Carrie Sona

Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit

Objective The purpose of the study was to determine whether an education initiative aimed at improving central venous catheter insertion and care could decrease the rate of primary bloodstream infections. Design Pre- and postintervention observational study. Setting Eighteen-bed surgical/burn/trauma intensive care unit (ICU) in an urban teaching hospital. Patients A total of 4,283 patients were admitted to the ICU between January 1, 1998, and December 31, 2000. Interventions A program primarily directed toward registered nurses was developed by a multidisciplinary task force to highlight correct practice for central venous catheter insertion and maintenance. The program consisted of a 10-page self-study module on risk factors and practice modifications involved in catheter-related infections as well as a verbal in-service at staff meetings. Each participant was required to take a pretest before taking the study module and an identical test after its completion. Fact sheets and posters reinforcing the information in the study module were also posted throughout the ICU. Measurements and Main Results Seventy-four primary bloodstream infections occurred in 6874 catheter days (10.8 per 1000 catheter days) in the 18 months before the intervention. After the implementation of the education module, the number of primary bloodstream infections fell to 26 in 7044 catheter days (3.7 per 1000 catheter days), a decrease of 66% (p < .0001). The estimated cost savings secondary to the decreased infection rate for the 18 months after the intervention was between

Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices.

185,000 and

Heparin or 0.9% sodium chloride to maintain central venous catheter patency: A randomized trial

2.808 million. Conclusions A focused intervention primarily directed at the ICU nursing staff can lead to a dramatic decrease in the incidence of primary bloodstream infections. Educational programs may lead to a substantial decrease in cost, morbidity, and mortality attributable to central venous catheterization.

Capnography Application in Acute and Critical Care

Objective: To determine a) if a checklist covering a diverse group of intensive care unit protocols and objectives would improve clinician consideration of these domains and b) if improved consideration would change practice patterns. Design: Pre‐ and postobservational study. Setting: A 24‐bed surgical/burn/trauma intensive care unit in a teaching hospital. Patients: A total of 1399 patients admitted between June 2006 and May 2007. Interventions: The first component of the study evaluated whether mandating verbal review of a checklist covering 14 intensive care unit best practices altered verbal consideration of these domains. Evaluation was performed using real‐time bedside audits on morning rounds. The second component evaluated whether the checklist altered implementation of these domains by changing practice patterns. Evaluation was performed by analyzing data from the Project IMPACT database after patients left the intensive care unit. Measurements and Main Results: Verbal consideration of evaluable domains improved from 90.9% (530/583) to 99.7% (669/671, p < .0001) after verbal review of the checklist was mandated. Bedside consideration improved on the use of deep venous thrombosis prophylaxis (p < .05), stress ulcer prophylaxis (p < .01), oral care for ventilated patients (p < 0.01), electrolyte repletion (p < .01), initiation of physical therapy (p < .05), and documentation of restraint orders (p < .0001). Mandatory verbal review of the checklist resulted in a greater than two‐fold increase in transferring patients out of the intensive care unit on telemetry (16% vs. 35%, p < .0001) and initiation of physical therapy (28% vs. 42%, p < .0001) compared with baseline practice. Conclusions: A mandatory verbal review of a checklist covering a wide range of objectives and goals at each patients bedside is an effective method to improve both consideration and implementation of intensive care unit best practices. A bedside checklist is a simple, cost‐effective method to prevent errors of omission in basic domains of intensive care unit management that might otherwise be forgotten in the setting of more urgent care requirements.

Tracheostomy protocol: experience with development and potential utility.

Objective:To compare heparin (3 mL, 10 units/mL) and 0.9% sodium chloride (NaCl, 10 mL) flush solutions with respect to central venous catheter lumen patency. Design:Single-center, randomized, open label trial. Setting:Medical intensive care unit and Surgical/Burn/Trauma intensive care unit at Barnes-Jewish Hospital, St. Louis, MO. Patients:Three hundred forty-one patients with multilumen central venous catheters. Patients with at least one lumen with a minimum of two flushes were included in the analysis. Interventions:Patients were randomly assigned within 12 hrs of central venous catheter insertion to receive either heparin or 0.9% sodium chloride flush. Measurements and Main Results:The primary outcome was lumen nonpatency. Secondary outcomes included the rates of loss of blood return, inability to infuse or flush through the lumen (flush failure), heparin-induced thrombocytopenia, and catheter-related blood stream infection. Assessment for patency was performed every 8 hrs in lumens without continuous infusions for the duration of catheter placement or discharge from intensive care unit. Three hundred twenty-six central venous catheters were studied yielding 709 lumens for analysis. The nonpatency rate was 3.8% in the heparin group (n = 314) and 6.3% in the 0.9% sodium chloride group (n = 395) (relative risk 1.66, 95% confidence interval 0.86–3.22, p = .136). The Kaplan-Meier analysis for time to first patency loss was not significantly different (log rank = 0.093) between groups. The rates of loss of blood return and flush failure were similar between the heparin and 0.9% sodium chloride groups. Pressure-injectable central venous catheters had significantly greater rates of nonpatency (10.6% vs. 4.3%, p = .001) and loss of blood return (37.0% vs. 18.8%, p <.001) compared to nonpressure-injectable catheters. The frequencies of heparin-induced thrombocytopenia and catheter-related blood stream infection were similar between groups. Conclusion:0.9% sodium chloride and heparin flushing solutions have similar rates of lumen nonpatency. Given potential safety concerns with the use of heparin, 0.9% sodium chloride may be the preferred flushing solution for short-term use central venous catheter maintenance.

