Central Line Infections Research Articles

Beating the Benchmark: Adopting a Learning Organization Approach to Clabsi Reduction in BMT

Topic Significance & Study Purpose/Background/Rationale Preventing central line-associated blood stream infections (CLABSIs) is a priority in blood and marrow transplantation (BMT). A central line infection is both costly and potentially a fatal event. Our hybrid unit of 33 inpatient beds and seven outpatient rooms is designed for hematology/oncology patients receiving autologous and allogeneic BMT. According to the National Healthcare Safety Network (2013), our unit is classified as a hematology/oncology unit, with a CLABSI benchmark of 1.4 per 1000 central line days, not a BMT unit with a rate of 2.6 (NHSN, 2013). In 2016, an analysis of our practice identified opportunities for improvement based on a BMT CLABSI rate of 2.5. The goal of this quality improvement initiative was to reduce the CLABSI rate below the benchmark of 1.4, a 44% reduction. Methods, Intervention, & Analysis Our approach included: a collaborative unit-based task force of direct care nurses, nursing assistants, nurse managers, advanced practice providers, infection preventionists and quality specialists; standardizing central line catheters for BMT patients; and clinical surveillance with a focus on line care. Nurse-sensitive practice changes included: education of BMT nurses and assistants, focused risk awareness and practice “musts”; continual review of data at all task force and staff meetings; minimizing intravenous tubing disconnections; product changes for line care; and focused patient education. Findings & Interpretation Subsequent to interventions outlined below, we achieved a remarkable improvement, achieving a rate much less than the national benchmark of 1.4. With the exception of mucosal barrier injury-related CLABSIs, the 2016 CLABSI rate of 2.5 was reduced to zero in 2017, and 0.59 in 2018 (attributed to an increase in allogeneic transplant volume and acuity). The current 2019 rate is zero! Discussion & Implications CLABSI prevention is best accomplished by creating a team environment, where everyone involved is a stakeholder. Reflection and shared decision-making can result in a significant, sustained CLABSI rate reduction in BMT.

Comparison of Hickman Versus Proline Central Venous Catheters in Pediatric Patients Undergoing Hematopoietic Stem Cell Transplant

Introduction Central venous catheter (CVC) access is an essential component of pediatric hematopoietic stem cell transplant (HSCT). Long-term CVC access is associated with an increased risk of infection and device dysfunction. Studies have shown that one in four CVC devices in the pediatric population require removal prior to completion of treatment due to infectious or mechanical complications. A retrospective analysis evaluated CVC-related complications in Hickman versus Proline catheters among pediatric HSCT recipients. Methods We performed a detailed retrospective chart review of CVC related complications among pediatric patients who underwent HSCT between June 2016 and October 2019. During the study period there was a change in the standard CVC access device from Hickman to Proline catheter. We compared the complications related to Hickman Catheter (Cohort 1) to Proline line (Cohort 2). All patients received antibacterial prophylaxis with cefepime. Results Thirty- two patients with a median age 7 years (range 0.75-19) underwent HSCT for malignant (N=16) or nonmalignant (N=16) disease. The majority underwent allogeneic HSCT (N=29). CVC complications requiring line removal occurred in 3 out of 15 (20%) HSCTs in Cohort 1 in comparison to 2 out of 18 (11%) in Cohort 2. Of the 3 complications in Cohort 1, 2 (66%) were related to infection and 1 (33%) due to device malfunction. Both line removals in Cohort 2 were due to device malfunction. There was one documented central line infection in Cohort 2 that did not require line removal. Conclusion Results of this small pilot study suggests that Proline catheters for long-term access in pediatric HSCT recipients may lead to a decrease incidence of complications requiring line removal in comparison Hickman catheters. Further research is indicated in order to provide recommendations for the optimal CVC for long-term access in pediatric HSCT.

