Central-line Bloodstream Infections Research Articles

Patient-level cost analysis of intensive care unit-acquired infections: a prospective cohort study

Hospital-associated infections (HAIs) are associated with increased mortality and prolonged hospital length-of-stay (LOS). Although some studies have shown that HAIs are associated with increased costs, these studies only used cost estimates, were carried out in a small number of centres, or only in high-income countries. We carried out a prospective cohort study in ten Brazilian intensive care units (ICUs) selected from a collaborative platform study (IMPACTO MR). We included all patients aged 18 years or older admitted from October 2019 to December 2021 and who had an ICU LOS of at least two days. The costs were adjusted for official inflation until December 2022 and converted into international dollars using the 2021 purchasing power parity (PPP) conversion rate. We used a propensity score matching method to compare patients with HAIs and patients without HAIs, and patients with and without ventilator-associated pneumonia (VAP), central-line bloodstream infection (CLABSI), catheter-associated urinary tract infection (CA-UTI) and multidrug-resistant (MDR) HAIs. We included 7,953 patients in the study, of whom 574 (7.2%) had an HAI during their ICU stay. After propensity-score matching, patients with HAIs had ICU costs that were more than three times higher than those of patients without HAIs [$ 19,642 (IQR; 12,884-35,134) vs. 6,086 (IQR; 3,268-12,550); p <0.001). Patients with VAP, CLABSI, and CA-UTI, but not with MDR-HAIs also had higher total ICU costs. HAIs acquired in the ICU are associated with higher ICU costs. These findings were consistent across specific types of infection.

Impact of Vascular Access Teams on Central Line Associated Bloodstream Infections

Background: During the COVID-19 pandemic, rates of central line bloodstream infections (CLABSI) increased nationally. Studies pre-pandemic showed improved CLABSI rates with implementation of a standardized vascular access team (VAT).[PL1] [PL2] [mi3] Varying VAT resources and coverage existed in our 10 acute care facilities (ACF) prior to and during the pandemic. VAT scope also varied in 1) process for line selection during initial placement, 2) ability to place a peripherally inserted central catheter (PICC), midline or ultrasound-guided peripheral IV in patients with difficult vascular access, 3) ownership of daily assessment of central line (CL) necessity, and 4) routine CL dressing changes. We aimed to define and implement the ideal VAT structure and evaluate the impact on CLABSI standardized infection ratios (SIR) and rates prior to and during the pandemic. Methods: A multidisciplinary workgroup including representatives from nursing, infection prevention, and vascular access was formed to understand the current state of VAT responsibilities across all ACFs. The group identified key responsibilities a VAT should conduct to aid in CLABSI prevention. Complete VAT coverage[mi4] was defined as the ability to conduct the identified responsibilities daily. We compared the SIR and CLABSI rates between hospitals who had complete VAT (CVAT) coverage to hospitals with incomplete VAT (IVAT) coverage. Given this work occurred during the pandemic, we further stratified our analysis based on a time frame prior to the pandemic (1/2015 – 12/2019) and intra-pandemic (1/2020 - 12/2022). Results: The multidisciplinary team identified 6 key components of complete VAT coverage: Assessment for appropriate line selection prior to insertion, ability to insert PICC and midlines, daily CL and midline care and maintenance assessments, daily assessment of necessity for CL, and weekly dressing changes for CL and midlines[NA5] . A cross walk of VAT scope (Figure 1) was performed in October 2022 which revealed two facilities (A and E) which met CVAT criteria. Pre-pandemic, while IVAT CLABSI rates and SIR were higher than in CVAT units, the difference was not statistically significant. During the pandemic, however, CLABSI rates and SIR were 40-50% higher in IVAT compared to CVAT facilities (Incident Rate Ratio 1.5, 95% CI 1.1-2.0 and SIR Relative Ratio 1.4, 95% CI1.1-1.9 respectively) (Table 1). Conclusions: CLABSI rates were lower in facilities with complete VAT coverage prior to and during the COVID-19 pandemic suggesting a highly functioning VAT can aid in preventing CLABSIs, especially when a healthcare system is stressed and resources are limited.

Impact of Povidone Application to Nares in Addition to Chlorhexidine Bath in Critically Ill Patients on Nosocomial Bacteremia and Central Line Blood Stream Infection.

