Effect of Education on the Rate of and the Understanding of Risk Factors for Intravascular Catheter–Related Infections

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of a comprehensive care bundle educational program on device-associated infections in an emergency intensive care unit

Introduction

Implementation of care bundles was shown to reduce the incidence of device-associated infections (DAIs). Substantial improvements in the rate of infection have been achieved by applying educational programs for infection control. Objectives: To demonstrate the impact of a comprehensive care bundle educational program (CCBEP) on DAIs, mortality rates in an emergency Intensive Care Unit (ICU), and improving healthcare workers (HCWs') knowledge, compliance to care bundle, and infection control practice.

Methods

A quasi-experimental study was carried out in an 15-beds emergency ICU, from May 2017 to October 2018. A comprehensive care bundle educational program was implemented. It covers items regarding device care bundle and infection control.

Results

Device care bundle compliance was variable between different bundle items. There was a significant improvement in HCWs' knowledge after the educational program intervention especially in hand hygiene, catheter-associated urinary tract infection (CAUTI) bundle, and total knowledge. There was a higher risk of ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLABSI), and CAUTI in the pre-intervention phase compared to post-intervention (RR: 1.4, 1.4, and 1.9 respectively). The total mortality rate decreased from 24.2/100 to 16.7/100 patients after intervention.

Conclusions

There was a statistically significant improvement in compliance with device care bundles with a decrease in the incidence of DAIs.

Care bundle approach to reduce device-associated infections in a tertiary care teaching hospital, South India

CONTEXT:

The care bundle approach is a set of evidence-based practices that when performed collectively and reliably have been shown to improve the patient outcome.

AIMS:

To evaluate the impact of the bundle care approach on reducing device-associated infections (DAIs).

SETTINGS AND DESIGN:

The study was conducted at a tertiary care hospital, South India. The study period was from January 2016 to September 2016 which was divided into three phases, each comprising 3 months.

SUBJECTS AND METHODS:

During the implementation phase, bundle care forms were implemented in all Intensive Care Units (ICUs) and the ICU staff were given a basic education on the importance of bundle care approach. The DAI rates (ventilator-associated pneumonia [VAP] rates, central line-associated bloodstream infection [CLABSI] rate, and catheter-associated urinary tract infection [CAUTI] rate) were calculated throughout the study period.

STATISTICAL ANALYSIS USED:

Statistical analysis was performed using SPSS 19 software.

RESULTS:

During preimplementation phase, the VAP rate, CLABSI rate, and CAUTI rate were 14.79, 4.98, and 4.86 per 1000 device days, respectively. Rates were reduced to 13.03, 3.98, and 3.39 per 1000 device days, respectively, during the implementation phase and further reduced into 11.91, 3.49, and 2.36 per 1000 device days during the postimplementation phase. The month-wise decreasing trend of DAI rates was significant for medical ICUs as compared to surgical and pediatric ICUs.

CONCLUSIONS:

The month-wise decreasing trend of VAP rate, CLABSI rate, and CAUTI rate was noted, which signifies that the use of care bundle approach has a great impact on reducing DAIs

Impact of Nursing Education on CLABSI Rates: An Experience from a Tertiary Care Hospital in Eastern India

BACKGROUND AND AIMS

Central line associated bloodstream infections (CLABSI) have a higher incidence in the intensive care units of developing countries.

MATERIALS AND METHODS

The baseline CLABSI rate in intensive care unit (ICU) was evaluated for 6 months. An educational program for nurses on basic hand hygiene steps was conducted. Objective assessment tests were done to assess their knowledge and percentage of non-compliance with hand hygiene practice. CLABSI rate over the post-intervention 6 month period was assessed.

RESULTS

Thirty-four nurses were enrolled. The pre-intervention CLABSI rate was 12.5 per 1000 catheter days, pretest score 15.9 +/- 3.35 and 53.4% opportunities for hand hygiene were missed. Post workshop, there was significant (p=0.02) decrease in CLABSI rate i.e. 8.6, improvement in test score 17.76 +/- 2.1 (p=0.011) and missed opportunities decreased to 33.75%. 6 months post intervention, percentage of noncompliance with hand hygiene practice were 51.75% and test score was 17 ± 2.

DISCUSSION

The effectiveness of educational program on hand hygiene compliance was reflected in the improvement of posttest score, reduced number of missed opportunities and reduction of CLABSI rates in ICU. The posttest scores and hand hygiene compliance, however, decreased 6 months post-intervention necessitating repeated feedbacks and reminders.