THE EFFECT OF APPLYING NURSING CARE BUNDLE ON CONTROLLING CENTRAL VENOUS LINE INFECTION IN NEONATAL INTENSIVE CARE UNITS

Central venous line (CVL) is a necessary device used frequently in neonatal intensive care units (NICUs) for critically ill neonates who need continuous monitoring and resuscitation treatment. Significant evidence has accumulated indicating that CVL nursing care bundle is considered as an essential component of CVL infection prevention practice to combat the incidence of CVL infection. Aim: This study aimed to examine the effect of applying nursing care bundle on controlling central venous line infection in neonatal intensive care units. Subject and method: A quasi-experimental design was used. The study was conducted at NICU at Kafr El Sheikh General Hospital. The study included a convenience sample of all available bedside/ working nurses (n= 30), 79 preterm infant (recruited for 3 months’ period). Tools: Three tools were used to collect data. Tool 1: An interview questionnaire for nurse's knowledge. Tool 2: Observational checklist used to assess nurses’ performance regarding CVL care bundle. Tool 3: Laboratory investigations tool for preterm infants. Results: More than half of studied nurses (56.7%) didn't receive any training program about CVL care bundle for controlling CVL infection in NICU and the majority of the studied nurses had insufficient knowledge, as well as the majority of the studied nurses, had an unsatisfactory practice regarding CVL care bundle preprogram. The sufficient knowledge level and satisfactory practices had improved immediately post and 3 months post program implementation. About half (51,9%) had negative CRP post-program implementation, while (54,4%) of neonates had negative blood culture post-program. Conclusion: The program had a positive effect on the NICU nurses’ knowledge & practices immediately post& post 3 months of the program implementation. Recommendation: Including CVL nursing care bundle practices into nurses’ routine care and developing regular and continuous educational programs for the nurses in NICU according to their needs aiming to upgrading their knowledge and improving their practice for critically ill neonates.

Impact of allogeneic blood transfusions on clinical outcomes in severely burned patients.

Allogeneic blood transfusions are common in the treatment of severely burned patients as surgery may lead to major blood loss. However, transfusions are associated with a number of adverse events. Therefore, the purpose of our study was to investigate the impact of allogeneic blood transfusions on clinical outcomes in severely burned patients. This retrospective study included all adult patients admitted to the burn center of the University Hospital Zurich between January 2004 and December 2014, with burn injuries greater than 10% of total body surface area and receiving both surgical and intensive care treatment. Primary Endpoints were infectious or thromboembolic complications and mortality and secondary endpoints were length of hospital and ICU stay. Simple and multivariable logistic and linear regression models, adjusted for injury severity and confounders, were applied. 413 patients met inclusion criteria of which 212 patients (51%) received allogenic blood products. After adjustment for injury severity and confounders, red blood cell transfusion was independently associated with wound infection (OR 13.5, 95% CI 1.7-107, p = 0.014), sepsis (OR 8.3, 4.2-16.3; p < 0.001), pneumonia (OR 4.7, 2.2-10.0; p < 0.001), thrombosis (OR 3.0, 1.2-7.4; p = 0.015), central line infection (OR 34.7, 4.6-260; p = 0.001) and a longer ICU and hospital stay (difference 17.7, CI 12.1-23.4, p < 0.001 and 22.0, 15.8-28.2, p < 0.001, respectively). Fresh frozen plasma transfusion was independently associated with a longer ICU and hospital stay (difference 13.7, 95% CI 5.5-21.8, p = 0.001 and 13.5, 4.6-22.5, p = 0.003, respectively). Platelet transfusion was independently associated with systemic inflammatory response syndrome (OR 4.5, 1.3-15.5; p = 0.018) and mortality (OR 5.8, 2.1-16.0; p = 0.001). Transfusion of allogeneic blood products is associated with an increased infection rate and thromboembolic morbidity and a longer hospital stay in severely burned patients.

Associated Co-Morbidities, Healthcare Utilization, and Mortality in Hospitalized Children and Adults with Hemophilia in the United States: Updated Nationally Representative Estimates and a Comparative Analysis

