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A survey of academic medical-center hospital epidemiologists indicated substantial deviation from Centers for Disease Control and Prevention guidance regarding healthcare providers (HCPs) recovering from coronavirus disease 2019 (COVID-19) returning to work. Many hospitals continue to operate under contingency status and have HCPs return to work earlier than recommended.
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
Background: The COVID-19 pandemic has challenged healthcare facilities since its discovery in late 2019. Notably, the subsequent COVID-19 pandemic has led to an increase in healthcare-acquired infections such as ventilator associated events (VAEs). Many hospitals in the United States perform surveillance for the NHSN for VAEs by monitoring mechanically ventilated patients for metrics that are generally considered to be objective and preventable and that lead to poor patient outcomes. The VAE definition is met in a stepwise manner. Initially, a ventilator-associated condition (VAC) is met when there an increase in ventilator requirements after a period of stability or improvement. An IVAC is then met when there is evidence of an infectious process such as leukocytosis or fever and a new antimicrobial agent is started. Finally, possible ventilator-associated pneumonia (PVAP) is met when there is evidence of microbial growth or viral detection. Since the beginning of the COVID-19 pandemic, our hospital has seen an increase in VAEs, which is, perhaps, not unexpected during a respiratory illness pandemic. However, the NSHN definitions of VAE, and PVAP in particular, do not account for the novelty and nuances of COVID-19. Methods: We performed a chart review of 144 patients who had a VAE reported to the NHSN between March 1 and December 31, 2020. Results: Of the 144 patients with a VAE reported to NHSN, 39 were SARS-CoV-2 positive. Of the 39 patients, 4 patients (10.25%) met the NHSN PVAP definition due to a positive SARS-CoV-2 PCR that was collected in the prolonged viral shedding period of their illness (< 90 days). One of the four patients also had a bacterial infection in addition to their subsequent positive COVID-19 result. All these patients were admitted to the hospital with a COVID-19 diagnosis and their initial PCR swab was performed upon admission. Conclusions: We believe that the PVAP definition was inappropriately triggered by patients who were decompensating on the ventilator due to a novel respiratory virus that was present on admission. Early in the pandemic, frequent swabbing of these patients was performed to try and understand the duration of viral shedding and to determine when it would be safe to transfer patients from isolation after prolonged hospitalization. The NSHN definition should take into consideration the prolonged viral shedding period of COVID-19 and natural history of the illness, and subsequent COVID-19 testing within 90 days of an initial positive should not require classification as a hospital-acquired PVAP.
Background: Mechanical ventilation is a lifesaving therapy for critically ill patients. Hospitals perform surveillance for the NHSN for ventilator-associated events (VAE) by monitoring mechanically ventilated patients for metrics that are generally thought to be objective and preventable and that lead to poor patient outcomes. The VAE definition is met in a stepwise manner; initially, a ventilator-associated condition (VAC) is triggered with an increase in positive end-expiratory pressure (PEEP, >3 cm H2O) or fraction of inspired oxygen (FIO2, 0.20 or 20 points) after a period of stability or improvement on the ventilator. We believe that many reported VAEs could be avoided by provider and respiratory therapy attention to “knobmanship.” We define knobmanship as knowledge of the VAE definition and trigger points combined with appropriate clinical care for mechanically ventilated patients while avoiding unnecessary triggering of the VAE definition by avoiding small unneeded changes in PEEP or FIO2. Methods: We performed a chart review of 283 patients who had a reported VAE to the NHSN between January 1, 2019, and December 31, 2020. We collected data including type of VAE, VAE triggering criteria, and clinical course. Results: Of the 283 VAEs, 59 were triggered by a PEEP increase from 5 to 8 with stable or decreasing FIO2. Of the 59 VAEs, 33 were VACs, 18 were infection-related ventilator- associated complications (IVACs), and 8 were possible ventilator-associated pneumonia (PVAP). Most of these transient changes in PEEP were deemed clinically unnecessary. A 21% reduction of VAEs reported to the NSHN over the 2-year review period could have been avoided by knobmanship. Conclusions: The VAE definition may often be triggered by provider bias to the ventilator settings rather than what the patient’s clinical-condition requires. Attention to knobmanship may result in substantial decrease in reported VAE.
The decision to discontinue isolation in hospitalized patients with persistently positive severe acute respiratory coronavirus virus 2 (SARS-CoV-2) molecular testing is nuanced. Improvement in clinical status should be evaluated with expert consultation when considering whether discontinuation of isolation is appropriate. The cycle threshold value may serve as a useful adjunct to this decision-making process.
Background: Central-line–associated bloodstream infections (CLABSIs) result in increased patient morbidity. Guidelines recommend against peripheral venous catheters when access is required for longer than 6 days, often leading to central venous catheter (CVC) placement. To improve vascular access device choice and reduce the potential risk of CLABSI, we implemented a quality improvement initiative comprised of a vascular access algorithm and introduction of a midline vascular access device (MVAD). We report complications associated with MVAD use including deep vein thrombosis (DVT), thrombophlebitis, and BSI. Methods: A prospective quality improvement assessment from October 2017 through March 2018. All MVADs were monitored for DVT, thrombophlebitis, and BSI. Insertion time and removal of MVAD were tracked, as well as presence of other vascular access devices. Results: From October 2017 through March 2018, 858 MVADs were inserted in 726 different patients, yielding 3,588 MVD days. In total, 6 primary BSIs occurred in patients with MVADs. In patients with only a MVAD, the rate was 0.72 BSI per 1,000 MVAD days, whereas patients with an MVAD as well as a CVC had a rate of 1.98 per 1,000 MVAD days. The overall CLABSI rate at the institution during this period of time was 1.24 per 1,000 CVC days. Also, 29 cases of thrombophlebitis occurred, for a rate of 3.84 per 1,000 catheter days in patients with only an MVAD compared to 4.63 per 1,000 catheter days in patients with an MVAD and a CVC. Also, 25 DVTs occurred during this time, resulting in a rate of 2.88 per 1,000 catheter days in patients with only an MVAD and 4.63 per 1,000 catheter days in patients with multiple vascular-access devices. A significant correlation was noted between MVAD indwell time and BSI (P = .0021) and thrombophlebitis (P = .0041). The median indwell time for patients experiencing BSI was 16.17 days ± 8.04 days, whereas the median indwell time for patients experiencing thrombophlebitis was 9.24 days ± 7.99 days. Conclusions: The implementation of a vascular-access algorithm including MVAD may effectively reduce CVC insertions and BSIs. The rate of BSI in MVAD was below that of CLABSI during the assessment period. Known complications associated with MVAD include DVTs and thrombophlebitis, which correlates with the duration of catheterization, and these risks appear to be further compounded in patients requiring multiple devices for vascular access. Further research into comparing the risk of vascular access of MVAD with CVC is warranted.
Social media, prevention of healthcare-associated infections (HAIs) and antimicrobial stewardship (ASP) each impact every area of medicine. Independently, each have power to change medicine, however, synergistically, the impact could be transformative. Given the profound clinical, financial, and public health impact of infection prevention and antimicrobial stewardship combined with the incomplete uptake of best practices, multimodal strategies employing social media are critical to increase the speed and reach of research. This review discusses the strategic utilization of online communication platforms to increase the dissemination of critical publications.
This narrative review addresses vascular access device choice from peripheral intravenous catheters through central venous catheters, including the evolving use of midline catheters. The review incorporates best practices, published algorithms, and complications extending beyond CLABSI and phlebitis to assist clinicians in navigating complex vascular access decisions.