CONCLUSION

Educational interventions on hand hygiene can have a significant impact in CLABSI control particularly in ICUs with a high infection rate and resource constraints.

HOW TO CITE THIS ARTICLE

Acharya Ranjita, Mishra SB, Ipsita S, Azim A. Impact of Nursing Education on CLABSI Rates: An Experience from a Tertiary Care Hospital in Eastern India. Indian J Crit Care Med 2019;23(7):316-319.

Reassessing standards of vascular access device care: a follow-up audit

This article reports on the findings of a repeat audit of vascular access devices (VADs) in a district general hospital undertaken 4 years after a previous audit. The first demonstrated poor standards of care and low compliance with evidence-based guidelines, indicating that a change in practice was necessary. A strategy of training, education and standardisation for intravenous devices was introduced, with the goal of transforming practice to raise standards and improve compliance. The findings of the follow-up audit show that the strategy has been successful in raising standards of care and reducing infections.

A New Central venous Catheter Cap: Decreased Microbial Growth and Risk for Catheter-Related Bloodstream Infection

Objective

Catheter-related blood stream infection (CRBI) is a major cause of morbidity and mortality, and is a source of significant healthcare expenditures in patients that require central venous catheters for intravenous nutrition, chemotherapy, and other products. The source of many catheter-related infections is contamination of the catheter hub. Herein an antimicrobial catheter cap, the AB Cap is described.

Methods

The AB Cap device is a catheter cleaning device designed to keep needleless luer valves clean by encapsulating them in a cleaning solution. This device was evaluated using an in vitro model of hub contamination with Staphylococcus aureus, Staphylococcus epidermidis (S. epidermidis), Klebsiella pneumonia (K. pneumonia), Pseudomonas aeruginosa, Escherichia coli and Candida albicans (C. albicans). Following hub contamination on days 1, 3, 5 and 7, saline was infused through the AB Cap and effluent collected from the efferent end. The effluent fluid was cultured for the index organisms, and allowed to incubate in culture for up to 7 days. Negative control caps were not contaminated and positive controls lacked cleaning solution and were contaminated.

Results

Microbial growth developed for all index organisms, and generally within 1 day of culture growth following the first day of contamination (day 1) in effluent from all positive controls, while no growth occurred in effluent from negative controls. No growth of any organism occurred in any of the test items after the first day of contamination. Growth of three organisms was detected in two of the three test AB Caps following contamination day 3, after 1–4 days of incubation. All organisms could be cultured in the effluent from two of the three test items at contamination day 5, generally by the second day of incubation. One test item remained free of growth for the entire test period except for one organism. By day 7, this particular test item grew an additional organism and the testing was concluded. All positive growth test items remained positive on subsequent inoculations during culture of newly obtained effluent with the exception of test item A, from which effluent following inoculation on day 3 showed growth of S. epidermidis and K. pneumonia, but no growth for these organisms from effluent obtained on inoculation day 5. In addition, effluent from test item C showed growth of C. albicans from inoculation day 5, but no growth from effluent obtained on inoculation day 7. The growth of S. epidermidis from effluent of test item A from the day 3 inoculation, and C. albicans from effluent of test items B and C did not occur until day 4 of incubation, suggesting a very small amount of contamination.

Conclusion

An antimicrobial catheter cap is not a complete substitute for a proper catheter cleaning technique and other anti-infection precautions. However, we describe a unique catheter cap that significantly decreased the likelihood of a catheter-related infection from a non-cleaned cap in an in vitro model.

Evaluation the effectiveness of an educational intervention to decrease central line-associated bloodstream infections among hemodialysis patients

The study aimed to compare the rates of central line-associated bloodstream infection (CLABSI) for all hemodialysis patients with a central catheter across the majority of Shariati hospital wards during a 6-month, 2-phase, before-and-after intervention. The median rate of CLABSI decreased from 18.1% at baseline to 6.5% after implementation of the intervention (64% reduction in CLABSI rate) (P = .002). The data analysis indicated that providing intensive training can positively influence the control of CLABSI in large teaching hospitals.

Poor adherence to guidelines for preventing central line-associated bloodstream infections (CLABSI): results of a worldwide survey

Background

Central line-associated bloodstream infections (CLABSI) are a cause of increased morbidity and mortality, and are largely preventable. We documented attitudes and practices in intensive care units (ICUs) in 2015 in order to assess compliance with CLABSI prevention guidelines.