Introduction Hemophilia is one of the most common inherited bleeding disorders. This study aims to estimate associated diagnoses, healthcare utilization, and mortality in hospitalized pediatric and adult patients with hemophilia A and B and evaluate outcome improvement trends. Methods The 2016 Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (HCUP-NIS) was utilized for the analysis. The NIS uses a stratified probability sample of 20% of all inpatient discharges (representing more than 97% of the US population). We applied sampling weights to represent all hospital discharges for hemophilia identified using ICD-10 codes D66 and D67 and generate nationally representative estimates. For comparative historical data, we used 2007 data from a prior published study [Goel et al., Hemophilia (2012), 18, 688-692]. Results In 2016, there were n=10,840 hospital discharges with hemophilia A or B as one of all listed diagnoses (n=1600 as principal diagnosis). Of these, 2445 were children, and 8395 were adults. The median age (interquartile range) was 52 (33-68) years for adults and 5 (1-11) years for children. Associated Diagnoses (Table 1a) The most common associated diagnoses in adults with hemophilia were hypertension (34.7 ± 1.2%), Type 2 diabetes (21.1 ± 1.2%), and hyperlipidemia (18.8 ± 1.0%). Other noteworthy ones include hepatitis C (16.4 ± 1.1%), coronary artery disease (13.3 ± 0.9%), and congestive heart failure (11.1 ± 0.8%). In pediatric hemophilia cases, central line infection and fever (13.5 ± 1.5%), hemarthrosis (10.4 ± 1.3%), and anemia (8.6 ± 1.3%) were the most common discharge diagnoses. HIV/AIDS and hepatitis C were not reported in children and listed in 5.9 ± 0.6% and 16.4 ± 1.1% of adults, with the youngest age at reported diagnosis being 32 and 21 years, respectively. Mortality (Table 1b) The all-cause in-hospital mortality was 1.9% for hemophilia related admissions, which was comparable to all NIS hospitalizations at 1.9%. The median age at death in years (interquartile range) for hemophilia patients was 72 (57-78) and comparable to 73 (61-83) for all hospitalizations. The most common diagnoses associated with mortality included respiratory failure, "do not resuscitate" status, and sepsis. There was no inpatient mortality reported in children, and the youngest age for in-hospital death was 27 years. Health Care Utilization 96.0% of all hemophilia admissions had insurance coverage with the distribution as follows: Medicare: 33.4%, Medicaid: 28.8%, private insurance: 28.6%. For all NIS hospitalizations, 96.1% had coverage (Medicare: 39.6%, Medicaid: 23.1%, private insurance: 30.1%). The median hospital stay length per hemophilia admission was 3 days (2-6) and was similar to all hospital stays at 3 days (2-5). The median hospital charge per hemophilia admission was $50,662 as compared to $25,261 for all hospital admissions. 2007 Comparison When we compared our data to 2007, serving as a near-decade long follow-up, insurance distribution, inpatient mortality rate, and length of stay were relatively unchanged. Amongst the most common diagnoses for adults with hemophilia were hypertension (up from 28.1% to 34.7%), hepatitis C (down from 21.8% to 16.4%), congestive heart failure (up from 8.1% to 11.1%), and HIV/AIDS (stable at 5.6% and 5.9% respectively). In both 2007 and 2016, there were no HIV or hepatitis C cases amongst children with hemophilia. Notably, in 2007, there were more bleeding related diagnoses, such as hematuria and hemorrhages. There was no inpatient mortality for children in 2016, while there were 15 day of life zero deaths (7% mortality rate) in 2007. The median age at death was also greater in 2016 (72 and 68.3 years). Discussion/Conclusions Adult hemophilia hospitalizations were in large part related to non-bleeding complications and age-related co-morbidities. In contrast, catheter-related infections and bleeding remain the top reasons for pediatric admissions. Most hemophilia patients had insurance coverage. The median hospital charge for those with hemophilia was nearly twice that of all-cause hospitalizations. Advancements in hemophilia treatment and outcomes are continuing, as evidenced by the improved mortality rate and median survival range approaching those from all hospitalizations. These changes all cumulatively demonstrate significant treatment and health care advancements in hemophilia management. Disclosures Takemoto: Genetech: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Other: DSMB for aplastic anemia trial.

Depression Predicts Prolonged Length of Hospital Stay in Pediatric Inflammatory Bowel Disease.

Few studies report the impact of depression on inflammatory bowel disease (IBD)-related hospitalizations. We evaluated the association between depression and pediatric IBD-related hospitalizations. Our primary aim was to test the hypothesis that depression is associated with hospital length of stay (LOS); our secondary goal was to evaluate if patients with depression are at higher risk for undergoing additional imaging and procedures. Data were extracted from the 2012 Kids Inpatient Database (KID), the largest nationally representative publicly available all-payer pediatric inpatient cross-sectional database in the United States. Hospitalizations for patients less than 21 years with a primary diagnosis Crohn disease (CD) or ulcerative colitis (UC) by ICD-9 code were included. Multivariable logistic regression was used to predict long LOS controlling for patient- and hospital-level variables and for potential disease confounders. For primary IBD-related hospitalizations (N = 8222), depression was associated with prolonged LOS (odds ratio [OR] 1.50; 95% confidence interval [CI] 1.19-1.90) and total parenteral nutrition use (OR 1.54; 95% CI 1.04-2.27). Depression was not associated with increased likelihood of surgery (OR 0.97; 95% CI 0.72-1.30), endoscopy (OR 0.91; 95% CI 0.74-1.14), blood transfusion (OR 0.85; 95% CI 0.58-1.23), or abdominal imaging (OR 1.15; 95% CI 0.53-2.53). Depression is associated with prolonged LOS in pediatric patients with IBD, even when controlling for gastrointestinal disease severity. Future research evaluating the efficacy of standardized depression screening and early intervention may be beneficial to improving inpatient outcomes in this population.

