Brian P. Currie

The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population*

Objective:The objective was to assess the risk of central venous catheter infection with respect to the site of insertion in an intensive care unit population. The subclavian, internal jugular, and femoral sites were studied. Design:An epidemiologic, prospective, observational study. Setting:The setting is a well-functioning intensive care unit under a unified critical care medicine division in a university teaching hospital. Critical care medicine attendings and fellows covered on site 17 and 24 hrs per day, respectively. Patients:Patients were critically ill. All patients were triaged into the intensive care unit by on-site critical care medicine fellows. Interventions:None. Measurements and Main Results:In an intensive care unit population, we prospectively studied the incidence of central venous catheter infection and colonization at the subclavian, internal jugular, and femoral sites. The optimal insertion site for each individual patient was selected by experienced intensive care physicians (critical care medicine attendings and fellows). All of the operators were proficient in inserting catheters at all three sites. Confounding factors were eliminated; there were a limited number of experienced operators inserting the catheters, a uniform protocol stressing strict sterile insertion was enforced, and standardized continuous catheter care was provided by dedicated intensive care nurses proficient in all aspects of central venous catheter care. Two groups of patients were analyzed. Group 1 was patients with one catheter at one site, and group 2 was patients with catheters at multiple sites. Group 1 was the primary analysis, whereas group 2 was supporting. A total of 831 central venous catheters and 4,735 catheter days in 657 patients were studied. The incidence of catheter infection (4.01/1,000 catheter days, 2.29% catheters) and colonization (5.07/1,000 catheter days, 2.89% catheters) was low overall. In group 1, the incidence of infection was subclavian: 0.881 infections/1,000 catheter days (0.45%), internal jugular: 0/1,000 (0%), and femoral: 2.98/1,000 (1.44%; p = .2635). The incidence of colonization was subclavian: 0.881 colonization/1,000 catheter days (0.45%), internal jugular: 2.00/1,000 (1.05%), and femoral: 5.96/1,000 (2.88%, p = .1338). There was no statistically significant difference in the incidence of infection and colonization or duration of catheters (p = .8907) among the insertion sites. In group 2, there was also no statistically significant difference in the incidence of infection and colonization among the three insertion sites. Conclusion:In an intensive care unit population, the incidence of central venous catheter infection and colonization is low overall and, clinically and statistically, is not different at all three sites when optimal insertion sites are selected, experienced operators insert the catheters, strict sterile technique is present, and trained intensive care unit nursing staff perform catheter care.

Effects of the August 2003 blackout on the New York City healthcare delivery system: a lesson for disaster preparedness.

Background:On August 14, 2003, the United States and Canada suffered the largest power failure in history. We report the effects of this blackout on New York City’s healthcare system by examining the following: 1) citywide 911 emergency medical service (EMS) calls and ambulance responses; and 2) emergency department (ED) visits and hospital admissions to one of New York City’s largest hospitals. Methods:Citywide EMS calls and ambulance responses were categorized by 911 call type. Montefiore Medical Center (MMC) ED visits and hospital admissions were categorized by diagnosis and physician-reviewed for relationship to the blackout. Comparisons were made to the week pre- and postblackout. Results:Citywide EMS calls numbered 5,299 on August 14, 2003, and 5,021 on August 15, 2003, a 58% increase (p < .001). During the blackout, there were increases in “respiratory” (189%; p < .001), “cardiac” (68%; p = .016), and “other” (40%; p < .001) EMS call categories, but when expressed as a percent of daily totals, “cardiac” was no longer significant. The MMC-ED reflected this surge with only “respiratory” visits significantly increased (expressed as percent of daily total visits; p < .001). Respiratory device failure (mechanical ventilators, positive pressure breathing assist devices, nebulizers, and oxygen compressors) was responsible for the greatest burden (65 MMC-ED visits, with 37 admissions) as compared with 0 pre- and postblackout. Conclusions:The blackout dramatically increased EMS and hospital activity, with unexpected increases resulting from respiratory device failures in community-based patients. Our findings suggest that current capacity to respond to public health emergencies could be easily overwhelmed by widespread/prolonged power failure(s). Disaster preparedness planning would be greatly enhanced if fully operational, backup power systems were mandated, not only for acute care facilities, but also for community-based patients dependent on electrically powered lifesaving devices.

Bioterrorism: Preparing for the impossible or the improbable.

Objective:To review the current literature surrounding the history of bioterrorism, the relative risk of a bioterrorist attack, methods of surveillance for biological agents, identification and management of various biological agent casualties, as well as the role of the intensivist in managing a bioterrorist attack. Methods:Internet and Medline search (from 1966 to 2004) for articles relating to bioterrorism, biological agents, biological warfare, hospital preparedness, disaster management, and intensive care. Conclusions:There are few instances of a successful large-scale biological weapons attack in history. Weaponization of biological agents for aerosol dispersal is difficult and has often proved to be the rate-limiting step for a successful attack. Although a successful biological attack is currently unlikely, it is still feasible. More importantly, the threat of one is likely to cause much panic in the public, while a successful attack would overburden the current healthcare infrastructure. Intensivists will need to have specific knowledge of identifying and managing casualties from various biological agents. In addition, they will need to play an integral part in the preparedness of their institutions and communities for managing a bioterrorist event.