Methods

Between June and October 2015, an online questionnaire was made available to medical doctors and nurses working in ICUs worldwide. We investigated practices related to central line (CL) insertion, maintenance and measurement of CLABSI-related data following the SHEA guidelines as a standard. We computed weighted estimates for high, middle and low-income countries using country population as a weight. Only countries providing at least 10 complete responses were included in these estimates.

Results

Ninety five countries provided 3407 individual responses; no low income, 14 middle income (MIC) and 27 high income (HIC) countries provided 10 or more responses. Of the total respondents, 80% (MIC, SE = 1.5) and 81% (HIC, SE = 1.0) reported availability of written clinical guidelines for CLABSI prevention in their ICU; 23% (MIC,SE = 1.7) and 62% (HIC,SE = 1.4) reported compliance to the following (combined) recommendations for CL insertion: hand hygiene, full barrier precaution, chlorhexidine >0.5%, no topic or systemic antimicrobial prophylaxis; 60% (MIC,SE = 2.0) and 73% (HIC,SE = 1.2) reported daily assessment for the need of a central line. Most considered CLABSI measurement key to quality improvement, however few were able to report their CLABSI rate. Heterogeneity between countries was high and country specific results are made available.

Conclusions

This study has identified areas for improvement in CLABSI prevention practices linked to CL insertion and maintenance. Priorities for intervention differ between countries.

Electronic supplementary material

The online version of this article (doi:10.1186/s13756-016-0139-y) contains supplementary material, which is available to authorized users.

Central line-associated bloodstream infections in the intensive care unit: importance of the care bundle

Background

The importance and efficacy of a care bundle for preventing central line-associated bloodstream infections (CLABSIs) and infectious complications related to placing a central venous catheter (CVC) in patients in the intensive care unit (ICU).

Methods

A care bundle was implemented from July 2013 to June 2014 in a medical ICU and surgical ICU. Data were divided into three periods: the prior period (July 2012–June 2013), the intervention period (July 2013–June 2014; first and second periods), and the post-intervention period (July 2014–December 2014; third period). A care bundle consisting of optimal hand hygiene, skin antisepsis with chlorhexidine (2%) allowing the skin to dry, maximal barrier precautions for inserting a catheter (sterile gloves, gown, mask, and drapes), choice of optimal insertion site, prompt catheter removal, and daily evaluation of the need for the CVC was introduced.

Results

The catheterization duration was longer and femoral access was more frequently observed in patients with CLABSIs. CLABSI rates decreased with use of the care bundle. The CLABSI rate in the medical ICU was 6.20/1,000 catheter days during the prior period, 3.88/1,000 catheter days during the intervention period, and 1.05/1,000 catheter days during the third period. The CLABSI rate in the surgical ICU was 8.27/1,000, 4.60/1,000, and 3.73/1,000 catheter days during these three periods, respectively.

Conclusions

The choice of an optimal catheter insertion site, use of all barrier precautions, and removal of catheters when they are no longer needed are essential to decrease the CLABSI rate.

Defining the Specialty of Vascular Access through Consensus: Shaping the Future of Vascular Access

The Association for Vascular Access (AVA) is an organization of health care professionals founded in 1985 to support and promote the specialty of vascular access. The mission of AVA is to distinguish the vascular access specialty and define standards of vascular access through an evidence-based approach designed to enhance health care. There is little guidance for multidisciplinary procedures/practice, and this is the case for vascular access. There are also inconsistencies and conflicts in terminology. Additionally, there is no consensus of vascular access as a specialty. It is the focus of AVA to promote consistency in vascular access practice. This document embraces a common title for a clinician with knowledge and skills in the area of vascular access. This establishes a new paradigm that will strengthen the advancement of the vascular access specialty.

The Effect of a Freely Available Flipped Classroom Course on Health Care Worker Patient Safety Culture: A Prospective Controlled Study

Background

Patient safety culture is an integral aspect of good standard of care. A good patient safety culture is believed to be a prerequisite for safe medical care. However, there is little evidence on whether general education can enhance patient safety culture.

Objective

Our aim was to assess the impact of a standardized patient safety course on health care worker patient safety culture.