118. Factors Associated with Positive Follow-up Blood Cultures in Gram-Negative Septicemia

BackgroundBloodstream infections remain a significant cause of morbidity and mortality. No guidelines for the management of noncatheter-associated Gram-negative septicemia exist. There is considerable debate regarding the role of follow-up blood cultures. Studies have shown inadequate antibiotic therapy increases mortality in Gram-negative sepsis. We evaluated factors associated with a higher likelihood of positive follow-up blood cultures (FUBC).MethodsA retrospective cohort study was conducted to look at factors associated with an increased likelihood of positive FUBC. Data were obtained via Epic chart review. Empiric antimicrobial regimens were reviewed in all patients with MDRO infections.ResultsWe identified 1,527 patients ≥18 years admitted with gram-negative septicemia from January 1, 2013 through January 1, 2018. A total of 8.4% had positive FUBC. Patients with positive FUBC had a younger median age than the no-growth group (64.7 vs. 69.4, P <0.001). Admission systolic blood pressure was lower in the group with positive FUBC than the no-growth group (107 vs. 116, P = 0.008). The odds ratio for positive FUBC for cardiac device was 2.08 (95% CI = [0.97, 4.35], P = 0.061); central line infection (vs. urinary tract infection) adjusted odds ratio was 2.08 (95% CI = [1.10, 3.95], P = 0.025). The positive FUBC group had a larger proportion of multidrug-resistant organisms (MDRO) (21.9% vs. 10.4%, P < 0.001) with an odds ratio of 2.40 (95% CI = [1.53, 3.78]). In this group, those who received inadequate empiric antibiotics had a significantly higher percentage of repeat positive results (78.6% vs. 57.1%, P = 0.033). In summary, patients with either an MDRO, a central line infection (vs. urinary tract infection), or the presence of a cardiac device (vs. no cardiac device present) had over twice the odds of positive FUBC than those without.ConclusionThough the role of FUBC for Gram-negative septicemia has been brought into question, our results show that the presence of central lines, cardiac devices, infections with MDRO organisms, or inadequate empiric antibiotics on admission were factors strongly correlated with subsequent positive FUBC. Therefore, we believe that repeating blood cultures in this subset of patients require further study and consideration.Disclosures All authors: No reported disclosures.

Introducing a nursing maintenance bundle for patients with pulmonary arterial catheters.

We undertook a quality improvement project to address challenges with pulmonary artery catheter (PAC) line maintenance in a setting of low-baseline central-line infection rates. We observed a subsequent reduction in Staphylococcal PAC line infections and a trend toward a reduction in overall PAC infection rates over 1 year.

A CASE OF MEDIASTINITS AND SEPTIC THROMBOPHLEBITIS SECONDARY TO SEPTIC STERNOCLAVICULAR JOINT ARTHRITIS

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Septic Sternoclavicular joint (SCJ) is a rare diagnosis. Certain risk factors such as diabetes mellitus have been associated with it. The most serious complication of this condition is mediastinits. CASE PRESENTATION: A 48-year-old male with history of type II diabetes mellitus presented with complaints of a progressively worsening left parasternal discomfort that started 3 days ago, which worsened with movement. He also described subjective fever, chills and diaphoresis at home. He denied upper respiratory symptoms. He has had no recent surgeries or instrumentation. He travelled recently to a but denied sick contacts. On presentation he was febrile, tachycardic, diaphoretic, hypertensive. His labs showed leukocytosis to 32000/mm3, a sodium level of 124 and elevated glucose of 484. On physical examination the patient had reproducible left shoulder and chest wall tenderness with palpation. Levaquin 750 mg intravenously was initiated along with supportive therapy. Computed Tomography (CT) of the chest showed anterior mediastinal fat infiltration consistent with mediastinitis and left sided pleural effusion. CT head and neck was ordered which showed inflammatory changes at the left thoracic inlet with involvement of adjacent mediastinal fat, with nonopacification of left subclavian vein and left innominate vein, suspicious for septic phlebitis and adjacent mediastinitis. Blood cultures grew methicillin-sensitive staphylococci. The patient was then started on cefazolin intravenously. Follow up blood cultures cleared and he was discharged on intravenous cefazolin for 4 weeks and outpatient follow up. DISCUSSION: SJC infection is rare occurring only about 0.5-1% of all infections [1]. Common causes include diabetes mellitus, intravenous drug use, trauma, immunosuppression, infected central lines among others. The clinical signs of SCJ septic arthritis are chest pain localizing to the SCJ (78 %), fever (65 %), and shoulder pain (24 %) and neck pain (2%) [1,2]. Joint swelling and overlying erythema is common. A CT scan of the chest or magnetic resonance imaging is recommended as the initial imaging study that helps identify bone destruction, however the final diagnosis is made from culture of the joint fluid obtained using needle aspiration or open biopsy. Common organisms that has been described are staphylococcus aureus coli, H influenza, Streptococcus pneumonia, streptococcus pyogenes [1,2]. The most potential and serious complication is mediastinitis, which occurs in less than 15% of cases [1,2] as in our case. Our case is unique because it also lead to septic thrombophelibitis of left subclavian vein. Antibiotics with or without drainage and surgical debridement is the treatment of choice. CONCLUSIONS: Sternoclavicular joint septic arthritis is a rare condition. Anterior mediastinitis and septic thrombophlebitis should be suspected as possible complications in uncontrolled diabetes. Reference #1: Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine (Baltimore). 2004;83(3):139-48. Reference #2: 2. Yood RA, Goldenberg DL. Sternoclavicular joint arthritis. Arthritis Rheum. 1980;23:232–9. DISCLOSURES: No relevant relationships by Janak Adhikari, source=Web Response No relevant relationships by Karim Anis, source=Web Response No relevant relationships by AHMET HAKKI KAPICI, source=Web Response No relevant relationships by Fnu Zafrullah, source=Web Response