Nosocomial Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia results in a significant increase in morbidity and mortality in hospitalized patients. We aimed to analyze the impact of applying 10% povidone iodine (PI) twice daily to both nares in addition to chlorhexidine (CHG) bathing on nosocomial (MRSA) bacteremia in critically ill patients. A quality improvement study was completed with pre and post-design. The study period was from January 2018 until February 2020 and February 2021 and June 2021. The control period (from January 2018 to May 2019) consisted of CHG bathing alone, and in the intervention period, we added 10% PI to the nares of critically ill patients. Our primary outcome is rates of nosocomial MRSA bacteremia, and our secondary outcome is central line associated blood stream infection (CLABSI) and potential cost savings. There were no significant differences in rates of MRSA bacteremia in critically ill patients. Nosocomial MRSA bacteremia was significantly lower during the intervention period on medical/surgical areas (MSA). CLABSIs were significantly lower during the intervention period in critically ill patients. There were no Staphylococcus aureus CLABSIs in critical care area (CCA)during the intervention period. The intervention showed potential significant cost savings. The application of 10% povidone iodine twice a day in addition to CHG bathing resulted in a significant decrease in CLABSIs in critically ill patients and a reduction in nosocomial MRSA in the non-intervention areas. Further trials are needed to tease out individual patients who will benefit from the intervention.

Disparities in Racial, Ethnic, and Payer Groups for Pediatric Safety Events in US Hospitals.

Health care disparities are pervasive, but little is known about disparities in pediatric safety. We analyzed a national sample of hospitalizations to identify disparities in safety events. In this population-based, retrospective cohort study of the 2019 Kids' Inpatient Database, independent variables were race, ethnicity, and payer. Outcomes were Agency for Healthcare Research and Quality pediatric safety indicators (PDIs). Risk-adjusted odds ratios were calculated using white and private payer reference groups. Differences by payer were evaluated by stratifying race and ethnicity. Race and ethnicity of the 5 243 750 discharged patients were white, 46%; Hispanic, 19%; Black, 15%; missing, 8%; other race/multiracial, 7%, Asian American/Pacific Islander, 5%; and Native American, 1%. PDI rates (per 10 000 discharges) were 331.4 for neonatal blood stream infection, 267.5 for postoperative respiratory failure, 114.9 for postoperative sepsis, 29.5 for postoperative hemorrhage/hematoma, 5.6 for central-line blood stream infection, 3.5 for accidental puncture/laceration, and 0.7 for iatrogenic pneumothorax. Compared with white patients, Black and Hispanic patients had significantly greater odds in 5 of 7 PDIs; the largest disparities occurred in postoperative sepsis (adjusted odds ratio, 1.55 [1.38-1.73]) for Black patients and postoperative respiratory failure (adjusted odds ratio, 1.34 [1.21-1.49]) for Hispanic patients. Compared with privately insured patients, Medicaid-covered patients had significantly greater odds in 4 of 7 PDIs; the largest disparity occurred in postoperative sepsis (adjusted odds ratios, 1.45 [1.33-1.59]). Stratified analyses demonstrated persistent disparities by race and ethnicity, even among privately insured children. Disparities in safety events were identified for Black and Hispanic children, indicating a need for targeted interventions to improve patient safety in the hospital.

2457. Improved Identification of Primary Infection Sites in Suspect Central Line Bloodstream Infections (CLABSI) through Preliminary Blood Culture Notifications