Methods

Health care workers from Intensive Care Units (ICU) at two hospitals (A and B) in Hong Kong were recruited to compare the changes in safety culture before and after a patient safety course. The BASIC Patient Safety course was administered only to staff from Hospital A ICU. Safety culture was assessed in both units at two time points, one before and one after the course, by using the Hospital Survey on Patient Safety Culture questionnaire. Responses were coded according to the Survey User’s Guide, and positive response percentages for each patient safety domain were compared to the 2012 Agency for Healthcare Research and Quality ICU sample of 36,120 respondents.

Results

We distributed 127 questionnaires across the two hospitals with an overall response rate of 74.8% (95 respondents). After the safety course, ICU A significantly improved on teamwork within hospital units (P=.008) and hospital management support for patient safety (P<.001), but decreased in the frequency of reporting mistakes compared to the initial survey (P=.006). Overall, ICU A staff showed significantly greater enhancement in positive responses in five domains than staff from ICU B. Pooled data indicated that patient safety culture was poorer in the two ICUs than the average ICU in the Agency for Healthcare Research and Quality database, both overall and in every individual domain except hospital management support for patient safety and hospital handoffs and transitions.

Conclusions

Our study demonstrates that a structured, reproducible short course on patient safety may be associated with an enhancement in several domains in ICU patient safety culture.

Cost Attributable to Nosocomial Bacteremia. Analysis According to Microorganism and Antimicrobial Sensitivity in a University Hospital in Barcelona

AIM

To calculate the incremental cost of nosocomial bacteremia caused by the most common organisms, classified by their antimicrobial susceptibility.

METHODS

We selected patients who developed nosocomial bacteremia caused by Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, or Pseudomonas aeruginosa. These microorganisms were analyzed because of their high prevalence and they frequently present multidrug resistance. A control group consisted of patients classified within the same all-patient refined-diagnosis related group without bacteremia. Our hospital has an established cost accounting system (full-costing) that uses activity-based criteria to analyze cost distribution. A logistic regression model was fitted to estimate the probability of developing bacteremia for each admission (propensity score) and was used for propensity score matching adjustment. Subsequently, the propensity score was included in an econometric model to adjust the incremental cost of patients who developed bacteremia, as well as differences in this cost, depending on whether the microorganism was multidrug-resistant or multidrug-sensitive.

RESULTS

A total of 571 admissions with bacteremia matched the inclusion criteria and 82,022 were included in the control group. The mean cost was € 25,891 for admissions with bacteremia and € 6,750 for those without bacteremia. The mean incremental cost was estimated at € 15,151 (CI, € 11,570 to € 18,733). Multidrug-resistant P. aeruginosa bacteremia had the highest mean incremental cost, € 44,709 (CI, € 34,559 to € 54,859). Antimicrobial-susceptible E. coli nosocomial bacteremia had the lowest mean incremental cost, € 10,481 (CI, € 8,752 to € 12,210). Despite their lower cost, episodes of antimicrobial-susceptible E. coli nosocomial bacteremia had a major impact due to their high frequency.

CONCLUSIONS

Adjustment of hospital cost according to the organism causing bacteremia and antibiotic sensitivity could improve prevention strategies and allow their prioritization according to their overall impact and costs. Infection reduction is a strategy to reduce resistance.

Prevention of central venous catheter-associated bloodstream infections: A questionnaire evaluating the knowledge of the selected 11 evidence-based guidelines by Polish nurses

This study evaluated the questionnaire testing nurses' knowledge about the maintenance of a central venous catheter (CVC) and assessed it with regard to age, work experience, type of ward, frequency of trainings, and postgraduate education. There were 1,180 questionnaires (N = 784; 66.4% of the total sample) distributed in several regions of Poland for a period of 7 months. The difficulty level for each question ranged from 0.22-0.88.

The Impact of Implementation of Bundle to Reduce Catheter-Related Bloodstream Infection Rates

Background

The aim of the study was to investigate how control bundles reduce the rate of central venous catheter-associated bloodstream infections (CVC-BSIs) rates in critically ill patients.

Methods

This is a prospective before-and-after study designed to evaluate whether a set of control measures (bundle) can help prevent CVC-BSI. The bundles included a checklist that aimed to correct practices related to CVC insertion, manipulation, and maintenance based on guidelines of the Center for Disease Control and Prevention (CDC).

Results

We examined 123 checklists before and 155 checklists after implementation of the training program. Compared with the pre-intervention period, CVC-BSI rates decreased. Hand hygiene techniques were used correctly. CVC-BSI incidence was 9.3 and 5.1 per 1,000 catheter-days before and after the training program, respectively.