A Protocol to Set Up Needle-Free Connector with Positive Displacement on Central Venous Catheter in Intensive Care Unit.

Needle-free connectors were initially designed and promoted to avoid blood exposure for healthcare workers. Some recent data suggest that the latest generation of connectors (with positive displacement) may be of interest for reducing central venous line infections. We have been using needle-free connectors for several years in our intensive care unit and here we present a protocol for installing these connectors on central venous catheters. After insertion of the catheter and control of the permeability of the lines, the connectors must be purged with 0.9% NaCl before being connected. The connectors replace all disposable caps used on infusion stopcocks and manifolds. All the connectors are changed every 7 days as recommended by the manufacturer (except when there is macroscopic contamination, which requires an immediate change of the connector). Before each injection, the connector must be disinfected for at least 3 seconds with 70% isopropyl alcohol. The connectors must not be disconnected (unless changed), as the injection is done through the device. Setting up the connectors slightly increases the total time required to place the catheter and there is no formal evidence that these connectors reduce the incidence of infectious or thrombotic complications. However, these devices simplify the management of central venous lines and prevent the catheter circuit from "opening" once it has been sterilely installed.

EXPRESS: Transition from Parental Prostacyclin to Selexipag: A Case Series of Five Pulmonary Arterial Hypertension Patients.

Parental prostacyclin is the only therapy with a proven survival benefit in pulmonary arterial hypertension (PAH). However, some patients are unable to tolerate continuous prostacyclin infusion because of central line infection, side effects, or sociocultural factors. Selexipag is a recently approved prostacyclin receptor agonist that is able to blunt PAH disease progression. Although in the same molecular pathway, the interchangeability of selexipag with prostacyclin infusions is relatively unexplored. Here, we present a case series of five stable PAH patients who were functional class (FC) I or II that were transitioned from prostacyclin infusion to selexipag using a standardized protocol in the inpatient setting. We show that the transition to selexipag in five highly selected patients was tolerated with no significant changes in FC, minimal changes in pulmonary vascular disease severity, and no significant PAH-related complications. However, there was a trend for a reduction in cardiac index after transition to selexipag. These data suggest that a transition from prostacyclin infusion to selexipag can be achieved in clinically stable PAH patients who are unable to tolerate continuous prostacyclin infusion. However, this approach should only be selectively implemented at specialized centers with close follow-up due to the trend for a reduction in cardiac index after transition to selexipag.

P1.15: Paediatric domino liver transplant following multivisceral transplant (liver-inclusive) with splenic preservation – A case report

