Browsing by Subject "Catheter-Related Infections"
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Item Changing the culture of culturing: diagnostic stewardship for healthcare-associated infections(2023-11-10) Kang, MinjiItem Improving Protocol Adherence in Central Line Placements(2022-05-01T05:00:00.000Z) Roy, Mathews Francis; Goff, Kristina L.; Yager, Ashley; Reed, W. GaryBACKGROUND: The placement of central lines is a very common exercise in medicine. Central lines are required for everything from acute trauma scenarios to long term cancer treatments. However, this ubiquitous procedure has several morbid complications that are not uncommon. Possible complications include infection, catheter misplacement, arterial puncture, hematoma, pneumothorax, and death[1]. Not only are the complications severe they are also quite prevalent with a complication rate of 15 to 25 percent[2]. LOCAL PROBLEM: Due to a concern for the rates of central line infections across campuses at the University of Texas Southwestern Medical Center (UTSW) there was a project underway to create a standardized central line placement protocol for all departments in the system. This protocol was taught to all incoming residents on a simulation session day. However, because a significant period of time can pass between central line training and the clinical practice of placing central lines, the rate of resident retention and adherence to the standardized procedure for central line placement is unknown. This report describes the results of a QI experiment meant to reduce the rate of catheter associated blood stream infections and ensure better resident protocol adherence at UTSW medical center using checklists and visual aids to ensure implementation of the standardized protocols. METHODS: The study was split into three phases. The first phase examined the baseline knowledge of UTSW residents regarding the placement of central lines and found the nursing position regarding possible interventions. The residents were interviewed regarding the standardized UTSW protocol and asked to detail the steps of placing a central line. The results were used to analyses areas of weakness in protocol adherence. Based on the results of the interviews, a checklist and visual aid were created highlighting key steps to ensure the adherence to the protocol. In phase two, to evaluate the feasibility of incorporating a checklist and CVA into the original CVC insertion methodology, a simulated pilot was conducted, and a survey was completed by the participants to determine how staff perceived the use of these new tools. In phase three after analyzing the ability to integrate the checklist and visual aid in a simulated setting, the utility of using a checklist to improve CVC insertions was tested by conducting a pilot study on real patients. During the pilot, CVCs placed in the ICU were observed by a medical student with the bedside nurse's participation and real time completion of the checklist RESULTS: Phase 1: It was found that there were significant variations in the average adherence between departments and training years. On average, post graduate year (PGY)3s did better than PGY2s. Furthermore, it was found that 50% of missed steps were caused by only 8 out 36 questions and 75% of mistakes were caused by just 15 out of 36 questions. Phase 2: Simulated pilot Survey results showed that all participants felt that their team successfully followed the standardized placement method. The participants also said that the implemented huddle helped to create teamwork and organization, and that it could easily be incorporated into the normal workflow. Phase 3: In-practice pilot All trial participants were asked for feedback regarding the perceived benefit of the process. Results were very positive with most participants saying that they thought that the new workflow was helpful and easy to implement. Analysis of the completed checklists show that participants were able to complete the forms without issue ensuring that complete adherence to the standardized protocol was possible. CONCLUSIONS: By interviewing residents to understand areas of difficulties and going through a multistep approach to ensure safety and efficacy of interventions, this project provides insight into the possible gaps in resident procedure adherences and retention of the UTSW protocol. It then also provides an intervention that strengthen the memory of the preforming physician and a layer of oversight to ensure that even if a mistake is made it is quickly corrected. The general concepts of simulation trials prior to clinical application and utilization of a checklist and cognitive visual aid can be applied not only to central lines at UTSW, but to many different procedures across multiple hospital systems.Item Long Term Central Venous Access in a Pediatric Leukemia Population(2015-01-26) Fu, Aurelia; Hodgman, Erica; Renkes, Rachel; Slone, Tamra; Alder, AdamBACKGROUND: Central venous access devices (CVADs) are used during the treatment of malignancies to facilitate chemotherapy administration and to reduce the pain and trauma of frequent blood sampling. Despite the importance of venous access, there is little recent data on complication rates associated with CVADs among pediatric patients. Our aim was to retrospectively analyze the complication rates among patients with acute leukemia at a single pediatric tertiary referral center. METHODS: After IRB approval, we reviewed the medical records of all patients with a diagnosis of acute lymphoblastic leukemia or acute myeloid leukemia admitted to our institution from May 2009-July 2014. Patient data, including demographics, CVAD type (subcutaneous port or tunneled catheter), peri-operative complications (<24 hours of surgery), long-term complications (>24 hours after surgery), and overall patient outcomes were collected. Chi square, t-tests and backward stepwise multivariate-regressions were used (significance p<0.05). RESULTS: There were 292 CVADs placed in 198 patients. The peri-operative complication rate was 4.8% (14 out of 292). Out of 292 CVADs, 23 did not have any long-term complications. Long-term complications included 93 line-associated infections (blood stream and/or port site infections), 6 episodes of deep vein thrombosis (DVT), and 136 instances of line malfunction without an identifiable cause. Seventy-five CVAD's were prematurely removed: 31 due to infection and 44 to malfunction. Univariate analysis identified age as a risk factor for a hematoma (p=0.02), and weight status as a risk factor for blood stream infection (p=0.02), DVT (p=0.009), line malfunction (p=0.02), and premature removal (p=0.02). The number of days from diagnosis to CVAD placement (p=0.008) and location of the subcutaneous port reservoir (p=0.01) were identified as predictors of early CVAD removal by multivariate analysis. There were no significant differences in long term complications between ports or tunneled catheters. CONCLUSION: Our rate of peri-operative complications compares to the 1.3-14% range reported in previous studies. Long term complications are high and require additional treatment, catheter replacement, or premature removal. This is costly in health, time, and money for both the patient and our institution, and should be addressed to improve patient care. Our retrospective study is the largest recent evaluation of CVAD complications within a single institution and also represents the largest Hispanic pediatric leukemia population reported upon to date.