Abstract Background Central Line Bloodstream Infections (CLABSI) pose a significant risk for patients with high burden of morbidity and mortality. Accurate and timely identification of these events is paramount for the development of effective interventions. Methods A quasi-experimental (before/after) study included all inpatients with central venous catheters (CVC) admitted to five acute care hospitals in North Carolina. Starting in 03/2022 all preliminary blood culture results were evaluated within 24 hours by surveillance infection preventionists (SIP) and results indicative of potential CVC infection were escalated to medical teams. Escalation included identification of potential primary site infections, and discussion of the need for further testing and documentation. Mid-P exact tests were used to compare CLABSI burden before and after the intervention. Results From 03/22 through 03/23 preliminary blood culture results in a total of 498 cases were reviewed by SIP. Of those, 201 (40%) were escalated to the IP team with 94 determined to be CLABSI, and 107 (53%) referred to further assessment by IP and medical teams. A primary infection site other than CVC was established based on escalation conversations in 23 events leading to a reduction in potential CLABSI cases by 11.4%. Standardized Infection Ratios for all and publicly reportable locations were reduced by 13% and 27% (table 1). Of the 23 events interventions led to the establishment of a primary site of infection or documentation for exclusion criteria: pneumonia (9, 39%), burn (6, 26%), endocarditis (2, 9%), patient line injection (2, 9%), central line documentation clarification (1, 4%), intraabdominal infection (1, 4%), necrotizing enterocolitis (1, 4%), and skin infection (1, 4%). Interventions included imaging studies, culture collection of purulent sites, and documentation clarification including: abnormal/changes in wound characteristics, patient line injection, central line documentation. Conclusion Moving the process of CLABSI identification from finalized blood cultures to preliminary blood culture results improved the accuracy of CLABSI detection. Early inclusion of medical teams in the discussion of potential CLABSI increased awareness of the source of infection. Disclosures All Authors: No reported disclosures

Modifying water use practices to eliminate Pseudomonas aeruginosa bloodstream infections in the neonatal intensive care unit

Objective: To describe the strategies implemented at a tertiary-care healthcare center neopnatal intensive care unit (NICU) to control and assure prevention of subsequent central-line bloodstream infections (CLABSIs) with Pseudomonas aeruginosa after 4 cases of CLABSI with this organism were detected. Methods: During the months of September 2020 to February 2021, 4 cases of CLABSI with Pseudomonas aeruginosa were reported in our NICU in patients meeting criteria for extremely low birthweight (ELBW) infants. All patients were treated according to IDSA guidelines for management of bloodstream infections. To avoid the appearance of new events and to improve existing policies, we implemented a stepwise approach by reviewing routine disinfection and/or cleaning procedures of isolettes: (1) liners for bath basins were applied, (2) sterile water was provided for bathing newborns, (3) we ensured timely biomed preventive maintenance of water reservoirs for patient care equipment (nebulizers, isolettes and fluid warmers), and (4) we implemented the installment of point-of-care filters for tap water. Results: Measures were implemented from February 2021 to July 2021. During the following year from July 2021 to June 2022, no CLBSIs related to Pseudomonas aeruginosa were reported in our NICU in patients meeting criteria for ELBW infants. Conclusions: Recognition of CLABSI from organisms from water resources is important to implementing focused prevention strategies targeting water resources and water utilization practices. In our institution, these interventions yielded complete resolution, with no new infection events.Disclosure: None

Preventing Central Line Bloodstream Infections: An Interdisciplinary Virtual Model for Central Line Rounding and Consultation

Background: Central line–associated bloodstream infections (CLABSI) account for many harms suffered in healthcare and are associated with increased costs and disease burden. Central line rounds, like medical rounds, are a multidisciplinary bedside assessment strategy for all active central lines on a unit. In-person line rounds in this 144-bed oncology acute care setting are challenging due to a variety of unchangeable factors. The aim was to develop a process for addressing concerning central lines in this context. Methods: The project team designed a HIPAA-protected, text-based process for assessing central lines for risk factors contributing to infection. Staff initiated a consultation via a virtual platform with an interdisciplinary team composed of oncology and infectious diseases experts. The virtual discussion included recommendations for a line-related plan of care. Results: The number of consultations averaged about five per month, with 27.4% resulting in the central line being removed, which is believed to have contributed to an overall reduction in infection rates. The CLABSI standardized infection ratio, a risk-adjusted measure which accounts for patient acuity and volumes, improved from 0.85 prior to the intervention (November 2020–October 2021) to 0.57 after the intervention (November 2021–August 2022), a 33% reduction. Conclusion: A virtual process for central line consultation and interdisciplinary planning was effective and, in this setting, perhaps optimal. This type of process could be applied to nearly any aspect of clinical care where teams are solving problems in an environment with complex geography and relationships.

The Attributable Factors That Increase the Likelihood of Central Line Associated Blood Stream Infection Related In-Hospital 30-Day Mortality.