Introduction:A multivisceral transplant followed by domino implantation of the resected liver to another patient was first reported by Tzakis in 1999. Since then there has not been much development in this technique and its implications for both recipients. We present a paediatric multivisceral transplantation with native spleen preservation followed by the use of the recipient’s liver as a domino graft for another child. Patients and Methods:Multivisceral donor: 3 year old boy with hypoxic brain damage, blood group O+, weight 14kg. Multivisceral recipient: 7 year old boy, blood group A+, weight 24 kg, with severe intestinal failure (Neuropathic intestinal dysmotility). No enteral feed and 24-h PN, with persistent central line infections. Listed for multivisceral transplant seeking immunological advantage. At transplant, normal native liver (mild portal fibrosis at biopsy) preserved for domino transplant. Splenic artery and left gastric artery were preserved. Pancreas removed leaving splenic vein. Spleno-caval shunt performed preserving native spleen. Native liver perfused with UW solution and stored. Multiorgan graft implanted (liver, stomach, duodenum, pancreas, small bowel and right haemicolon). CIT: 10h. Domino liver recipient: 3 year old boy, blood group: A+, weight 12 kg, with cholestatic liver disease. Domino liver transplant (graft weight: 484 g, CIT: 10h, duct-to-duct anastomosis). Results:Multivisceral recipient had bowel obstruction (day 3 post-transplant) that required laparotomy. No acute cellular rejection and no serious infections post-operatively. Stoma reversed at 5 m. He remains on enteral feeding and PN support due to rapid bowel transit. The domino liver recipient had acute cellular rejection (day 8 post-transplant). Anastomotic biliary stricture corrected with biliary reconstruction (6 m post-transplant). Conclusion:A liver-inclusive intestinal transplant seems to give an immunological advantage to the recipient by decreasing rejection episodes but make them vulnerable to lethal infections (Wu & Cruz, 2018), which is maybe worsened by native splenectomy at transplantation. Preserving the native spleen may reduce the incidence of PTLD, GVHD and risk of infections. The above case could be a better option than a modified multivisceral transplantation and using the multivisceral recipient’s liver as a domino graft will decrease the impact on the donor pool. More cases are required to establish the advantages of these surgical techniques.

P1.23: Use of Pureed Green Beans Through a G-tube in Pediatric Patients with Short Bowel Syndrome – A Single Center Experience

Background: Pectin and other water-soluble fibers have been used in certain patients with short bowel syndrome. Fermented fibers may provide energy contribution via short chain fatty acids produced by colonic bacteria, while soluble fibers that retain a gel may improve the consistency of watery or loose stools and thus decrease stool output. At our institution, we aimed to study the effects of pureed green beans, a good source of pectin, given in a reliable and easy manner, through a G-tube. Methods: Pureed green beans administered via syringe directly into the G-tube was prescribed in a handful of patients with short bowel syndrome. Dose of green beans was adjusted at regularly scheduled clinical visits. Patients and their stools were closely monitored. Results: Of the 71 intestinal rehabilitation patients at our center, 7 are currently receiving pureed green beans through G-tube. All patients experienced a decrease in stool frequency and 6 of them experienced improvement in stool consistency. Over half of the patients also tolerated a decrease in loperamide. Of the 6 patients receiving either TPN or IV hydration, 5 tolerated a decrease in the overall volume. One patient was weaned off of IV hydration fluids entirely. Please refer to Table 1. Conclusion: Overall, our cases highlight the improvement in stool frequency and consistency, TPN volume requirements, and loperamide administration following the administration of pureed green beans into a G-tube. For our patients with G-tubes and difficult to manage loose stools, the introduction of pureed green beans is now being considered more frequently. Potential future research may include: examining if higher doses of green beans increase the risk of malabsorption of certain nutrients (such as magnesium, zinc, and iron), monitoring the incidence of central line infections following stool normalization, and studying the effects of specific fibers or foods on the microbiome in patients with short bowel syndrome.

Complication Rates for Pediatric Hepatectomy and Nephrectomy: A Comparison of NSQIP-P, PHIS, and KID

BackgroundThree large national data sets are commonly used to assess operative outcomes in pediatric surgery; National Surgical Quality Improvement Program Pediatric (NSQIP-P), Pediatric Health Information System (PHIS), and Kids' Inpatient Data set (KID). Hepatectomy and nephrectomy are rare pediatric surgical procedures, which may benefit from large administrative data sets for the assessment of short-term complications. Materials and methodsA retrospective review of NSQIP-P (2012-2015), KID (2012), and PHIS (2012-2015) was performed for hepatectomy or nephrectomy cases for children aged 0 to 18 y. Thirty-day perioperative outcomes were collected, analyzed, and compared across data sets and surgical cohorts. ResultsRates of surgical site infection, wound dehiscence, central line infection, sepsis, and venous thromboembolism were similar across NSQIP-P, PHIS, and KID in both cohorts. Rates of pneumonia and renal insufficiency were higher in PHIS and KID versus NSQIP-P in both cohorts. Blood transfusions in NSQIP-P were higher than PHIS and KID in the hepatectomy group (50.9% versus 43.0% versus 32.4%, P < 0.001), but similar across data sets in the nephrectomy cohorts (12.0% versus 14.0% versus 13.0%, P = 0.15). PHIS reported higher readmission rates than NSQIP-P for both the hepatectomy (56.5% versus 17.9%, P < 0.001) and nephrectomy (32.6% versus 7.6%,P < 0.001) cohorts. Thirty-day mortality rates were similar between NSQIP-P and PHIS, but higher in KID as compared with NSQIP-P for hepatectomy (6.4% versus 0.4%, P < 0.001) and nephrectomy (2.0% versus 0.3%, P < 0.001) cases. ConclusionsAdministrative data sets provide large sample sizes for the study of low-volume procedures in children, but there are significant variations in the reported rates of perioperative outcomes between NSQIP-P, PHIS, and KID. Therefore, surgical outcomes should be interpreted within the context of the strengths and limitations of each data set.

