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Peripheral venous catheters (PVCs) can be associated with serious infectious complications. We evaluated the effect of education and feedback on process measures to improve PVC care and infectious complications.
Quasi-experimental controlled crossover study with sampling before and after education.
An 804-bed tertiary care teaching hospital.
Nurses and patients in 10 non-intensive care units.
We implemented a process to improve PVC care in 10 non-intensive care units. The 4 periods (each 3 months in duration) included a preintervention period and a staggered educational intervention among nurses. During intervention period 1, 5 units participated in the intervention (group A), and 5 units served as a control group (group B). Group B underwent the intervention during intervention period 2, and both groups A and B received feedback on performance during intervention period 3. Process measures were evaluated twice monthly, and feedback was given to nurses directly and to the unit manager on a monthly basis.
During the preintervention period, there were no significant differences between groups A and B. Of 4,904 intravascular catheters evaluated, 4,434 (90.4%) were peripheral. By the end of the study, there were significant improvements in processes, compared with the preintervention period, including accurate documentation of dressing (from 442 cases [38%] to 718 cases [59%]; P<.0001), catheter dressing being intact (from 968 cases [88.5%] to 1,024 cases [95.2%]; P<.0001), and correct demonstration of scrubbing the hub before infusion (from 161 demonstrations [54%] to 316 demonstrations [95%]; P <.0001). There was a significant reduction in PVC-associated bloodstream infection, from 2.2 cases per 10,000 patient-days during the preintervention period (5 cases) to 0.44 cases per 10,000 patient days during the 3 intervention periods (3 cases; P = .016).
Education and real-time feedback to nurses increases and sustains compliance with processes to reduce the risk of infection from PVCs.
To determine the effect of nurse-led multidisciplinary rounds on reducing the unnecessary use of urinary catheters (UCs).
Quasi-experimental study with a control group, in 3 phases: preintervention, intervention, and postintervention.
Twelve medical-surgical units within a 608-bed teaching hospital, from May 2006 through April 2007.
A nurse trained in the indications for UC utilization participated in daily multidisciplinary rounds on 10 medical-surgical units. If no appropriate indication for a patient's UC was found, the patient's nurse was asked to contact the physician to request discontinuation. Data were collected before the intervention (for 5 days), during the intervention (for 10 days), and 4 weeks after the intervention (for 5 days). Two units served as controls.
Of 4,963 patient-days observed, a UC was present in 885 (for a total of 885 “UC-days”). There was a significant reduction in the rate of UC utilization from 203 UC-days per 1,000 patient-days in the preintervention phase to 162 UC-days per 1,000 patient-days in the intervention phase (P = .002). The postintervention rate of 187 UC-days per 1,000 patient-days was higher than the rate during the intervention (P = .05) but not significantly different from the preintervention rate (P = .32). The rate of unnecessary use of UCs also decreased from 102 UC-days per 1,000 patient-days in the preintervention phase to 64 UC-days per 1,000 patient-days during the intervention phase (P < .001); and, significantly, the rate rose to 91 UC-days per 1,000 patient-days in the postintervention phase (P = .01). The rate of discontinuation of unnecessary UCs in the intervention phase was 73 (45%) of 162.
A nurse-led multidisciplinary approach to evaluate the need for UCs was associated with a reduction of unnecessary UC use. Efforts to sustain the intervention-induced reduction may be successful when trained advocates continue this effort with each team.
To evaluate factors related to a gradual rise in sternal surgical site infection (SSI) rates.
Retrospective cohort study.
A 608-bed, tertiary care teaching hospital.
All patients who underwent coronary artery bypass graft (CABG) from January 2000 through September 2004.
Of 3,578 patients who underwent CABG, 144 (4%) had sternal SSI. There was an increase in infection rate, with a marked reduction in the number of operations per year. The percentage of patients with peripheral vascular disease increased from 12% to 24.3% (P < .001), and the percentage with congestive heart failure increased from 17% to 22% (P < .001). Between 2002 and 2004, the mean duration of surgery increased from 233 to 290 minutes (P < .001), the percentage of patients with a National Nosocomial Infections Surveillance System (NNIS) risk index of 2 increased from 14.3% to 38% (P < .001), and the percentage of patients with a postoperative stay in the intensive care unit of greater than 72 hours increased from 29% to 40.6% (P < .001). Multivariate analysis showed diabetes mellitus, peripheral vascular disease, obesity, duration of surgery, and postoperative stay in the intensive care unit of greater than 72 hours to be independently associated with infection.
An increase in infection in the CABG population not associated with an outbreak may be a reflection of a change in the severity of illness. Preoperative, intraoperative, and postoperative markers for increased infection risk may be used, in addition to the NNIS risk index, to assess the patient population risk.
Surgical-site infection (SSI) is a serious and costly complication following coronary artery bypass graft (CABG). We analyzed surgical factors, microbiology, and complications at a 608-bed community teaching hospital to identify opportunities for prevention.
All patients undergoing CABG procedures from June 1997 through December 2000 were analyzed. Hospital records and postdischarge surveillance data were reviewed for demographics, surgical information, timing and classification of infection, microbiology, and bacteremic events.
Of 3,443 patients undergoing CABG, sternal SSI developed in 122 (3.5%); 71 (58.2%) were classified as superficial SSI and 51 (41.8%) as deep SSI. Surgical antimicrobial prophylaxis was employed in all cases. On average, infection occurred 21.5 days (range, 4 to 315) after CABG. Most cases were diagnosed on readmission (59%); 20 cases (16%) were identified by postdischarge surveillance. Microbiological data were positive in 109 (89.3%), with a single pathogen implicated in most (86.2%). Gram-positive cocci were most frequently recovered (81%); gram-negative bacilli (17%), gram-positive bacilli (1%), and yeast (1%) were less common. Staphylococcus aureus was the most frequently isolated pathogen (49%). Bacteremia was noted in 22 instances (18%). It was significantly associated with deep SSI (P =. 002) and identified only in S. aureus cases.
SSI complicated 3.5% of the procedures. S. aureus was implicated in most of the cases and was significantly associated with deep SSI. It was the only pathogen associated with secondary bacteremia. In addition to standard guidelines, targeted methods against S. aureus should help reduce the overall rate of SSI.
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