Impact of adding prophylactic probiotics to a bundle of standard preventative measures for Clostridium difficile infections: enhanced and sustained decrease in the incidence and severity of infection at a community hospital

Abstract Background: In 2003, hospitals in Quebec, Canada experienced an increase of NAP1/027 Clostridium difficile infections following antibiotic administration (CDIAA). At Pierre-Le Gardeur Hospital (PLGH), the incidence increased from 10 to over 25 cases per 1000 patient admissions. Methods: We report a quasi-experimental, prospective cohort study evaluating the effect on CDIAA of a probiotic added to existing C. difficile infection (CDI) standard preventative measures (SPM) in 31,832 hospitalized patients receiving antibiotics. Phase I (1580) measured the impact of SPM alone. In Phase II, 50 to 60 × 109 cfu daily dose of oral Lactobacillus acidophilus CL1285 and L. casei LBC80R probiotic formula (Bio-K+) was administered to all patients receiving antibiotics. Phase III included the same intervention after a move to a new hospital facility. Phases II and III included 4968 patients. During Phase IV, 25,284 patients were submitted to the same regimen but outcome data were compared to those of similar hospitals in Quebec. Results: At the end of Phase III, CDIAA had decreased from more than 18 cases per 1000 patient admissions in Phase I to less than 5 cases. Reductions of CDI cases (73%) (p < 0.001) and severe CDI cases (76.4%) (p < 0.001) were observed. CDI recurrence rate was reduced by 39% (p < 0.001). During the following 6 years, the CDI rate averaged 2.71 cases per 10,000 patient-days at PLGH compared to 8.50 cases per 10,000 patient-days in equivalent hospitals located in Quebec. Study limitation: This study is not a randomized clinical trial; it is an open prospective study and should be treated as such. Also, following Phase II, PLGH moved into a new facility and this could have contributed to lower CDI. Conclusions: Specific probiotic product added to SPM and antibiotic stewardship activities resulted in a further reduction in CDI rates and was shown to be safe.

Incidence of Clostridium difficile infection in patients with acute leukemia and lymphoma after allogeneic hematopoietic stem cell transplantation.

after Allogeneic Hematopoietic Stem Cell Transplantation • Author(s): Sharon Leung, MD; Brian S. Metzger, MD, MPH; Brian P. Currie, MD, MPH Source: Infection Control and Hospital Epidemiology, Vol. 31, No. 3 (March 2010), pp. 313-315 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/651066 . Accessed: 25/03/2013 21:21

IMPROVING THE RATES OF INPATIENT PNEUMOCOCCAL VACCINATION: IMPACT OF STANDING ORDERS VERSUS COMPUTERIZED REMINDERS TO PHYSICIANS

OBJECTIVE To determine the impact of interventions using standing orders and computerized reminders to physicians on inpatient pneumococcal vaccination rates relative to a control group. DESIGN Open trial of the following approaches, each on a different ward: (1) standing orders for vaccination of eligible consenting patients, (2) computerized reminders to physicians, and (3) usual practice. SETTING AND PATIENTS Four hundred twenty-four patients were admitted to three 30-bed inpatient medical wards during a 4-month period in 1999 at one hospital. Unvaccinated patients 65 years or older and competent to give oral consent were included. INTERVENTION A pharmacist activated a standing orders protocol for vaccination of all eligible consenting patients on one ward and computerized reminders to physicians on a second ward. A third ward served as a control group. RESULTS Forty-two patients met inclusion criteria and accepted vaccination in the standing orders arm versus 35 patients in the computerized reminder arm. Vaccination rates on the standing orders ward included 98% of those eligible and accepting vaccination, 73% of eligible patients, and 28% of all patients admitted. Rates on the computerized reminder ward were 23%, 15%, and 7%, respectively. All of the rates from the standing orders ward were significantly greater than those from the computerized reminder ward (P < .0001). Only 0.6% of all patients on the control arm were vaccinated. CONCLUSION Although both interventions were effective in increasing inpatient pneumococcal vaccination rates relative to baseline practice, physician independent initiation of standing orders was clearly more effective.