Implementation of a Central Line Maintenance Bundle for Dislodgement and Infection Prevention in the NICU.

Infants in the newborn intensive care unit (NICU) often receive medications or nutritional support for extended periods. Due to the fragility of veins, central lines are often used. Adverse outcomes from central lines such as infections and line dislodgements, where the line terminates in a peripheral vessel rather than centrally, can drastically increase infant morbidity and mortality. Although evidence exists addressing the specialized needs of premature or smaller infants, there is far less evidence regarding infants that are larger, more physiologically complex, and have longer stays. Using evidence-based practice strategies, we examined the literature for central line maintenance practices specific to the NICU population and created a care maintenance bundle to reduce infection and line dislodgement rates. Furthermore, we examined implementation of this bundle. A systematic search of PubMed, Cochrane Library, and CINAHL provided evidence for a practice change for central line maintenance for our nontunneled central lines. During project implementation, infection and dislodgement rates for both tunneled and nontunneled lines were examined in order have a control and intervention group. Prior to central line maintenance bundle implementation, there were 19 total incidences of central line dislodgements and 5 central line infections (14 dislodgements and 4 infections were from nontunneled lines, 5 dislodgements and 1 infection from a tunneled line). Postintervention there were 1 total dislodgement and 4 central line infections (the dislodgement was from a nontunneled line and all infections were from tunneled lines). Although research has shown frequent, scheduled dressing changes using the chlorhexidine patch decreases infection rates, the risk of dislodgement and skin breakdown for NICU infants outweighs the potential benefit of decreased infection. Further research is needed to determine whether this central line maintenance bundle would be beneficial for tunneled central lines.

Etiology of Continuous-Flow LVAD (CF-LVAD) Infections

Purpose Infection is a frequent problem following CF-LVAD implantation. We were interested in determining the spectrum of infectious complications following implantation of HeartMate II (HMII) and Heartware (HW) CF-LVADs. Methods We reviewed 893 HMII and HW implants from 1999 to 2018 performed at our institution. Infections were classified as device-specific (superficial/deep driveline infection or pocket/device infection) or as device-related (bacteremia). Other infections, such as urinary tract infections, central line infections, and pneumonia were recorded, but are not analyzed here. Etiology of the infection was also recorded. In some infections, multiple infectious agents were cultured. Results 801 CF-LVADs were implanted; 542 HMIIs, and 256 HWs. 180/542 (33.2%) of HMII, and 70/256 (27.3%) of HW pumps developed an infection. The incidence of infection / support year was 20.6% for HMII pumps and 20.3% for HW pumps. Driveline infections (superficial or deep) occurred in 136/542 (25.1%) HMII implants and in 53/250 (21.2%) HW implants. Pocket/device infections occurred in 102/542 (18,8%) HMII pumps and in 23/256 (9.0%) HW pumps. Bacteremia occurred in 84/542 (15.1%) HMII pumps and in 28/256 (10.9%) HW pumps. Staph aureus, pseudomonas, and coagulase negative species were the most common isolates (see Table). Median time to first infection was not statistically different (p=748) between HMII (1021 days) and HW devices (1273 days); (See Figure). Conclusion Infection continues to be a major problem after CF-LVAD implantation. Driveline infections, both superficial and deep, as well as pocket and device infections occur commonly after both HMII and HW implants.

Central line infections in United States hospitals: An exploration of variation in central line device days and infection rates across hospitals that serve highly complex patient populations

Our descriptive analyses show a wide distribution in rates of central line device days and central line-associated bloodstream infections for a given standardized infection ratio-the measure linked to federal payment penalties-among 215 US hospitals serving highly complex patient populations. We established that the standardized infection ratio masks hospital-level variation in device use and associated patient safety.