National Survey of Central Venous Catheter Flushing in the Intensive Care Unit

The use of capnography has expanded over recent years. Currently, capnography is used in a variety of acute care settings. This article describes what capnography is and how it is used. The normal and abnormal capnogram or waveforms are described to assist in identifying various clinical situations. The multiplicity of clinical indications include detection of pulmonary embolism as well as malpositioned endotracheal/tracheal, gastric, and small bowel tubes. Capnography also provides clinicians with information regarding expiratory breathing patterns and assists in perfusion assessments such as those for cardiopulmonary resuscitation. Finally, case studies are provided to help the reader apply the concepts of capnography to a variety of acute care settings.

Chlorhexidine Gluconate Bathing to Reduce Methicillin-Resistant Staphylococcus aureus Acquisition

Objectives:To examine the feasibility and potential utility of a tracheostomy protocol based on a standardized approach to ventilator weaning. Design:Prospective, observational data collection. Setting:Academic medical center. Patients:Surgical intensive care unit patients requiring mechanical ventilatory support. Interventions:None. Measurements and Main Results:Tracheostomy practice in 200 patients was analyzed in relation to spontaneous breathing trial (SBT) weaning. Decision for, and performance of, tracheostomy occurred (median [interquartile range]) 5.0 (3.75–8.0) and 7.0 (5.0–10.0) days following initiation of mechanical ventilation, respectively. Duration of mechanical ventilation was greater in tracheostomy compared with nontracheostomy patients (15.0 [11.0–19.0] vs. 6.0 [4.0–8.0], p < .001). For patients requiring ventilatory support for ≥20 days, 100% of patients were maintained via tracheostomy. A protocol based on weaning performance, which included technical considerations, was developed. Individuals who failed preliminary weaning assessment or SBT for 3 successive days following 5 days (nonreintubated patients) or 3 days (reintubated patients) of ventilatory support met tracheostomy criteria. The protocol was implemented on a pilot basis in 125 individuals. Of the 55 (44.0%) patients undergoing tracheostomy, 25 (45.5%) did so consistent with criteria. Eighteen patients (32.7%) underwent tracheostomy before the time interval of data collection targeting weaning protocol performance, and 12 patients (21.8%) passed SBT on one or more occasions, were not extubated, and proceeded to tracheostomy. Conclusions:A standardized approach in which the decision for tracheostomy is based on objective measures of weaning performance may be a means of using this procedure more consistently and effectively.

Improving Caregivers’ Perceptions Regarding Patient Goals of Care/End-of-Life Issues for the Multidisciplinary Critical Care Team:

BACKGROUND Evidence is needed on the best solution for flushing central venous catheters. OBJECTIVE To understand current flushing practices for short-term central venous catheters among critical care nurses before implementation of a randomized, controlled trial comparing physiological saline with heparin solution for flushing to maintain catheter patency. METHODS A 6-item survey including demographic data was mailed to 2000 practicing critical care nurses in the United States. An additional 316 surveys were completed at the annual conference of the American Association of Critical-Care Nurses. RESULTS Most (71.5%) of the 632 respondents who completed the survey were staff nurses. Most respondents (64.6%; 95% CI, 60.86%-68.34%) reported using physiological saline exclusively to flush central venous catheters and maintain patency. For heparin-containing solutions, the concentration and volume used varied. The most commonly reported volumes for flushing were 10 mL for saline (63%; 95% CI, 59.18%-66.82%) and 3 mL for heparin (50.2%; 95% CI, 43.5%-56.9%). CONCLUSION Flushing practices for central venous catheters vary widely. A randomized controlled trial is needed to determine the optimal flushing solution to maintain short-term patency.

Discrepancies in measuring bladder volumes with bedside ultrasound and bladder scanning in the intensive care unit: A pilot study

BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) is a virulent organism causing substantial morbidity and mortality in intensive care units. Chlorhexidine gluconate, a topical antiseptic solution, is effective against a wide spectrum of gram-positive and gram-negative bacteria, including MRSA. Objectives To examine the impact of a bathing protocol using chlorhexidine gluconate and bath basin management on MRSA acquisition in 5 adult intensive care units and to examine the cost differences between chlorhexidine bathing by using the bath-basin method versus using prepackaged chlorhexidine-impregnated washcloths. METHODS The protocol used a 4-oz bottle of 4% chlorhexidine gluconate soap in a bath basin of warm water. Patients in 3 intensive care units underwent active surveillance for MRSA acquisition; patients in 2 other units were monitored for a new positive culture for MRSA at any site 48 hours after admission. RESULTS Before the protocol, 132 patients acquired MRSA in 34333 patient days (rate ratio, 3.84). Afterwards, 109 patients acquired MRSA in 41376 patient days (rate ratio, 2.63). The rate ratio difference is 1.46 (95% CI, 1.12-1.90; P = .003). The chlorhexidine soap and bath basin method cost

Comparison of nasal and forehead oximetry accuracy and pressure injury in critically ill patients

3.18 as compared with