Conclusions

The implementation of a bundle and training program effectively reduces CVC-BSI rates.

Role of research in best practices

Evidence based care (EBP) is imperative to the promotion of best practices. EBP forms the foundation for safe, efficient, and cost-effective patient management. It gives nurses the ability to implement care activities with proved outcomes and validate interventions from a database of sources. EBP not only has an impact on nursing practice but also affects theoretic models and care frameworks. It forms a foundation for professional care activities that use grounded protocols and guidelines and nursing education. This article includes resources to promote continued use of research evidence to guide in patient care areas.

Carbapenem-resistant Pseudomonas aeruginosa in Taiwan: Prevalence, risk factors, and impact on outcome of infections

BACKGROUND

The prevalence and clinical impact on mortality of carbapenem-resistant Pseudomonas aeruginosa (CRPA) is unclear in Taiwan. We aim to clarify these clinical issues by using data from the Taiwan Surveillance of Antimicrobial Resistance (TSAR) program.

METHODS

Patients from five hospitals with their P. aeruginosa isolates collected by TSAR II-VII (2000-2010) program were considered as the potential study population. All patients with CRPA were enrolled as case patients. Patients with carbapenem-susceptible P. aeruginosa were randomly selected in a 1:1 ratio to case patients as control patients. CRPA isolates were tested for the presence of carbapenemase-producing genes. The clinical data were collected to identify risk factors for CRPA carriage and mortality of P. aeruginosa infection.

RESULTS

The overall prevalence of CRPA was 10.2% (349/3408), which increased significantly by the TSAR period (p = 0.007). Among the 164 enrolled patients, the risk factor for carrying CRPA was previous fluoroquinolone exposure (p = 0.004). The risk factors for mortality among 80 patients with infection by P. aeruginosa included: intensive care unit (ICU) setting, receipt of antifungal therapy, and presence of invasive devices (p = 0.001, 0.010, and 0.017; respectively). Carbapenem resistance did not play a role. Among the 82 CRPA isolates enrolled in this study, 15 isolates were found to carry carbapenemase-producing genes.

CONCLUSION

In Taiwan, the prevalence of CRPA and carriage of carbapenemase-producing genes was high. However, carbapenem resistance did not play a role in the mortality of patients with P. aeruginosa infections.

Measuring competence in central venous catheterization: a systematic-review

Objectives

Central venous catheterization is a complex procedural skill. This study evaluates existing published tools on this procedure and systematically summarizes key competencies for the assessment of this technical skill.

Methods

Using a previously published meta-analysis search strategy, we conducted a systematic review of published assessment tools using the electronic databases PubMed, MEDLINE, Education Resource Information Center (ERIC), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica, and Cochrane Central Register of Controlled Trials. Two independent investigators abstracted information on tool content and characteristics.

Results

Twenty-five studies were identified assessing a total of 147 items. Tools used for assessment at the bedside (clinical tools) had a higher % of items representing “preparation” and “infection control” than tools used for assessment using simulation (67 ± 26% vs. 32 ± 26%; p = 0.003 for “preparation” and 60 ± 41% vs. 11 ± 17%; p = 0.002 for “infection control”, respectively). Simulation tools had a higher % of items on “procedural competence” than clinical tools (60 ± 36% vs. 17 ± 15%; p = 0.002). Items in the domains of “Team working” and “Communication and working with the patient” were frequently under-represented.

Conclusion

This study presents a comprehensive review of existing checklist items for the assessment of central venous catheterization. Although many key competencies are currently assessed by existing published tools, some domains may be under-represented by select tools.

Electronic supplementary material

The online version of this article (doi:10.1186/2193-1801-3-33) contains supplementary material, which is available to authorized users.

Clinical epidemiology of central venous catheter-related bloodstream infections in an intensive care unit in China

BACKGROUND

Central venous catheters (CVCs) are universally used during the treatment of critically ill patients. Their use, however, is associated with a substantial infection risk. At present, there are few studies on catheter-related bloodstream infections (CRBSIs) that are comparable with international similar research. The aim of this study was to determine the rate, risk factors, and outcomes of CRBSIs in patients of an intensive care unit (ICU) in China.