The adherence to guidelines for preventing CVC-related infections: a survey among Italian health-care workers

BackgroundSince correct maintenance of intravascular catheters is an effective strategy for preventing central-line infections, the aim of this study was to assess the level of adherence to guidelines for CVC maintenance amongst Italian HCWs.MethodsFrom July 2016 thru January 2017, a cross sectional survey was carried out in a random sample of 549 HCWs working in different hospitals of Campania region (Italy).ResultsThe 68.9% of interviewees returned the questionnaire. Overall, respondents’ level of knowledge about CDC guidelines was low, with only the 20.7% of HCWs acknowledging guidelines main recommendations: the nurse stuff, the availability of hospital internal protocols, the use of guidelines themselves as source of information, and higher number of years of practice were significantly associated with a higher level of knowledge. An extremely positive attitude towards the utility of guidelines for preventing CVC-related infections was shown, with a linear regression model indicating a stronger attitude in physicians, in who knew the CDC main recommendations and correct use of antibiotic ointments, as well as in HCWs needing additional information on the prevention of CVC-related infections. Regarding the behaviors, physicians were more likely to be adherent about recommended evidence-based practices. Two more multivariate logistic and ordinal logistic regression models were built to investigate characteristics associated with correct behavior regarding the removal of catheter dressing if patients have tenderness at insertion site or fever without an obvious source, respectively.ConclusionsThis study reflected an important lack of evidence-based knowledge and practices regarding the CVC management, highlighting the baseline role of education and training programs, as well as pointing out the role of organizational interventions to address the adherence to best practices for the reduction of CLABSIs.

Analysis of Healthcare Institutional Costs of Pediatric Home Parenteral Nutrition Central Line Infections.

Although previous literature suggests home parenteral nutrition (HPN)-dependent children experience frequent complications like community-acquired central line-associated bloodstream infections (CLABSI), few studies have characterized the cost. The aim of this study was to evaluate institutional cost of community-acquired CLABSI in pediatric patients with HPN. This is a single-center retrospective review of institutional costs for patients with HPN with community-acquired CLABSI at a tertiary care children's hospital. Inclusion was age 18 years or less between October 2011 and April 2016. Exclusions were death during hospitalization and readmission within 2 days of discharge. Patient-level factors were compared between high-cost group and all others using Welch 2-sample t test and analysis of variance. Multivariable logistic regression was used to determine predictors of higher cost. There were 176 CLABSI admissions among 68 patients during the study period (median 2 hospitalizations per patients). The mean cost and length of stay per hospital admission are $28,375 (2015 US dollars) and 8 days, and both were associated with intensive care unit admission (ICU), central venous catheter removal, private insurance, and age <2 years at admission. Nine percent of patients were classified as "super-utilizers" whose 54 hospitalizations accounted for 28% of total institutional costs. Among pediatric patients with HPN, community-acquired CLABSI is associated with significant cost and length of stay. Healthcare utilization is disproportionately concentrated in a small number of patients. These study findings may help inform cost analysis for future CLABSI prevention strategies.

Retrospective Cohort Analysis of Central Line Associated Blood Stream Infection following Introduction of a Central Line Bundle in a Neonatal Intensive Care Unit.

Background Central Line Associated Bloodstream Infections (CLABSI) constitute a leading cause of morbidity and mortality in neonatal populations. There has been an overwhelming increase in the use of evidence-based care practices, also known as bundles, in the reduction of these infections. In this report, rates of CLABSI and central line utilisation were examined following the introduction of a central line bundle in our Neonatal Intensive Care Unit (NICU) at the Canberra Hospital. Methods The research undertaken was a retrospective cohort study in which newborn infants admitted to the Canberra Hospital NICU between January 2011 and December 2016 and had a central line inserted were included in the study. Data regarding central line days, bed days, infection rates, and patient demographics were collected before and after the introduction of an intervention bundle. CLABSI rates were calculated per 1,000 central line days for before (2011-2013) and after (2014-2016) the introduction of the bundle. The postintervention period was retrospectively analysed for compliance, with data regarding the completion of maintenance forms and insertion forms collected. Results Overall, the results showed a significant decrease in CLABSI rates from 8.8 per 1,000 central line days to 4.9 per 1,000 central line days in the intervention period (p<0.001). Central line utilisation ratio (CLUR: ratio of central line days to bed days) was also reduced between pre- and postintervention periods, from 0.177 (4414/25013) to 0.13 (3633/27384; p<0.001). Compliance to insertion forms and maintenance forms was observed to increase within the intervention period. Conclusion The implementation of a central line bundle was effective in reducing both CLABSI rates and dwell time (CLUR) for central venous catheters.