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Downing M, Modrow M, Thompson-Brazill KA, Ledford JE, Harr CD, Williams JB. Eliminating sternal wound infections: Why every cardiac surgery program needs an I hate infections team. JTCVS Tech 2023; 19:93-103. [PMID: 37324338 PMCID: PMC10268509 DOI: 10.1016/j.xjtc.2023.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/23/2023] [Accepted: 03/27/2023] [Indexed: 06/17/2023] Open
Abstract
Objectives The majority of studies examining deep sternal wound infection (DSWI) prevention focus on ameliorating 1 variable at a time. There is a paucity of data regarding the synergistic effects of combining clinical and environmental interventions. This article describes an interdisciplinary, multimodal approach to eliminate DSWIs at a large community hospital. Methods We developed a robust, multidisciplinary infection prevention team to evaluate and act in all phases of perioperative care to achieve a cardiac surgery DSWI rate of 0, named: the I hate infections team. The team identified opportunities for improved care and best practices and implemented changes on an ongoing basis. Results Patient-related interventions consisted of preoperative methicillin-resistant Staphylococcus aureus identification, individualized perioperative antibiotics, antimicrobial dosing strategies, and maintenance of normothermia. Operative-related interventions involved glycemic control, sternal adhesives, medications and hemostasis, rigid sternal fixation for high-risk patients, chlorhexidine gluconate dressings over invasive lines, and use of disposable health care equipment. Environment-related interventions included optimizing operating room ventilation and terminal cleaning, reducing airborne particle counts, and decreasing foot traffic. Together, these interventions reduced the DSWI incidence from 1.6% preintervention to 0% for 12 consecutive months after full bundle implementation. Conclusions A multidisciplinary team focused on eliminating DSWI identified known risk factors and implemented evidence-based interventions in each phase of care to ameliorate risk. Although the influence of each individual intervention on DSWI remains unknown, use of the bundled infection prevention approach reduced the incidence to 0 for the first 12 months after implementation.
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Affiliation(s)
- Maren Downing
- WakeMed Health and Hospitals, Raleigh, NC
- Campbell University School of Osteopathic Medicine, Lillington, NC
| | - Michael Modrow
- WakeMed Health and Hospitals, Raleigh, NC
- Department of Cardiovascular and Thoracic Surgery, WakeMed Heart and Vascular, Raleigh, NC
| | - Kelly A. Thompson-Brazill
- WakeMed Health and Hospitals, Raleigh, NC
- Department of Cardiovascular and Thoracic Surgery, WakeMed Heart and Vascular, Raleigh, NC
| | - J. Erin Ledford
- WakeMed Health and Hospitals, Raleigh, NC
- Department of Cardiovascular and Thoracic Surgery, WakeMed Heart and Vascular, Raleigh, NC
| | - Charles D. Harr
- WakeMed Health and Hospitals, Raleigh, NC
- Department of Cardiovascular and Thoracic Surgery, WakeMed Heart and Vascular, Raleigh, NC
| | - Judson B. Williams
- WakeMed Health and Hospitals, Raleigh, NC
- Department of Cardiovascular and Thoracic Surgery, WakeMed Heart and Vascular, Raleigh, NC
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Okwose NC, Russell SL, Rahman M, Steward CJ, Harwood AE, McGregor G, Ninkovic S, Maddock H, Banerjee P, Jakovljevic DG. Validity and reliability of short-term heart-rate variability from disposable electrocardiography leads. Health Sci Rep 2023; 6:e984. [PMID: 36514326 PMCID: PMC9731360 DOI: 10.1002/hsr2.984] [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: 08/03/2022] [Revised: 11/21/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022] Open
Abstract
