSI, but bundle compliance is imperfect. We explored factors impacting bundle performance in the pediatric intensive care unit (PICU) by bedside nurses. METHODS Single-center cross-sectional electronic survey of PICU bedside nurses in an academic tertiary care center; using the COM-B (capability, opportunity, motivation) and TDF (theoretical domains framework) behavioral models to explore CLABSI bundle performance and identify barriers to compliance. RESULTS We analyzed 160 completed surveys from 226 nurses (71% response rate). CLABSI knowledge was strong (capability). However, challenges related to opportunity were identified: 71% reported that patient care requirements impact bundle completion; 32% described the bundle as stressful; and CLABSI was viewed as the most difficult of all bundles. Seventy-five percent reported being highly impacted by physician attitude toward the CLABSI bundle (motivation). CONCLUSIONS PICU nurses are knowledgeable and motivated to prevent CLABSI, but face challenges from competing clinical tasks, limited resources, and complex family interactions. Physician engagement was specifically noted to impact nurse motivation to complete the bundle. Interventions that address these challenges may improve bundle performance and prevent CLABSI in critically ill children.
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Affiliation(s)
- Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA; The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Kelly Papili
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Eileen Nelson
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kathryn Lipinski
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Judy Shea
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rinad Beidas
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), Philadelphia, PA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Meghan Lane-Fall
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Central Vascular Access Device Complications in Pediatric Home Care Patients Managed by Family Caregivers or Nurses. JOURNAL OF INFUSION NURSING 2021. [DOI: 10.1097/nan.0000000000000417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Heijting IE, Antonius TAJ, Tostmann A, de Boode WP, Hogeveen M, Hopman J. Sustainable neonatal CLABSI surveillance: consensus towards new criteria in the Netherlands. Antimicrob Resist Infect Control 2021; 10:31. [PMID: 33546759 PMCID: PMC7866773 DOI: 10.1186/s13756-021-00900-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/21/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSI) are a main focus of infection prevention and control initiatives in neonatal care. Standardised surveillance of neonatal CLABSI enables intra- and interfacility comparisons which can contribute to quality improvement. To date, there is no national registration system for CLABSI in neonatal care in the Netherlands and several criteria are used for local monitoring of CLABSI incidence rates. To achieve standardised CLABSI surveillance we conducted a consensus procedure with regard to nationwide neonatal CLABSI surveillance criteria (SC). METHODS A modified Delphi consensus procedure for the development of nationwide neonatal CLABSI SC was performed between January 2016 and January 2017 in the Netherlands. An expert panel was formed by members of the Working Group on Neonatal Infectious Diseases of the Section of Neonatology of the Dutch Paediatric Society. The consensus procedure consisted of three expert panel rounds. RESULTS The expert panel achieved consensus on Dutch neonatal CLABSI SC. Neonatal CLABSI is defined as a bloodstream infection occurring more than 72 h after birth, associated with an indwelling central venous or arterial line and laboratory confirmed by one or more blood cultures. In addition, the blood culture finding should not be related to an infection at another site and one of the following criteria can be applied: 1. a bacterial or fungal pathogen is identified from one or more blood cultures; 2. the patient has clinical symptoms of sepsis and 2A) a common commensal is identified in two separate blood cultures or 2B) a common commensal is identified by one blood culture and C-reactive protein level is above 10 mg/L in the first 36 h following blood culture collection. CONCLUSIONS The newly developed Dutch neonatal CLABSI SC are concise, specified to the neonatal population and comply with a single blood culture policy in actual neonatal clinical practice. International agreement upon neonatal CLABSI SC is needed to identify best practices for infection prevention and control.
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Affiliation(s)
- I E Heijting
- Department of Paediatrics, Division of Neonatology, Amalia Children's Hospital, Radboud University Medical Center, Radboud Institute for Health Sciences, Internal Postal Code 804, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands.
