Geoffrey Playford

Risk factors for peripheral intravenous catheter failure: a multivariate analysis of data from a randomized controlled trial.

OBJECTIVEnTo assess the relative importance of independent risk factors for peripheral intravenous catheter (PIVC) failure.nnnMETHODSnSecondary data analysis from a randomized controlled trial of PIVC dwell time. The Prentice, Williams, and Peterson statistical model was used to identify and compare risk factors for phlebitis, occlusion, and accidental removal.nnnSETTINGnThree acute care hospitals in Queensland, Australia.nnnPARTICIPANTSnThe trial included 3,283 adult medical and surgical patients (5,907 catheters) with a PIVC with greater than 4 days of expected use.nnnRESULTSnModifiable risk factors for occlusion included hand, antecubital fossa, or upper arm insertion compared with forearm (hazard ratio [HR], 1.47 [95% confidence interval (CI), 1.28-1.68], 1.27 [95% CI, 1.08-1.49], and 1.25 [95% CI, 1.04-1.50], respectively); and for phlebitis, larger diameter PIVC (HR, 1.48 [95% CI, 1.08-2.03]). PIVCs inserted by the operating and radiology suite staff had lower occlusion risk than ward insertions (HR, 0.80 [95% CI, 0.67-0.94]). Modifiable risks for accidental removal included hand or antecubital fossa insertion compared with forearm (HR, 2.45 [95% CI, 1.93-3.10] and 1.65 [95% CI, 1.23-2.22], respectively), clinical staff insertion compared with intravenous service (HR, 1.69 [95% CI, 1.30-2.20]); and smaller PIVC diameter (HR, 1.29 [95% CI, 1.02-1.61]). Female sex was a nonmodifiable factor associated with an increased risk of both phlebitis (HR, 1.64 [95% CI, 1.28-2.09]) and occlusion (HR, 1.44 [95% CI, 1.30-1.61]).nnnCONCLUSIONSnPIVC survival is improved by preferential forearm insertion, selection of appropriate PIVC diameter, and insertion by intravenous teams and other specialists.nnnTRIAL REGISTRATIONnThe original randomized controlled trial on which this secondary analysis is based is registered with the Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au; ACTRN12608000445370).

Role of overcrowding in meticillin-resistant Staphylococcus aureus transmission: Bayesian network analysis for a single public hospital

The transmission of multiple antibiotic-resistant organisms (MROs) in hospitals is affected by many inter-related factors. These include the background prevalence of the organism (burden), hand hygiene, the efficiency of patient screening, the isolation or cohorting of carriers, the quality of hospital cleaning, and bed occupancy. In addition, the prevalence of one MRO may influence the transmission of another by occupying isolation beds, and thus reducing isolation resources for the latter. For example, the overuse of third generation cephalosporin antibiotics can increase extended-spectrum β-lactamase-producing Klebsiella pneumoniae, thus indirectly influencing the transmission of meticillin-resistant Staphylococcus aureus (MRSA). In order to study this complex system of interrelationships, we have employed a Bayesian network. We report results of the first two years of analysis for a single public hospital. We conclude that, within this institution, the association between high bed occupancy and increased transmission of MRSA may be subject to a dynamic multidimensional threshold and tipping point. This may be influenced by other factors such as MRSA burden and whether the high bed occupancy interferes with preparation and cleaning of beds for new patients and with hand hygiene and efforts to isolate or cohort carriers.

REPRESENTATIVENESS OF HONEYPOT TRIAL PARTICIPANTS TO AUSTRALASIAN PD PATIENTS

Background: The HONEYPOT trial failed to establish the superiority of exit-site application of Medihoney compared with nasal mupirocin prophylaxis for the prevention of peritonitis in peritoneal dialysis (PD) patients. This study aimed to assess the representativeness of the patients in the HONEYPOT trial to the Australian and New Zealand PD population. Methods: This study compared baseline characteristics of the 371 PD patients in the HONEYPOT trial with those of 6,085 PD patients recorded on the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Results: Compared with the PD population, the HONEYPOT sample was older (standardized difference [d] = 0.19, p = 0.003), more likely to be treated with automated PD (d = 0.58, p < 0.001), had higher residual renal function (d = 0.26, p < 0.001) and a higher proportion of participants with end-stage kidney disease due to polycystic kidney disease (d = 0.17) and lower proportion due to diabetes (d = -0.17) and glomerulonephritis (d = -0.18) (p < 0.001), and lower proportions of indigenous people (d = -0.17, p < 0.001), current smokers (d = -0.10, p < 0.001), and people with prior histories of hemodialysis (d = -0.16, p < 0.001), diabetes mellitus (d = -0.18, p < 0.001), and coronary artery disease (d = -0.15, p < 0.001). Conclusions: HONEYPOT trial participants tended to be healthier than the Australian and New Zealand PD patient population. Although the differences between the groups were generally modest, it is possible that their cumulative effect may have had some impact on external generalizability, which is not an uncommon occurrence in clinical trials.

Using Centers for Disease Control National Nosocomial Infections Surveillance surgical site infection risk-adjustment for a group of related orthopaedic procedures

Abstract An important component of hospital infection control is surveillance to detect diminished levels of care and unforeseen problems. This involves morbidity and mortality audit and sequential data analysis using control charts and time series methods. In addition, regular public reporting of among-institution aggregated data is necessary for transparency and accountability. Analysis of hospital adverse event data may require risk-adjustment (RA) to ensure that changes are not due to differing patient populations. We examine the use of National Nosocomial Infections Surveillance surgical site infection (SSI) RA using data on 12 838 orthopaedic procedures. We evaluate the effectiveness of RA for these data using observed and expected tabulations and assessing discrimination by calculating the area under the Receiver Operating Characteristic Curve (AUC). RA may be of greater use with complex (deep and organ space) rather than all SSIs (superficial plus complex). We therefore suggest that, when reference data are available, the value of RA should be tested empirically. When there is no practically important difference between observed and expected reference data SSI rates, or when the AUC value is low, for example below 0.6, RA may be unnecessary.

Nosocomial Urinary Tract Infections

Nosocomial urinary tract infections (UTls) are the most common cause of nosocomial infection, and are an important cause of septicaemia and mortality. The problem occurs in both acute-care and long-stay facilities. Despite improvements in the understanding of nosocomial UTls and infection control practices, the incidence has remained fairly constant over the past two decades.