Background and Aims Single-use electrocardiography (ECG) leads have been developed to reduce healthcare-associated infection. This study compared the validity and reliability of short-term heart rate variability (HRV) obtained from single-use disposable ECG leads. Methods Thirty healthy subjects (33 ± 10 years; 9 females) underwent 5-min resting HRV assessments using disposable (single use) ECG cable and wire system (Kendall DL™ Cardinal Health) and a standard, reusable ECG leads (CardioExpress, Spacelabs Healthcare). Results Intraclass correlation coefficient (ICC) with 95% confidence interval (CI) between disposable and reusable ECG leads was for the time domain [R-R interval (ms); 0.99 (0.91, 1.00)], the root mean square of successive normal R-R interval differences (RMSSD) (ms); 0.91 (0.76, 0.96), the SD of normal-to-normal R-R intervals (SDNN) (ms); 0.91 (0.68, 0.97) and frequency domain [low-frequency (LF) normalized units (nu); 0.90 (0.79, 0.95), high frequency (HF) nu; 0.91 (0.80, 0.96), LF power (ms2); 0.89 (0.62, 0.96), HF power (ms2); 0.90 (0.72, 0.96)] variables. The mean difference and upper and lower limits of agreement between disposable and reusable leads for time- and frequency-domain variables were acceptable. Analysis of repeated measures using disposable leads demonstrated excellent reproducibility (ICC 95% CI) for R-R interval (ms); 0.93 (0.85, 0.97), RMSSD (ms); 0.93 (0.85, 0.97), SDNN (ms); 0.88 (0.75, 0.95), LF power (ms2); 0.87 (0.72, 0.94), and HF power (ms2); 0.88 (0.73, 0.94) with coefficient of variation ranging from 2.2% to 5% (p > 0.37 for all variables). Conclusion Single-use Kendall DL™ ECG leads demonstrate a valid and reproducible tool for the assessment of HRV.
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Affiliation(s)
- Nduka C Okwose
- Cardiovascular and Lifestyle Medicine Research Theme, Faculty Research Centre (CSELS), Institute for Health and Wellbeing Coventry University Coventry UK.,Department of Cardiology University Hospitals Coventry and Warwickshire NHS Trust Coventry UK
| | - Sophie L Russell
- Cardiovascular and Lifestyle Medicine Research Theme, Faculty Research Centre (CSELS), Institute for Health and Wellbeing Coventry University Coventry UK.,Department of Cardiology University Hospitals Coventry and Warwickshire NHS Trust Coventry UK
| | - Mushidur Rahman
- Cardiovascular and Lifestyle Medicine Research Theme, Faculty Research Centre (CSELS), Institute for Health and Wellbeing Coventry University Coventry UK.,Department of Cardiology University Hospitals Coventry and Warwickshire NHS Trust Coventry UK
| | - Charles J Steward
- Cardiovascular and Lifestyle Medicine Research Theme, Faculty Research Centre (CSELS), Institute for Health and Wellbeing Coventry University Coventry UK
| | - Amy E Harwood
- Cardiovascular and Lifestyle Medicine Research Theme, Faculty Research Centre (CSELS), Institute for Health and Wellbeing Coventry University Coventry UK.,Department of Cardiology University Hospitals Coventry and Warwickshire NHS Trust Coventry UK
| | - Gordon McGregor
- Cardiovascular and Lifestyle Medicine Research Theme, Faculty Research Centre (CSELS), Institute for Health and Wellbeing Coventry University Coventry UK.,Department of Cardiology University Hospitals Coventry and Warwickshire NHS Trust Coventry UK
| | - Srdjan Ninkovic
- Department of Surgery, Clinical Centre, Faculty of Medical Sciences University of Kragujevac Kragujevac Serbia
| | - Helen Maddock
- Cardiovascular and Lifestyle Medicine Research Theme, Faculty Research Centre (CSELS), Institute for Health and Wellbeing Coventry University Coventry UK
| | - Prithwish Banerjee
- Cardiovascular and Lifestyle Medicine Research Theme, Faculty Research Centre (CSELS), Institute for Health and Wellbeing Coventry University Coventry UK.,Department of Cardiology University Hospitals Coventry and Warwickshire NHS Trust Coventry UK
| | - Djordje G Jakovljevic
- Cardiovascular and Lifestyle Medicine Research Theme, Faculty Research Centre (CSELS), Institute for Health and Wellbeing Coventry University Coventry UK.,Department of Cardiology University Hospitals Coventry and Warwickshire NHS Trust Coventry UK