| | - T A J Antonius
- Department of Paediatrics, Division of Neonatology, Amalia Children's Hospital, Radboud University Medical Center, Radboud Institute for Health Sciences, Internal Postal Code 804, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
| | - A Tostmann
- Unit of Hygiene and Infection Control, Department of Medical Microbiology, Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - W P de Boode
- Department of Paediatrics, Division of Neonatology, Amalia Children's Hospital, Radboud University Medical Center, Radboud Institute for Health Sciences, Internal Postal Code 804, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
| | - M Hogeveen
- Department of Paediatrics, Division of Neonatology, Amalia Children's Hospital, Radboud University Medical Center, Radboud Institute for Health Sciences, Internal Postal Code 804, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
| | - J Hopman
- Department of Quality and Safety, Department of Medical Microbiology, Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
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Bierlaire S, Danhaive O, Carkeek K, Piersigilli F. How to minimize central line-associated bloodstream infections in a neonatal intensive care unit: a quality improvement intervention based on a retrospective analysis and the adoption of an evidence-based bundle. Eur J Pediatr 2021; 180:449-460. [PMID: 33083900 DOI: 10.1007/s00431-020-03844-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/10/2020] [Accepted: 10/13/2020] [Indexed: 11/30/2022]
Abstract
Central line-associated bloodstream infection (CLABSI) is a significant cause of morbidity and mortality in neonatal intensive care units (NICUs). A "bundle" is defined as a combination of evidence-based interventions that provided they are followed collectively and reliably, are proven to improve patient outcomes. The aim of this quasi-experimental study was to assess the impact of new central line insertion, dressing, and maintenance "bundles" on the rate of CLABSI and catheter-related complications. We performed a quality improvement (QI), prospective, before-after study. In the first 9-month period, the old "bundles" and pre-existing materials were used/applied. An intervention period then occurred with changes made to materials used and the implementation of new "bundles" related to various aspects of central lines care. A second 6-month period was then assessed and the CLABSI rates were measured in the NICU pre- and post-intervention period. The QI measures were the rate of CLABSI and catheter-related complications. Data are still being collected after the study to verify sustainability. The implementation of the new "bundles" and the change of certain materials resulted in a significantly decreased rate of CLABSI (8.4 to 1.8 infections per 1000 central venous catheter (CVC) days, p = 0.02,) as well as decreased catheter-related complications (47 to 10, p < 0.007).Conclusions: The analysis of pre-existing "bundles" and the implementation of updated central line "bundles" based on best practice recommendations are crucial for reducing the rate of CLABSI in the NICU. The implementation of the new evidence-based central line "bundles" was associated with a significant reduction in CLABSI rate in our unit soon after implementation. What is Known: • Central line-associated bloodstream infection (CLABSI) is a major cause of morbidity and mortality in the neonatal population. • The implementation of evidence-based "bundles" in the NICU is associated with a reduction in the incidence of CLABSI. What is New: • For the improvement in quality care in the NICU, audits are necessary to assess the existing systems. • The "Plan-Do-Study-Act cycle" is an effective tool to use when tackling challenges in an existing system. Using this tool assisted in the approach to reducing CLABSI in our NICU.
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Affiliation(s)
- Stéphanie Bierlaire
- Department of Neonatology, Saint-Luc University Clinics, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Olivier Danhaive
- Department of Neonatology, Saint-Luc University Clinics, Avenue Hippocrate 10, 1200, Brussels, Belgium.,Department of Pediatrics, University of California San Francisco, San Francisco, USA
| | - Katherine Carkeek
- Department of Neonatology, Saint-Luc University Clinics, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Fiammetta Piersigilli
- Department of Neonatology, Saint-Luc University Clinics, Avenue Hippocrate 10, 1200, Brussels, Belgium. .,Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy.
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Rinke ML, Heo M, Saiman L, Bundy DG, Rosenberg RE, DeLaMora P, Rabin B, Zachariah P, Mirhaji P, Ford WJH, Obaro-Best O, Drasher M, Klein E, Peshansky A, Oyeku SO. Pediatric Ambulatory Central Line-Associated Bloodstream Infections. Pediatrics 2021; 147:peds.2020-0524. [PMID: 33386333 DOI: 10.1542/peds.2020-0524] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Inpatient pediatric central line-associated bloodstream infections (CLABSIs) cause morbidity and increased health care use. Minimal information exists for ambulatory CLABSIs despite ambulatory central line (CL) use in children. In this study, we identified ambulatory pediatric CLABSI incidence density, risk factors, and outcomes. METHODS Retrospective cohort with nested case-control study at 5 sites from 2010 through 2015. Electronic queries were used to identify potential cases on the basis of administrative and laboratory data. Chart review was used to confirm ambulatory CL use and adjudicated CLABSIs. Bivariate followed by multivariable backward logistic regression was used to identify ambulatory CLABSI risk factors. RESULTS Queries identified 4600 potentially at-risk children; 1658 (36%) had ambulatory CLs. In total, 247 (15%) patients experienced 466 ambulatory CLABSIs with an incidence density of 0.97 CLABSIs per 1000 CL days. Incidence density was highest among patients with tunneled externalized catheters versus peripherally inserted central catheters and totally implanted devices: 2.58 CLABSIs per 1000 CL days versus 1.46 vs 0.23, respectively (P < .001). In a multivariable model, clinic visit (odds ratio [OR] 2.8; 95% confidence interval [CI]: 1.4-5.5) and low albumin (OR 2.3; 95% CI: 1.2-4.3) were positively associated with CLABSI, and prophylactic antimicrobial agents for underlying conditions within the preceding 30 days (OR 0.22; 95% CI: 0.12-0.40) and operating room CL placement (OR 0.36; 95% CI: 0.16-0.79) were inversely associated with CLABSI. A total of 396 patients (85%) were hospitalized because of ambulatory CLABSI with an 8-day median length of stay (interquartile range 5-13). CONCLUSIONS Ambulatory pediatric CLABSI incidence density is appreciable and associated with health care use. CL type, patients with low albumin, prophylactic antimicrobial agents, and placement setting may be targets for reduction efforts.