METHODS

A prospective study was performed in the Affiliated Shengjing Hospital of China Medical University. All patients admitted to the ICU from June 2007 to May 2008 who had a central line placed were monitored for the development of BSI from insertion until 48 hours after removal. One hundred seventy-four patients with 178 admissions to the ICU, 219 CVCs and 1913 CVC days, 21 episodes of CRBSI in 21 patients were enrolled.

RESULTS

The mean rate of CRBSI was 11.0 per 1000 CVC days with a catheter utilization rate of 72.8%. Analyses of the pathogens showed that gram-negative organisms were predominant. The univariate analysis showed that 3 things seemed to directly impact the occurrences of CRBSI. These were the number of lines insertion, the applications of antibiotics before CRBSI, and the duration of catheter. In a multiple logistic regression analysis of the risk factors, patients with multiple central lines (odds ratio = 5.981; 95% confidence intervals, 1.660-21.547; P = .006) and with the applications of multiple antibiotics before CRBSI (odds ratio = 6.335; 95% confidence interval, 2.001-20.054; P = .002) were more likely to develop CRBSI.

CONCLUSIONS

The CRBSI rate in our ICU is higher compared with that reported by the National Nosocomial Infection Surveillance and was associated with the applications of antibiotics before CRBSI and with the number of placed CVCs. Catheter-related bloodstream infections may be associated with a higher mortality rate and a higher incidence of ventilator-associated pulmonitis, which might lead to an increase in the total costs and medicine expenditures.

A Crossover Randomized Prospective Pilot Study Evaluating a Central Venous Catheter Team in Reducing Catheter-Related Bloodstream Infections in Pediatric Oncology Patients

Background: Treatment for most children with cancer includes the use of a central venous catheter (CVC). CVCs provide reliable venous access for delivery of chemotherapy and supportive care. This advantage is mitigated by an increased risk of bloodstream infections (BSIs). Despite the ubiquitous use of CVCs, few prospective studies have been conducted to address infection prevention strategies in pediatric oncology patients. Design: Prospective, crossover pilot study of a CVC team intervention versus standard care. Setting: Two inpatient oncology units in a metropolitan children’s hospital. Patients: A total of 41 patients/135 admissions for the experimental unit (EU) and 41/129 admissions for the control unit (CU). Methods: Patients received a CVC blood draw bundle procedure by a CVC registered nurse (RN) team member (experimental intervention: EU) for 6 months and by the assigned bedside RN (standard care: CU) for 6 months. Feasibility of implementing a CVC RN team; a significant difference in CVC-related BSIs between the team intervention versus standard care and risk factors associated in the development of CVC-related BSIs were determined. Results: There were 7 CVC-related BSIs/1238 catheter days in the EU group (5.7/1000 catheter days) versus 3 CVC-related BSIs/1419 catheter days in the CU group (2.1/1000 catheter days; P = .97). Selected risk factors were not significantly associated with the development of a CVC-related BSI. Conclusions: A CVC team in the care of pediatric oncology patients is feasible; however, a larger cohort will be required to adequately determine the effectiveness of the team reducing CVC-related BSIs.

"Targeting to zero" in pediatric oncology: a review of central venous catheter-related bloodstream infections

Reducing or eliminating hospital acquired infections is a national quality of care priority. The majority of the 12,400 children diagnosed with cancer each year require long-term intravenous access to receive intensive and complex therapies. These children are at high risk for infection by nature of their disease and treatment, which often involves use of a central venous catheter (CVC). Throughout the nation, nurses assume frontline responsibility for safe, quality CVC care to minimize the risk of potentially life-threatening infections. Substantial financial and human costs are associated with CVC-related bloodstream infections, including prolonged hospital lengths of stay and increased care required to treat these infections. The purpose of this review of the literature is to summarize existing adult and pediatric data on CVC-related bloodstream infections and explore nursing models of CVC care that may improve pediatric oncology patient outcomes.