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Saunders R, Hansson Hedblom A. The Economic Implications of Introducing Single-Patient ECG Systems for Cardiac Surgery in Australia. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:727-735. [PMID: 34413659 PMCID: PMC8370584 DOI: 10.2147/ceor.s325257] [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: 06/22/2021] [Accepted: 07/26/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Sternal wound infections (SWIs) are severe adverse events of cardiac surgery. This study aimed to estimate the economic burden of SWIs following coronary artery bypass grafts (CABG) in Australia. It also aimed to estimate the national and hospital cost-benefit of adopting single-patient electrocardiograph (spECG) systems for CABG monitoring, a measure that reduces the rate of surgical site infections (SSIs). Material and Methods A literature review, which focused on CABG-related SSIs, was conducted to identify data which were then used to adapt a published Markov cost-effectiveness model. The model adopted an Australian hospital perspective. Results The average SWI-related cost of care increase per patient was estimated at 1022 Australian dollars (AUD), and the annual burden to the Australian health care system at AUD 9.2 million. SWI burden comprised 360 additional intensive care unit (ICU) days; 1979 additional general ward (GW) days; and 186 readmissions. Implementing spECG resulted in 103 fewer ICU days, 565 fewer GW days, 48 avoided readmissions, and a total national cost saving of AUD 2.5 million, annually. A hospital performing 200 yearly CABGs was estimated to save AUD 54,830. Conclusion SWIs cause substantial costs to the Australian health care system. Implementing new technologies shown to reduce the SWI rate is likely to benefit patients and reduce costs.
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Saunders R, Lankiewicz J. The Cost Effectiveness of Single-Patient-Use Electrocardiograph Cable and Lead Systems in Monitoring for Coronary Artery Bypass Graft Surgery. Front Cardiovasc Med 2019; 6:61. [PMID: 31134212 PMCID: PMC6523521 DOI: 10.3389/fcvm.2019.00061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 04/25/2019] [Indexed: 01/08/2023] Open
Abstract
Background: During admission for coronary artery bypass graft (CABG) surgery patients receive electrocardiograph (ECG) monitoring; for which reusable ECG cable and leads (rECG) are standard. Objective: Evaluate the cost effectiveness of a single-patient-use ECG cable and lead system (spECG). Methods: Review of the Medicare 2011-2014 database followed by a cost-effectiveness model considering a Medicare facility transitioning from rECG ($9 per patient) to spECG ($15). In-hospital ECG monitoring was for ≤8 days. In the model, patients underwent CABG and recovered in the intensive care unit, before transfer to the general ward and discharge. Surgical site infection (SSI) resulted in increased length of stay, readmission, or outpatient care. Health outcomes impacted EQ-5D-measured quality adjusted life years (QALYs). Health and cost outcomes were discounted at 3.5% annually. All costs in 2016 USD. Significance (95% level) was assessed via 2,000 simulations. Results: In 2014, 5.49% of patients had an SSI by 90-days post-surgery, with spECG reducing the odds of an SSI (odds ratio: 0.74, 0.62-0.89). Mean 40-year, per-patient costs to Medicare were $65,497 with rECG and $65,048 with spECG. The $450 saving was significant, with a median (95% credible interval) reduction of $466 ($174 to $989). Cost drivers were days required to treat inpatient SSIs. QALYs increases with spECG were significant but minor (median increase 0.008). Medicare savings may total $40 million per year with use of spECG. Conclusions: Post-operative SSI is a concern for Medicare patients undergoing CABG, and use of spECG is likely to provide cost and patient benefits.