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Affiliation(s)
- Michael L Rinke
- The Children's Hospital at Montefiore, Bronx, New York; .,Albert Einstein College of Medicine, Bronx, New York
| | - Moonseong Heo
- Department of Public Health Sciences, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, South Carolina
| | - Lisa Saiman
- Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York
| | - David G Bundy
- Department of Pediatrics, College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Rebecca E Rosenberg
- Department of Pediatrics, School of Medicine, New York University, New York, New York
| | - Patricia DeLaMora
- Department of Pediatrics, Weill Cornell Medical College, New York, New York
| | - Barbara Rabin
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Philip Zachariah
- Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York
| | - Parsa Mirhaji
- Albert Einstein College of Medicine, Bronx, New York
| | - William J H Ford
- Department of Pediatrics, School of Medicine, New York University, New York, New York
| | - Oghale Obaro-Best
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, New York; and
| | - Michael Drasher
- School of Medicine, Wayne State University, Detroit, Michigan
| | | | | | - Suzette O Oyeku
- The Children's Hospital at Montefiore, Bronx, New York.,Albert Einstein College of Medicine, Bronx, New York
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47
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Willems J, Hermans E, Schelstraete P, Depuydt P, De Cock P. Optimizing the Use of Antibiotic Agents in the Pediatric Intensive Care Unit: A Narrative Review. Paediatr Drugs 2021; 23:39-53. [PMID: 33174101 PMCID: PMC7654352 DOI: 10.1007/s40272-020-00426-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2020] [Indexed: 02/08/2023]
Abstract
Antibiotics are one of the most prescribed drug classes in the pediatric intensive care unit, yet the incidence of inappropriate antibiotic prescribing remains high in critically ill children. Optimizing the use of antibiotics in this population is imperative to guarantee adequate treatment, avoid toxicity and the occurrence of antibiotic resistance, both on a patient level and on a population level. Antibiotic stewardship encompasses all initiatives to promote responsible antibiotic usage and the PICU represents a major target environment for antibiotic stewardship programs. This narrative review provides a summary of the available knowledge on the optimal selection, duration, dosage, and route of administration of antibiotic treatment in critically ill children. Overall, more scientific evidence on how to optimize antibiotic treatment is warranted in this population. We also give our personal expert opinion on research priorities.
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Affiliation(s)
- Jef Willems
- Department of Pediatric Intensive Care, Ghent University Hospital, Gent, Belgium
| | - Eline Hermans
- Department of Pediatrics, Ghent University Hospital, Gent, Belgium
- Heymans Institute of Pharmacology, Ghent University, Gent, Belgium
| | - Petra Schelstraete
- Department of Pediatric Pulmonology, Ghent University Hospital, Gent, Belgium
| | - Pieter Depuydt
- Department of Intensive Care Medicine, Ghent University Hospital, Gent, Belgium
| | - Pieter De Cock
- Department of Pediatric Intensive Care, Ghent University Hospital, Gent, Belgium.
- Heymans Institute of Pharmacology, Ghent University, Gent, Belgium.
- Department of Pharmacy, Ghent University Hospital, Gent, Belgium.