Changing the research landscape: the New York City Clinical Data Research Network

The New York City Clinical Data Research Network (NYC-CDRN), funded by the Patient-Centered Outcomes Research Institute (PCORI), brings together 22 organizations including seven independent health systems to enable patient-centered clinical research, support a national network, and facilitate learning healthcare systems. The NYC-CDRN includes a robust, collaborative governance and organizational infrastructure, which takes advantage of its participants’ experience, expertise, and history of collaboration. The technical design will employ an information model to document and manage the collection and transformation of clinical data, local institutional staging areas to transform and validate data, a centralized data processing facility to aggregate and share data, and use of common standards and tools. We strive to ensure that our project is patient-centered; nurtures collaboration among all stakeholders; develops scalable solutions facilitating growth and connections; chooses simple, elegant solutions wherever possible; and explores ways to streamline the administrative and regulatory approval process across sites.

Investigation of critical care unit utilization and mortality in patients infected with Clostridium difficile

BACKGROUND A nationwide increase in the rate and severity of Clostridium difficile-associated disease may reflect infection with a virulent strain characterized by polymerase chain reaction as ribotype 027 (NAP1/B1). HYPOTHESIS The high prevalence of ribotype 027 at our institution would allow investigation of the risk of mortality and admission to the intensive care unit (ICU) associated with C difficile infection. METHODS In a retrospective cohort study, we identified 108 patients with positive enzyme-linked immunosorbant assay tests for C difficile toxins over a 6-month period and compared them to 108 patients who were suspected to have C difficile but with negative toxin assays. Proportions of all-cause mortality and ICU admission were compared using chi(2), and odds ratios (ORs) were estimated using logistic regression to adjust for potential confounders. Mean log lengths of stay were compared using t test. RESULTS Comparing patients with C difficile to those without, mortality (20% vs 8%) and ICU admission (32% vs 17%) were significantly higher (P = .02 for both), whereas log length of stay was not (P = .29). Adjusting for potential confounders, the OR for mortality was 6.8 (95% confidence interval, 1.8-25.4; P = .01), whereas for ICU admission, the association was no longer observed (OR, 1.0; 95% confidence interval, 0.4-2.5; P = .97). CONCLUSION C difficile infection was associated with increased all-cause mortality. An observed association with ICU admission and C difficile infection was identified through univariate analysis but was not significant in multivariate analysis. Although we did not strain-type isolates for patients infected with C difficile, the institutional prevalence of ribotype 027 C difficile infection was known to be high. These results document a strong association between ribotype 027 C difficile infection and mortality and underscore the need to identify effective C difficile preventive strategies.

Investigation of inpatient probiotic use at an academic medical center

OBJECTIVES Despite the widespread use of probiotics, there are limited data regarding their safety. The aims of this study were to characterize inpatient probiotic use and to determine the incidence of probiotic-related bloodstream infections due to Lactobacillus acidophilus/Lactobacillus bulgaricus. METHODS This study was a two-part retrospective study conducted at a large academic medical center. The first part was the characterization of probiotic use during 2007-2008, which included the type of prescribing provider, choice of probiotic prescribed, indications for use, and presence of potential risk factors for probiotic infection among recipients; the second part was the determination of the incidence of probiotic-related bloodstream infections due to L. acidophilus/L. bulgaricus for September 2000-August 2008. RESULTS Probiotic use was uncommon (0.4%). Ninety-six percent of patients received Lactobacillus-based compounds. Use was common in patients at theoretical risk for probiotic infection. The maximum estimated incidence of probiotic-related bacteremia due to L. acidophilus/L. bulgaricus during the 8-year period was 0.2%. CONCLUSIONS L. acidophilus/L. bulgaricus probiotic use at our institution appeared to be associated with a minimal risk of probiotic-related infection, even though it was used at a high frequency among inpatients who could be considered at high theoretical risk for probiotic-related bloodstream infection.

Developing a multidisciplinary model of comparative effectiveness research within a clinical and translational science award.

The Clinical and Translational Science Awards (CTSAs) were initiated to improve the conduct and impact of the National Institutes of Healths research portfolio, transforming training programs and research infrastructure at academic institutions and creating a nationwide consortium. They provide a model for translating research across disciplines and offer an efficient and powerful platform for comparative effectiveness research (CER), an effort that has long struggled but enjoys renewed hope under health care reform. CTSAs include study design and methods expertise, informatics, and regulatory support; programs in education, training, and career development in domains central to CER; and programs in community engagement. Albert Einstein College of Medicine of Yeshiva University and Montefiore Medical Center have entered a formal partnership that places their CTSA at a critical intersection for clinical and translational research. Their CTSA leaders were asked to develop a strategy for enhancing CER activities, and in 2010 they developed a model that encompasses four broadly defined “compartments” of research strength that must be coordinated for this enterprise to succeed: evaluation and health services research, biobehavioral research and prevention, efficacy studies and clinical trials, and social science and implementation research. This article provides historical context for CER, elucidates Einstein-Montefiores CER model and strategic planning efforts, and illustrates how a CTSA can provide vision, leadership, coordination, and services to support an academic health centers collaborative efforts to develop a robust CER portfolio and thus contribute to the national effort to improve health and health care.