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Nandy P, Lucas AD, Gonzalez EA, Hitchins VM. Efficacy of commercially available wipes for disinfection of pulse oximeter sensors. Am J Infect Control 2016; 44:304-10. [PMID: 26589998 DOI: 10.1016/j.ajic.2015.09.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 09/23/2015] [Accepted: 09/24/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study examined the effectiveness of commercially available disinfecting wipes and cosmetic wipes in disinfecting pulse oximeter sensors contaminated with pathogenic bacterial surrogates. METHODS Surrogates of potential biological warfare agents and bacterial pathogens associated with hospital-acquired infections (HAIs) were spotted on test surfaces, with and without an artificial test soil (sebum), allowed to dry, and then cleaned with different commercially available cleaning and disinfecting wipes or sterile gauze soaked in water, bleach (diluted 1:10), or 70% isopropanol. The percentage of microbial survival and an analytical estimation of remaining test soil on devices were determined. RESULTS Wipes containing sodium hypochlorite as the active ingredient and gauze soaked in bleach (1:10) were the most effective in removing both vegetative bacteria and spores. In the presence of selective disinfectants, sebum had a protective effect on vegetative bacteria, but not on spores. CONCLUSIONS The presence of sebum reduces the cleaning efficiency of some commercially available wipes for some select microbes. Various commercial wipes performed significantly better than the designated cleaning agent (70% isopropanol) in disinfecting the oximetry sensor. Cosmetic wipes were not more effective than the disinfecting wipes in removing sebum.
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Addison N, Quatrara B, Letzkus L, Strider D, Rovnyak V, Syptak V, Fuzy L. Cleanliness of disposable vs nondisposable electrocardiography lead wires in children. Am J Crit Care 2014; 23:424-8. [PMID: 25179038 DOI: 10.4037/ajcc2014601] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Mediastinitis costs hospitals thousands of dollars a year and increases the incidence of patient morbidity and mortality. No studies have been done to evaluate adenosine triphosphate (ATP) counts on disposable and nondisposable electrocardiography (ECG) lead wires in pediatric patients. OBJECTIVE To compare the cleanliness of disposable and nondisposable ECG lead wires in postoperative pediatric cardiac surgery patients by measuring the quantity of ATP (in relative luminescence units [RLUs]). ATP levels correlate with microbial cell counts and are used by institutions to assess hospital equipment and cleanliness. METHODS A prospective, randomized trial was initiated with approval from the institutional review board. Verbal consent was obtained from the parents/guardians for each patient. Trained nurses performed ATP swabs on the right and left upper ECG cables on postoperative days 1, 2, and 3. RESULTS This study enrolled 51 patients. The disposable ECG lead wire ATP count on postoperative day 1 (median, 157 RLUs) was significantly lower (P < .001) than the count for nondisposable ATP lead wires (median, 610 RLUs). On postoperative day 2, the ATP count for the disposable ECG lead wires (median, 200 RLUs) was also lower (P = .06) than the count for the nondisposable ECG lead wires (median, 453 RLUs). CONCLUSION Results of this study support the use of disposable ECG lead wires in postoperative pediatric cardiac surgery patients for at least the first 48 hours as a direct strategy to reduce the ATP counts on ECG lead wires.
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Affiliation(s)
- Nancy Addison
- Nancy Addison is a research nurse clinician in the pediatric intensive care unit, Beth Quatrara is director and Lisa Letzkus is assistant director of nursing research for the medical center, David Strider is a nurse practitioner at the medical center, Virginia Rovnyak is a statistician at the school of nursing, and Virginia Syptak and Lisa Fuzy are nurse clinicians in the pediatric intensive care unit. All are employed at the University of Virginia Health System in Charlottesville
| | - Beth Quatrara
- Nancy Addison is a research nurse clinician in the pediatric intensive care unit, Beth Quatrara is director and Lisa Letzkus is assistant director of nursing research for the medical center, David Strider is a nurse practitioner at the medical center, Virginia Rovnyak is a statistician at the school of nursing, and Virginia Syptak and Lisa Fuzy are nurse clinicians in the pediatric intensive care unit. All are employed at the University of Virginia Health System in Charlottesville
| | - Lisa Letzkus