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48
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Lu H, Hou Y, Chen J, Guo Y, Lang L, Zheng X, Xin X, Lv Y, Yang Q. Risk of catheter-related bloodstream infection associated with midline catheters compared with peripherally inserted central catheters: A meta-analysis. Nurs Open 2020; 8:1292-1300. [PMID: 33372316 PMCID: PMC8046042 DOI: 10.1002/nop2.746] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/21/2020] [Accepted: 11/04/2020] [Indexed: 11/15/2022] Open
Abstract
Background Both midline catheters (MCs) and peripherally inserted central catheters (PICCs) can cause catheter‐related bloodstream infection (CRBSI), but the prevalence associated with each is not clear. Objective To compare the risk of CRBSI between MCs and PICCs with a meta‐analysis. Methods The Web of Science Core Collection, PubMed, Scopus, Embase, The Cochrane Library and ProQuest were searched. All studies comparing the risk of CRBSI between MCs and PICCs were included. Selected studies were assessed for methodological quality using the Downs and Black checklist. Two authors independently assessed the literature and extracted the data. A fixed effects model was used to generate estimates of CRBSI risk in patients with MCs versus PICCs. Publication bias was evaluated, and meta‐analyses were conducted with RevMan 5.3. Results A total of 167 studies were identified. Ten studies were collected, involving 33,322 patients. The prevalence of CRBSI with MCs and PICCs was 0.58% (40/6,900) and 0.48% (127/26,422), respectively. Meta‐analysis showed that the prevalence of CRBSI was not significantly different between MCs and PICCs (RR = 0.77, 95% CI: 0.50–1.17, p = .22). While the result showed that the prevalence of CRBSI with MCs was lower than that with PICCs (RR = 0.55, 95% CI: 0.33–0.92, p = .02) after poor‐quality studies were removed. The sensitivity analysis shows that the results from this meta‐analysis are fair in overall studies and non‐poor‐quality studies. All studies have no significant publication bias. Conclusions This study provides the first systematic assessment of the risk of CRBSI between MCs and PICCs and provides evidence for the selection of appropriate vascular access devices for intravenous infusion therapy in nursing. The prevalence of CRBSI was not significantly different between them.
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Affiliation(s)
- Huapeng Lu
- Department of Hepatobiliary and Pancreas Surgery, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Yeru Hou
- School of Nursing, Health Science Center, Yan'an University, Shaanxi, P. R. China
| | - Jiejie Chen
- School of Nursing, Health Science Center, Yan'an University, Shaanxi, P. R. China
| | - Yan Guo
- School of Nursing, Health Science Center, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Lan Lang
- Department of Hepatobiliary and Pancreas Surgery, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Xuemei Zheng
- Department of Nursing, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Xia Xin
- Department of Nursing, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Yi Lv
- Department of Hepatobiliary and Pancreas Surgery, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Qinling Yang
- Department of Hepatobiliary and Pancreas Surgery, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
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Wang C, Hao W, Yu R, Wang X, Zhang J, Wang B. Analysis of Pathogen Distribution and Its Antimicrobial Resistance in Bloodstream Infections in Hospitalized Children in East China, 2015-2018. J Trop Pediatr 2020; 67:6048386. [PMID: 33367870 PMCID: PMC7948388 DOI: 10.1093/tropej/fmaa077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study analyzed the pathogen distribution in bloodstream-infected (BSI) children hospitalized in Shandong Province from 2015 to 2018, to identify prevention strategies and select empiric antimicrobial therapy for BSI in children. Blood sample data from 14 107 children from 162 hospitals of Shandong Province were obtained from the China Antimicrobial Resistance Surveillance System and analyzed with WHONET 5.6 software. The results of the blood culture test showed the growth of 70.6% Gram-positive and 29.4% Gram-negative bacteria. Of the 14 107 blood isolates, 59.3% were collected from males and 40.7% were from females. Coagulase-negative staphylococci (47.1%) were the most commonly distributed pathogens. The distribution of pathogens varied according to age group and season. All Staphylococcus isolates were susceptible to vancomycin, teicoplanin and linezolid. Clinically, significant declines in penicillin-resistant Streptococcus pneumonia and carbapenem-resistant Escherichia coli were observed during the study period; however, detection rates of carbapenem-resistant Klebsiella pneumoniae increased over time (p < 0.05). Empiric antimicrobial therapy should be prescribed according to corresponding regional pediatric antimicrobial-resistant data.
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Affiliation(s)
- Cuicui Wang
- Medical Department, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China,Correspondence: Bo Wang, Medical Department, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Room 117, Renhe Building, No. 324 Jingwu Road, Huaiyin District, Jinan 250021, China. Tel: +86-531-68777020. Fax: +86-531-87030081. E-mail <>
| | - Wei Hao
- Pediatric Department, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Ruihua Yu
- Pediatric Department, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Xiaokang Wang
- Pediatric Department, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Jing Zhang
- Medical Department, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Bo Wang
- Medical Department, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
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50
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Standardizing Preoperative Evaluation for Pediatric Central Venous Access: A Care Algorithm to Improve Safety. JOURNAL OF INFUSION NURSING 2020; 43:262-274. [PMID: 32881813 DOI: 10.1097/nan.0000000000000386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Central vascular access device (CVAD) placement is a common procedure in children. When selecting a CVAD, available evidence and specified indications should be used to choose the device that best supports the patient's treatment and carries the lowest risks. A multidisciplinary team developed a care algorithm to standardize preoperative screening before pediatric CVAD placement, with 3 major parts: CVAD selection, patient risk stratification, and preoperative evaluation. Using a stepwise approach of provider education and incorporation into the electronic health record, the team achieved 82% stratification among inpatients. The team's algorithm integrates the existing literature and recommendations for safe and effective CVAD placement.
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