The objective is to investigate the attributable factors associated with an increase in hospital 30-daymortality of central line bloodstream infection (CLABSI). A retrospective cohort study was conducted at King Saud University Medical City (KSUMC). The sample included adult patients who developed CLABSI between March 2016 and February 2018 after having a central line inserted at KSUMCin Riyadh, Saudi Arabia. A total of 283 patients were involved in the study. The 30-day mortality rate was 18.8%. Patients were more likely to die if they were in the intensive care unit (ICU) or required ICU admission after infection (p<0.001). This was also observed in patients who required inotropes or intubation before or after culture (p<0.001). There was a statistically significant difference of 6.60±5.62 in the mean score on the Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II between before and after culture (p<0.001). The likelihood of death was significantly higher among patients with higher APACHE II scores before and after culture (p<0.001). The presence of CLABSI-related sequelae was not associated with increased mortality (p<0.595). The clinical characteristics of CLABSI patients are variable and can increase the risk of mortality or complicate the treatment course. Physicians should be aware of the significance of these factors as potential causes of increased mortality.

2022 Association for Vascular Access Scientific Meeting: Poster Abstracts

2022 Association for Vascular Access Scientific Meeting: Poster Abstracts

Midline Catheters: Could They Replace a Central Vascular Access Device?

In the past 30 years, midline catheter use has grown rapidly. For several reasons, many providers and facilities are attempting to reduce the number of central venous catheters and subsequent central line-associated bloodstream infections (CLABSIs) by using midline catheters. Vessel preservation requires attention to all vascular access device (VAD)-associated complications and not only central line bloodstream infection. There is still much confusion about the appropriate tip location and the characteristics of fluids and medications that can safely be infused through a midline catheter residing in a peripheral vein. The Infusion Therapy Standards of Practice (the Standards) focuses on assessment of characteristics of infusion therapies that must be considered for VAD selection as an evidence-based list of fluids and medications for infusion through peripheral veins has yet to be established. This review of midline catheter studies evaluates the evidence regarding the substitution of a midline catheter for a central venous catheter. Many issues need to be addressed, such as studies that include an outcome list that mixes defined clinical complications (eg, thrombosis) with signs and symptoms of complications (eg, leaking). Another issue is basing a major change of clinical practice on retrospective chart reviews. Although a midline catheter may be appropriate for some patients, additional studies of a higher level of evidence are needed before this major practice change should occur.

Developing an Infection Prevention Training Program for Infectious Disease Fellows

Background Hospital Infection Prevention (IP) is an increasingly important subdiscipline within infectious diseases (ID). We developed and evaluated a 2-week IP training program to allow ID fellows the opportunity to learn about IP. We aimed to educate on the scope of IP work with a focus on the role of ID within IP. Methods A training program was developed covering the role of IP in preventing hospital acquired infections focusing on 3 key areas: device related infections, outbreak exposures, and the hospital physical environment. We utilized the National Healthcare Safety Network (NHSN) patient safety component manual combined with practical experience performing surveillance, rounding and case study reviews. The effectiveness and utility of the program was evaluated with a pre- and post-training survey categorized on a Likert response scale (not at all familiar=1, slightly familiar=2, somewhat familiar=3, extremely familiar=4). Results The mean scored survey responses showed that prior to the rotation fellows reported slight familiarity with the scope of work of IP but had very little familiarity with the IP team members. All fellows reported slight familiarity with NHSN defined device related infections, the role of IP in outbreak investigations and their role in construction projects. Fellows reported that prior to their IP rotation they would be only slightly likely to contact the IP department for assistance or notification of a potential infection risk. Following the rotation, fellows reported being extremely familiar to all topics covered during the rotation. All fellows reported the rotation to be extremely useful. Conclusions The program was successful in improving the understanding of the scope of IP work. Fellows understood their role in documentation when a primary source of infection is suspected during central line bloodstream infection surveillance and the importance of communication when a hospital acquired environmental infection is suspected. The rotation has also fostered relationships between the departments. Hospital Infection Prevention (IP) is an increasingly important subdiscipline within infectious diseases (ID). We developed and evaluated a 2-week IP training program to allow ID fellows the opportunity to learn about IP. We aimed to educate on the scope of IP work with a focus on the role of ID within IP. A training program was developed covering the role of IP in preventing hospital acquired infections focusing on 3 key areas: device related infections, outbreak exposures, and the hospital physical environment. We utilized the National Healthcare Safety Network (NHSN) patient safety component manual combined with practical experience performing surveillance, rounding and case study reviews. The effectiveness and utility of the program was evaluated with a pre- and post-training survey categorized on a Likert response scale (not at all familiar=1, slightly familiar=2, somewhat familiar=3, extremely familiar=4). The mean scored survey responses showed that prior to the rotation fellows reported slight familiarity with the scope of work of IP but had very little familiarity with the IP team members. All fellows reported slight familiarity with NHSN defined device related infections, the role of IP in outbreak investigations and their role in construction projects. Fellows reported that prior to their IP rotation they would be only slightly likely to contact the IP department for assistance or notification of a potential infection risk. Following the rotation, fellows reported being extremely familiar to all topics covered during the rotation. All fellows reported the rotation to be extremely useful. The program was successful in improving the understanding of the scope of IP work. Fellows understood their role in documentation when a primary source of infection is suspected during central line bloodstream infection surveillance and the importance of communication when a hospital acquired environmental infection is suspected. The rotation has also fostered relationships between the departments.

