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Catheter-associated urinary tract infections (CAUTIs) are among the most common hospital-acquired infections (HAIs). Reducing CAUTI rates has become a major focus of attention due to increasing public health concerns and reimbursement implications.
To implement and describe a multifaceted intervention to decrease CAUTIs in our ICUs with an emphasis on indications for obtaining a urine culture.
A project team composed of all critical care disciplines was assembled to address an institutional goal of decreasing CAUTIs. Interventions implemented between year 1 and year 2 included protocols recommended by the Centers for Disease Control and Prevention for placement, maintenance, and removal of catheters. Leaders from all critical care disciplines agreed to align routine culturing practice with American College of Critical Care Medicine (ACCCM) and Infectious Disease Society of America (IDSA) guidelines for evaluating a fever in a critically ill patient. Surveillance data for CAUTI and hospital-acquired bloodstream infection (HABSI) were recorded prospectively according to National Healthcare Safety Network (NHSN) protocols. Device utilization ratios (DURs), rates of CAUTI, HABSI, and urine cultures were calculated and compared.
The CAUTI rate decreased from 3.0 per 1,000 catheter days in 2013 to 1.9 in 2014. The DUR was 0.7 in 2013 and 0.68 in 2014. The HABSI rates per 1,000 patient days decreased from 2.8 in 2013 to 2.4 in 2014.
Effectively reducing ICU CAUTI rates requires a multifaceted and collaborative approach; stewardship of culturing was a key and safe component of our successful reduction efforts.
The obstructive sleep apnea (OSA) patient presenting for OSA surgery presents a number of challenges to the anesthesiologist. OSA is diagnosed by clinical history and an overnight sleep study or polysomnography (PSG). PAP treatment attempts to maintain a competent airway through the application of continuous positive airway pressure (CPAP), bi-level positive pressure (BiPAP) or auto-titrating positive pressure (APAP). The three anatomic areas that can contribute to OSA as a result of increased nasal resistance include the alar cartilage/nasal valve area, the septum and the turbinates. These patients may have a number of cardiac and respiratory comorbidities as well as very challenging airways. Consideration should be given to optimization of medical comorbidities preoperatively, careful airway management, and minimization of sedating pain medications intraoperatively. Postoperatively airway edema, hemorrhage, and respiratory complications are a concern and the patient should be recovered in a monitored setting until they return to their baseline.
Conducting a family meeting to decide withdrawal of care can be a very difficult process. This chapter presents a case study of a 79-year-old male who was found unconscious in his home by his wife. The intensivist explained to the family that a meaningful outcome would be extremely unlikely given the large stroke, myocardial infarction, and multisystem organ failure. One of the more difficult situations a critical care physician faces is a discussion regarding withdrawal of care or limitation of support with family members whose loved one has developed medical problems from which he or she clearly cannot recover. Entering into discussions with families for these types of problems without prior consideration and expertise can be fraught with difficulty, negative emotions, and may lead to prolongation of suffering of an otherwise dying patient. Most families appreciate an open, honest approach when discussing withdrawal of life supportive measures.
Patients with penicillin allergy admitted to the intensive care unit (ICU) frequently receive non-beta-lactam antimicrobials for the treatment of infection. The use of these antimicrobials, more commonly vancomycin and fluoroquinolones, is associated with the emergence of multidrug-resistant infections. The penicillin skin test (PST) can help detect patients at risk of developing an immediate allergic reaction to penicillin and those patients with a negative PST may be able to use a penicillin antibiotic safely.
We determined the incidence of true penicillin allergy, the percentage of patients changed to a beta-lactam antimicrobial when the test was negative, the safety of the test, and the safety of administration of beta-lactam antimicrobials in patients with a negative test. Skin testing was performed using standard methodology.
One hundred patients admitted to 4 ICUs were prospectively studied; 58 of them were male. The mean age was 63 years. Ninety-six patients had the PST: one was positive (1.04%), 10 (10.4%) were nondiagnostic, and 85 (88.5%) were negative. Of the 38 patients who received antimicrobials for therapeutic reasons, 31(81.5%) had the antibiotic changed to a beta-lactam antimicrobial after a negative reading versus 7 patients of the 57 (12%) who had received a prophylactic antimicrobial (P < .001). No adverse effects were reported after the PST or after antimicrobial administration.
The PST is a safe, reliable, and effective strategy to reduce the use of non-beta-lactam antimicrobials in patients who are labeled as penicillin allergic and admitted to the ICU.
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