Culture Positivity of CVCs Used for TPN: Investigation of an Association with Catheter-Related Infection and Comparison of Causative Organisms between ICU and Non-ICU CVCs

A relationship between central venous catheter (CVC) tip colonisation and catheter-related blood-stream infection (CRBSI) has been suggested. We examined culture positivity of CVC tips (colonised and infected CVCs) in a total parenteral nutrition (TPN) population. Our aims were to define the relationship between culture positivity and CRBSI, and to compare causative organisms between culture positive and CRBSI CVCS, and between ward and ICU CVCs. All patients receiving TPN via non-tunnelled CVCs during the study (1997–2009) were included. All CVC tips were analysed. Data were collated contemporaneously. A TPN audit committee determined whether CVC tip culture positivity reflected colonisation/CRBSI using CDC criteria. 1,392 patients received TPN via 2,565 CVCs over 15,397 CVC days. 25.4% of CVCs tips were culture positive, of these 32% developed CRBSI. There was a nonsignificant trend of higher Gram negative Bacilli isolation in ICU CVCs (P = 0.1), ward CVCs were associated with higher rates of staphylococcal isolation (P = 0.01). A similar pattern of organisms were cultured from CRBSI and culture positive CVCs. The consistent relationship between CRBSI and culture positive CVCs, and similar pattern of causative organisms further supports an aetiological relationship between culture positive CVC tips and CRBSI, supporting the contention that CVC culture-positivity may be a useful surrogate marker for CRBSI rates.

Infection control practice in countries with limited resources

Nosocomial infections and their control are a world-wide challenge. The prevalence of nosocomial infections is generally higher in developing countries with limited resources than industrialized countries. In this paper we aimed to further explain the differences with regard to infection control challenges between Turkey, a country with "limited" resources, and the Netherlands, a country with "reasonable" resources. Infrastructure of hospitals, low compliance of hand hygiene, understaffing, overcrowding, heavy workload, misuse of personal protective equipments, late establishment of infection control programme are major problems in limited-resources countries. These problems cause high infection rates and spread of multi-drug resistant pathogens. To improve the control and prevention of infections in countries with limited resources, a multi-facet approach is needed.

[Results of a multidisciplinary and multifocal project to reduce bacteraemia caused by central venous catheters in non critical patients in a university hospital]

OBJECTIVE

To evaluate a multidisciplinary and multifocal intervention in order to reduce catheter related bloodstream infections (CRBI), based on previously identified risk factors in non-critical patients.

METHODS

A pre-post-intervention study, 2004-2006.

POPULATION

patients with a central venous catheter (CVC). The primary endpoint was the CRBI. Other studied variables were patient characteristics, insertion, maintenance and removal of the catheter. The intervention consisted of baseline knowledge and identifying risk factors. In a second period, there was specific training on these identified risk factors and communication of the results, monitoring and evaluation of the CVC inserted.

RESULTS

We analysed 175 and 200 CVC, respectively. The incidence of CRBI was 15.4% during the pre-intervention and 4.0% in the post-intervention period (P<.001). The incidence of BRC by CVC days in the first group was 8.8 infections 1.000 days of CVC and the second 2,3 (P=.0009). The multivariate analysis found an increased risk of CRBI during the first period (OR 4.32; 95% CI: 1.81-10.29) and the use of total parenteral nutrition (OR: 2.37; 95% CI: 1.10-5. 12).

CONCLUSION

The application of specific measures directed at all non-critical patients in the entire hospital and involving a large number of professionals has achieved a decrease incidence of 73.9% of CRBI. An acceptable incidence of CRBI was obtained, and, with the completion of the project together with a new awareness, the situation will continue to improve.

Anti-infective external coating of central venous catheters: a randomized, noninferiority trial comparing 5-fluorouracil with chlorhexidine/silver sulfadiazine in preventing catheter colonization

OBJECTIVE

The antimetabolite drug, 5-fluorouracil, inhibits microbial growth. Coating of central venous catheters with 5-fluorouracil may reduce the risk of catheter infection. Our objective was to compare the safety and efficacy of central venous catheters externally coated with 5-fluorouracil with those coated with chlorhexidine and silver sulfadiazine.

DESIGN

Prospective, single-blind, randomized, active-controlled, multicentered, noninferiority trial.

SETTING

Twenty-five US medical center intensive care units.

PATIENTS

A total of 960 adult patients requiring central venous catheterization for up to 28 days.

INTERVENTIONS

Patients were randomized to receive a central venous catheter externally coated with either 5-fluorouracil (n = 480) or chlorhexidine and silver sulfadiazine (n = 480).