The downstream effects of the COVID-19 pandemic: The supply chain failure, a wicked problem

The failure of the global supply chain became rapidly apparent at the beginning of the COVID-19 pandemic when healthcare organizations were left without supplies needed to care for patients. The supply chain failure is one downstream effect of the pandemic and indirectly impacts patient morbidity and mortality. This column presents a case study of one staff nurse's experience working in a pediatric intensive care unit at a rural children's hospital two years into the pandemic and the toll the global supply chain failure continues to take on patients and healthcare professionals. Central Line Blood Stream Infections (CLABSIs) are used to showcase the severity of the supply chain failure at the point of care. Standardized central line insertion and care bundles have proven to be effective in reducing the incidence of CLABSI; however, they are dependent on the availability of materials and supplies. Health care providers face a “wicked problem" in preventing CLABSIs. The failure of the global supply chain must be examined by healthcare organizations, manufacturers, and government officials so that new systems can be put into place, so we are prepared for a public health emergency.

Central Venous Line Bloodstream Infections during Hematopoietic Stem Cell Transplantation for Primary Immunodeficiency Disorders

Central Venous Line Bloodstream Infections during Hematopoietic Stem Cell Transplantation for Primary Immunodeficiency Disorders

Impact of number of lumens in central-venous catheters on central-line bloodstream infection (CLABSI) and venous thromboembolism (VTE) risk in patients with acute leukemia.

This retrospective study was conducted to determine whether the number of peripherally inserted central-catheter lumens affected the rate of central-line associated bloodstream infections (CLABSIs) in adult patients with acute leukemia. The results show that CLABSI rates were not significantly different between patients with triple-lumen or double-lumen PICCs (22.1% vs 23.4%; P = .827).

Implementing a Robust Process Improvement Program in the Neonatal Intensive Care Unit to Reduce Harm.

ABSTRACTIntroduction:Preventable harm continues to occur with critically ill neonates despite efforts by hospital neonatal intensive care units (NICUs) to improve processes and reduce harm. Attaining significant and sustainable improvements will require training including leadership support, mentoring, and patient family engagement to improve care processes. This paper describes the implementation of a robust process improvement (RPI) program in the NICU to reduce harm.Methods:Leaders, staff, and parents were trained in RPI concepts and tools. Multidisciplinary teams including parent members applied the training and received regular mentorship for their improvement initiatives.Results:Participants (N = 67) completed pretraining and post-training surveys. Training scores (0–10 scale) improved from an average of 4.45–7.60 (p < .001) for confidence in leading process improvement work, 2.36 to 7.49 (p < .001) for RPI knowledge, and 2.19 to 7.30 (p < .001) for confidence in using RPI tools; relative improvement of 71%, 217%, and 233% respectively. Participants applied their RPI training on improvement initiatives that resulted in improvements of central line blood stream infections, very low birth weight infant nutrition, and unplanned extubations.Conclusions:Implementing an RPI program in the NICU to reduce harm resulted in significant and sustainable improvements on their improvement initiatives.

Trends in central-line-associated bloodstream infections and catheter-associated urinary tract infections in a large acute-care hospital system in New York City, 2016-2019.