- Nancy Addison is a research nurse clinician in the pediatric intensive care unit, Beth Quatrara is director and Lisa Letzkus is assistant director of nursing research for the medical center, David Strider is a nurse practitioner at the medical center, Virginia Rovnyak is a statistician at the school of nursing, and Virginia Syptak and Lisa Fuzy are nurse clinicians in the pediatric intensive care unit. All are employed at the University of Virginia Health System in Charlottesville
| | - David Strider
- Nancy Addison is a research nurse clinician in the pediatric intensive care unit, Beth Quatrara is director and Lisa Letzkus is assistant director of nursing research for the medical center, David Strider is a nurse practitioner at the medical center, Virginia Rovnyak is a statistician at the school of nursing, and Virginia Syptak and Lisa Fuzy are nurse clinicians in the pediatric intensive care unit. All are employed at the University of Virginia Health System in Charlottesville
| | - Virginia Rovnyak
- Nancy Addison is a research nurse clinician in the pediatric intensive care unit, Beth Quatrara is director and Lisa Letzkus is assistant director of nursing research for the medical center, David Strider is a nurse practitioner at the medical center, Virginia Rovnyak is a statistician at the school of nursing, and Virginia Syptak and Lisa Fuzy are nurse clinicians in the pediatric intensive care unit. All are employed at the University of Virginia Health System in Charlottesville
| | - Virginia Syptak
- Nancy Addison is a research nurse clinician in the pediatric intensive care unit, Beth Quatrara is director and Lisa Letzkus is assistant director of nursing research for the medical center, David Strider is a nurse practitioner at the medical center, Virginia Rovnyak is a statistician at the school of nursing, and Virginia Syptak and Lisa Fuzy are nurse clinicians in the pediatric intensive care unit. All are employed at the University of Virginia Health System in Charlottesville
| | - Lisa Fuzy
- Nancy Addison is a research nurse clinician in the pediatric intensive care unit, Beth Quatrara is director and Lisa Letzkus is assistant director of nursing research for the medical center, David Strider is a nurse practitioner at the medical center, Virginia Rovnyak is a statistician at the school of nursing, and Virginia Syptak and Lisa Fuzy are nurse clinicians in the pediatric intensive care unit. All are employed at the University of Virginia Health System in Charlottesville
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Blot S, Afonso E, Labeau S. Insights and advances in multidisciplinary critical care: a review of recent research. Am J Crit Care 2014; 23:70-80. [PMID: 24382619 DOI: 10.4037/ajcc2014403] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The intensive care unit is a work environment where superior dedication is pivotal to optimize patients' outcomes. As this demanding commitment is multidisciplinary in nature, it requires special qualities of health care workers and organizations. Thus research in the field covers a broad spectrum of activities necessary to deliver cutting-edge care. However, given the abundance of research articles and education activities available, it is difficult for modern critical care clinicians to keep up with the latest progress and innovations in the field. This article broadly summarizes new developments in multidisciplinary intensive care, providing elementary information about advanced insights in the field by briefly describing selected articles bundled in specific topics. Issues considered include cardiovascular care, monitoring, mechanical ventilation, infection and sepsis, nutrition, education, patient safety, pain assessment and control, delirium, mental health, ethics, and outcomes research.
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Affiliation(s)
- Stijn Blot
- Stijn Blot is a professor in the Department of Internal Medicine, Faculty of Medicine and Health Science, Ghent University, Belgium. Elsa Afonso is a research nurse and clinical trial coordinator, CIBERES, Barcelona, Spain. Sonia Labeau is a lecturer in the Faculty of Education, Health and Social Work, University College Ghent, Belgium
| | - Elsa Afonso
- Stijn Blot is a professor in the Department of Internal Medicine, Faculty of Medicine and Health Science, Ghent University, Belgium. Elsa Afonso is a research nurse and clinical trial coordinator, CIBERES, Barcelona, Spain. Sonia Labeau is a lecturer in the Faculty of Education, Health and Social Work, University College Ghent, Belgium
| | - Sonia Labeau
- Stijn Blot is a professor in the Department of Internal Medicine, Faculty of Medicine and Health Science, Ghent University, Belgium. Elsa Afonso is a research nurse and clinical trial coordinator, CIBERES, Barcelona, Spain. Sonia Labeau is a lecturer in the Faculty of Education, Health and Social Work, University College Ghent, Belgium
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