MEASUREMENTS AND MAIN RESULTS

The primary antimicrobial outcome was a dichotomous measure (<15 colony-forming units or ≥ 15 colony-forming units) for catheter colonization determined by the roll plate method. Secondary antimicrobial outcomes included local site infection and catheter-related bloodstream infection. Central venous catheters coated with 5-fluorouracil were noninferior to chlorhexidine and silver sulfadiazine coated central venous catheters with respect to the incidence of catheter colonization (2.9% vs. 5.3%, respectively). Local site infection occurred in 1.4% of the 5-fluorouracil group and 0.9% of the chlorhexidine and silver sulfadiazine group. No episode of catheter-related bloodstream infection occurred in the 5-fluorouracil group, whereas two episodes were noted in the chlorhexidine and silver sulfadiazine group. Only Gram-positive organisms were cultured from 5-fluorouracil catheters, whereas Gram-positive bacteria, Gram-negative bacteria, and Candida were cultured from the chlorhexidine and silver sulfadiazine central venous catheters. Adverse events were comparable between the two central venous catheter coatings.

CONCLUSIONS

Our results suggest that central venous catheters externally coated with 5-fluorouracil are a safe and effective alternative to catheters externally coated with chlorhexidine and silver sulfadiazine when used in critically ill patients.

Educational interventions to reduce the rate of central catheter-related bloodstream infections in the NICU: a review of the research literature

Catheter-related bloodstream infections (CR-BSIs) are a significant cause of morbidity and mortality in the NICU, occurring at rates ranging from 11.3 per 1,000 catheter days in infants <1,000 g to 4 per 1,000 catheter days in infants >2,500 g. Cost-effective and successful educational interventions aimed at nurses have been shown to decrease CR-BSIs with adults, but no such studies address neonatal nurses. This literature review examined how educational interventions could help neonatal nurses reduce infection rates in patients with central venous catheters. Four databases were searched: PubMed, CINAHL, Cochrane, and OVID. Of ten studies that measured CR-BSIs before and after educational interventions, nine showed a postintervention reduction in the rate of CR-BSIs of 40 percent or greater (eight demonstrating statistically significant reductions), and the tenth reported a reduction rate of 21 percent. All of the educational programs had additional intervention components, so it is not possible to ascribe all the success to the education, but this review suggests that this topic needs to be studied with the NICU population.

Analytic Reviews: Prevention of Central Venous Catheter Bloodstream Infections

The majority of nosocomial bloodstream infections in critically ill patients originate from an infected central venous catheter (CVC). Catheter-related bloodstream infections (CRBSIs) cause significant morbidity and mortality and increase the cost of care. The most frequent causative organisms for CRBSI are coagulase-negative staphylococci (CoNSs), Staphylococcus aureus, enterococci, and Candida species. The path to infection frequently includes migration of skin organisms at the insertion site into the cutaneous catheter tract, resulting in microbial colonization of the catheter tip and formation of biofilm. Evidence-based strategies for the prevention of CRBSI include behavioral and educational interventions, effective skin antisepsis coupled with maximum barrier precautions, the use of antiseptic dressings, and the use of antiseptic or antibiotic impregnated catheters. Achieving and maintaining very low rates of CRBSI requires a multidisciplinary approach involving the entire health care team, the use of novel technologies in patients with the highest risk of CRBSI, and frequent reeducation of staff.

What features of educational interventions lead to competence in aseptic insertion and maintenance of CV catheters in acute care? BEME Guide No. 15

BACKGROUND

Up to 6000 patients per year in England acquire a central venous catheter (CVC)-related bloodstream infection (Shapey et al. 2008 ). Implementation of Department of Health guidelines through educational interventions has resulted in significant and sustained reductions in CVC-related blood stream infections (Pronovost et al. 2002), and cost (Hu et al. 2004 ).

AIM

This review aimed to determine the features of structured educational interventions that impact on competence in aseptic insertion technique and maintenance of CV catheters by healthcare workers.

METHODS

We looked at changes in infection control behaviour of healthcare workers, and considered changes in service delivery and the clinical welfare of patients involved, provided they were related directly to the delivery method of the educational intervention.

RESULTS

A total of 9968 articles were reviewed, of which 47 articles met the inclusion criteria.

CONCLUSIONS

Findings suggest implications for practice: First, educational interventions appear to have the most prolonged and profound effect when used in conjunction with audit, feedback, and availability of new clinical supplies consistent with the content of the education provided. Second, educational interventions will have a greater impact if baseline compliance to best practice is low. Third, repeated sessions, fed into daily practice, using practical participation appear to have a small, additional effect on practice change when compared to education alone. Active involvement from healthcare staff, in conjunction with the provision of formal responsibilities and motivation for change, may change healthcare worker practice.