Central-line bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) negatively impact clinical outcomes and hospital reimbursement. In this report, 4 year trends involving 11 hospitals in New York City were examined. Data from the National Healthcare Safety Network (NHSN) were extracted for 11 acute-care hospitals belonging to the NYC Health + Hospital system from 2016 through 2019. Trends in device infections per 1,000 patient days, device utilization ratios, and standardized infection ratios (SIRs) were examined for the 11 hospitals and for the entire system. Over the 4-year period, there were progressive declines in central-line days, infections per 1,000 central-line days, and device utilization ratios for the system. The average annual SIRs for the system also declined: 1.40 in 2016, 1.09 in 2017, 1.04 in 2018, and 0.82 in 2019. Case-mix indices correlated with SIRs for CLABSIs. Level 1 trauma centers had higher SIRs and a disproportionately greater number of CLABSIs in patients located in NHSN-defined surgical intensive care units. Similar trends with CAUTIs were noted, with progressive declines in catheter days, infections per 1,000 patient days, device utilization ratios, and SIRs (1.42 in 2016, 0.93 in 2017, 1.18 in 2018, and 0.78 in 2019) over the 4-year period. Across an 11-hospital system, continuing efforts to reduce device utilization and infection rates resulted in declining SIRs for CLABSIs and CAUTIs. Hospitals with higher case-mix indices, and particularly level 1 trauma centers, had significantly higher central-line infection rates and SIRs.

No Device, No Problem? Healthcare-Associated Bloodstream and Urinary Tract Infections in a Children’s Hospital

Background: Central-line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) definitions continue to be refined to ensure accuracy. As facilities decrease CLABSI and CAUTI, and as midline catheters become more widely utilized, we sought to understand our non–central-line bloodstream infections (NCLBSI) and non–catheter-associated urinary tract infections (NCAUTI). Total healthcare-associated bloodstream infections (HABSIs) and urinary tract infections (HAUTIs) may provide more objective measures. Methods: The CHOC Children’s Hospital is a 334-bed quaternary-care hospital in Orange, California, with 146 intensive care unit (ICU) beds. We retrospectively reviewed all HABSIs (CLABSIs + NCLBSIs) and HAUTIs (CAUTIs + NCAUTIs) from July 1, 2016, to June 30, 2019, for demographic and microbiologic data. Both HABSI and HAUTI were defined as healthcare-associated infection when the date of event occurs on or after the third calendar day of admission. CLABSI and CAUTI were both defined using CDC-NHSN criteria. Mucosal barrier injury laboratory-confirmed bloodstream infections were excluded. Results: In a 3-year period, there were 100 HABSIs, of which 26 (26%) were NCLBSIs. The mean age for HABSI was 81 months. Enteric gram-negative infections (42%) and Staphylococcus aureus (35%) were the most common etiology for NCLBSI. The most common etiologies for CLABSI were coagulase-negative staphylococci (23%), Staphylococcus aureus (22%), and enteric gram-negatives (22%). Pseudomonas aeruginosa accounted for 16% of CLABSIs, but no NCLBSIs (Fig. 1). There was 1 midline catheter NCLBSI. There were 49 HAUTIs, of which 39 (80%) were NCAUTIs. One asymptomatic bacteremic urinary tract infection was included with the CAUTIs. The mean age for HAUTI was 55 months. The most common etiology of CAUTI was Pseudomonas aeruginosa (50%), whereas for NCAUTI the most common etiology was enteric gram-negative organisms (69%) (Fig. 2). In total, 11 HAUTIs (22%) resulted in secondary sepsis. Most HABSIs and HAUTIs occurred in the ICU setting. There were 6 deaths (6%) among HABSI patients and 3 deaths (8%) among HAUTI patients within 2 weeks of infection (Fig. 3). Conclusions: A preponderance of HABSIs were CLABSIs, but most HAUTIs were NCAUTIs. Although patient demographic and microbiologic differences exist in CLABSIs and NCLBSIs as well as CAUTIs and NCAUTIs, S. aureus and P. aeruginosa are important pathogens, particularly in device-associated infections. Trending total numbers of HABSIs and HAUTIs may be less subjective and may avert the shifting of categories seen with increased use of midline catheters. In addition, non–device-associated infections are potential causes of morbidity and mortality.Funding: NoneDisclosures: None

Intestinal failure-associated liver disease (IFALD): insights into pathogenesis and advances in management.

Premature infants and children with intestinal failure (IF) or short bowel syndrome are susceptible to intestinal failure-associated liver disease (IFALD, previously referred to as parenteral nutrition-associated liver disease, or PNALD). IFALD in children is characterized by progressive cholestasis and biliary fibrosis, and steatohepatitis in adults, and is seen in individuals dependent upon prolonged administration of PN. Many factors have been proposed as contributing to the pathogenesis of IFALD. In recent years, the focus has been on the potential synergistic roles of the intestinal microbiome, increased intestinal permeability, activation of hepatic innate immune pathways, and the use of intravenous soybean-oil-based intravenous lipid emulsions (SO-ILE). In vitro and in vivo studies have identified stigmasterol, a component of the plant sterols present in SO-ILE, as playing an important role. Although various strategies have been adopted to prevent or reverse IFALD, most suffer from a lack of strong evidence supported by well-designed, prospective clinical trials with clearly defined endpoints. Reduction in the amount of SO-ILEs or replacement with non-SO-ILEs has been shown to reverse IFALD although safety and long-term effectiveness have not been studied. Medical and surgical modalities to increase intestinal adaptation, advance enteral feedings, and prevent central line bloodstream infections are also important preventative strategies. There is a continued need to conduct high-quality, prospective trials with clearly define outcome measures to ascertain the potential benefits of these strategies.

Improvement in Patient Safety May Precede Policy Changes: Trends in Patient Safety Indicators in the United States, 2000-2013.

Quality and safety improvement are global priorities. In the last two decades, the United States has introduced several payment reforms to improve patient safety. The Agency for Healthcare Research and Quality (AHRQ) developed tools to identify preventable inpatient adverse events using administrative data, patient safety indicators (PSIs). The aim of this study was to assess changes in national patient safety trends that corresponded to U.S. pay-for-performance reforms. This is a retrospective, longitudinal analysis to estimate temporal changes in 13 AHRQ's PSIs. National inpatient sample from the AHRQ and estimates were weighted to represent a national sample. We analyzed PSI trends, Center for Medicaid and Medicare Services payment policy changes, and Inpatient Prospective Payment System regulations and notices between 2000 and 2013. Of the 13 PSIs studied, 10 had an overall decrease in rates and 3 had an increase. Joinpoint analysis showed that 12 of 13 PSIs had decreasing or stable trends in the last 5 years of the study. Central-line blood stream infections had the greatest annual decrease (-31.1 annual percent change between 2006 and 2013), whereas postoperative respiratory failure had the smallest decrease (-3.5 annual percent change between 2005 and 2013). With the exception of postoperative hip fracture, significant decreases in trends preceded federal payment reform initiatives. National in-hospital patient safety has significantly improved between 2000 and 2015, as measured by PSIs. In this study, improvements in PSI trends often proceeded policies targeting patient safety events, suggesting that intense public discourses targeting patient safety may drive national policy reforms and that these improved trends may be sustained by the Center for Medicare and Medicaid Services policies that followed.

Incidence of catheter-related bloodstream infections after removal of peripherally inserted central catheters in preterm neonates

Background: Peripherally inserted central catheter (PICC) have become essential for a safe and reliable long term venous access in all neonatal intensive care units (NICU) for providing long term intravenous fluids and medications. However, they associated with central line blood stream infections (CRBSI) infections and it is postulated that this risk is more on during their removal but the true incidence is not known. The objective was to evaluate the incidence and identify risk factors associated with CRBSI following the PICC removal in preterm neonates.Methods: This was a retrospective cohort study was done on &lt;37 weeks premature neonates. Data included patient particulars, location of PICC placement, days of PICC, antibiotics and TPN through PICC, infections noted during or within 48 hours of PICC removal.Results: A total of 238 PICC removals in 215 neonates were analysed which did not show a significant difference in the prevalence of CRBSI within 48 hours of PICC removal. However, there was an increase in odds for sepsis following PICC removal in less than 29 weeks gestation and if it was not used for antibiotic infusion for more than 48 hours preceding its removal.Conclusions: This study does not support the use of prophylactic antibiotics during PICC removal in neonates as there was no increase in the incidence of CRBSI following PICC removal. However, they may have a role in very low gestation age, low birth weight infants who have not recently received antibiotics prior to PICC removal.