Central Venous Catheter Days Research Articles

Evaluation of Central Line Thrombosis in Children with Heart Failure on Continuous Infusion Milrinone

Milrinone is utilized for hemodynamic support in heart failure (HF) patients. Due to reduced cardiac output and systemic blood flow, patients with HF are at increased risk of thrombosis. Central venous catheter (CVC) placement compounds this risk. The aim of this study was to determine the incidence of thrombosis, identify thrombosis risk factors, and determine the impact of anticoagulation in pediatric patients receiving continuous milrinone via CVC at the Medical University of South Carolina. This retrospective study evaluated HF patients less than 18 years of age receiving continuous milrinone infusion via CVC for greater than or equal to 14 days between July 2014 and July 2019. Patients were evaluated based on anticoagulation (AC) status: therapeutic, prophylactic, or none (NAC). The primary outcome measure was the incidence of thrombosis. Possible risk factors for thrombus formation analyzed included age, pathogenesis of heart failure, ventricular assist device (VAD) use, duration of milrinone, and type of CVC. Blood product, factor VII, and prothrombin complex concentrate (PCC) utilization during VAD placement and transplant were analyzed as safety endpoints. A total of 35 patients were included - 16 patients receiving AC and 19 with NAC. There was no difference in thrombus formation between the AC and NAC groups [5 vs. 6; P = .49]. Of patients on prophylactic AC, 50% (n = 4) experienced a thrombus, compared to 25% (n = 12) of patients on therapeutic AC. Patients with CVC in place for greater than 300 days had an incidence of thrombosis of 83% (n = 6). Those receiving therapeutic AC used more PCC and Factor VII than the NAC group during transplant [17.37 units/kg vs. 0, P = .004, 74.74 mcg/kg vs. 18 mcg/kg, P = .025]. Those on therapeutic AC utilized more blood products than patients on prophylactic AC during both VAD placement and transplant (61.5 mL/kg vs. 3.5 mL/kg, P = .003) and NAC patients (61.5 mL/kg vs 24.6 mL/kg, P = .046). Incidence of thrombosis was similar among anticoagulated and non-anticoagulated patients who were on continuous infusion milrinone. Higher total CVC days increased the risk of thrombosis. Prophylactic anticoagulation had a limited effect on thrombus formation, but did not increase blood product use during VAD and transplant procedures as compared to therapeutic anticoagulation.

Safety Checklist Implementation Did Not Reduce Central Venous Catheter Duration in Pediatric Cardiac ICU Patients.

Introduction:The Center for Disease Control recommends prompt removal of nonessential central venous catheters (CVCs) to reduce the risk for central line–associated bloodstream infections. Safety checklists have been trialed to reduce nonessential CVC days, but pediatric studies are lacking. Our specific aim was to detect >10% reduction in mean CVC duration after implementation of a safety checklist addressing CVCs in our unit.Methods:All patients admitted to the Congenital Cardiovascular Care Unit at New York University Langone Medical Center who had a CVC placed between January 1, 2012, and December 31, 2017, were included. We implemented a checklist addressing CVC use in our unit on June 7, 2013, and modified it on March 10, 2016. We analyzed quarterly mean CVC duration and postsurgical CVC duration over the study period using statistical process control charts.Results:We placed 778 CVCs for 7,947 CVC days during the study period. We noted special cause variation from Q4 2013 to Q2 2014 and a centerline shift in mean CVC duration from 8.91 to 11.10 days in Q1 2015. In a subgroup analysis of the 657 lines placed in surgical patients, there was a centerline shift in mean CVC duration from 6.48 to 8.86 days in Q4 2013.Conclusions:Our study demonstrated an unexpected increase in mean CVC duration after the implementation of a safety checklist designed to decrease nonessential CVC days. Additional studies are needed to identify the ideal method to detect and remove nonessential CVCs and reduce the risk of preventable harm.

1168. Trends in Central-Line-Associated Blood Stream Infections in a Community Teaching Hospital: A Multi-Intervention Quality Improvement Project

BackgroundCentral line-associated bloodstream infection (CLABSI) is a preventable medical condition that results in increased patient morbidity and mortality as well as increased medical costs. We sought to describe the impact of various quality improvement interventions on the incidence of CLABSI in a large 990-bed community teaching hospital from the period of January 1, 2013 to December 31, 2017.MethodsRetrospective study of CLABSI events as defined by the CDC’s National Healthcare Safety Network was completed. Between 2013 to 2017, we introduced mandatory real-time root cause analysis for each CLABSI event to identify defects that could be used for quality improvement interventions. We implemented a bundle of interventions for proper central venous catheter (CVC) insertion and maintenance based on CDC recommendations and the results of the internal analysis. Interventions included utilizing chlorhexidine gluconate (CHG) skin preparation and maximum sterile barrier precautions, optimal site selection (avoiding femoral site), using antimicrobial-coated CVCs and antithrombotic Bioflo peripherally inserted central catheters (PICC), minimizing multi-lumen CVC and PICC use, de-escalating CVC to midline or preferential use of midline catheters while minimizing unnecessary PICC and CVC insertion, adding Curos disinfection caps on central lines and other vascular access sites, weekly scheduled CVC site dressing changes with Tegaderm CHG I.V. Securement Dressing, CHG baths for patients with CVCs, avoidance of blood culture draws from central lines, and daily review of line necessity with timely removal. Medical staff members received ongoing education on the implementation of the CLABSI bundle. Both ICU and non-ICU CLABSI cases in the adult patient population were analyzed.ResultsA comparison of 2013 with 2017 shows a 69% decline in a number of CLABSI cases from 36 to 11 patients (Figure 1). There was a 30% decline in CVC days from years 2014 to 2017 (No CVC days data for 2013 due to change in data collection system). Over the same period, CLABSI events per 1,000 CVC days decreased from 0.624 to 0.362 (Figure 2)—a 42% decline.ConclusionStudy findings show that our comprehensive bundle of interventions for CVC insertion and maintenance resulted in decreased rates of CLABSI. Disclosures All authors: No reported disclosures.

Evaluation of implanted venous port-a-caths in children with medical complexity and neurologic impairment.

Children with medical complexity and associated neurologic impairment frequently face difficulties with venous access. Intermittently they require urgent intravenous administration of fluids and medication. To analyze the use of implanted port-a-caths in children with medical complexity who have neurologic impairment and difficult venous access. We performed a single-center observational study of port-a-caths placed by interventional radiologists in children with medical complexity with neurologic impairment. We analyzed peripheral intravenous access attempts, peripheral intravenous starts, peripheral intravenous complications, alternative temporary central venous access devices, port-a-cath insertions, catheter days, access days, port-a-cath-related complications, hospital admissions and emergency department visits. We compared the year pre port-a-cath to the year post port-a-cath. Twenty-one children with medical complexity with neurologic impairment (10 boys, 11 girls; median age 4.1years; median weight 13.7kg) underwent 26 port-a-cath insertions (median catheter days 787). In the year post port-a-cath compared to pre port-a-cath there was a highly significant reduction (P<0.001) in numbers of peripheral intravenous attempts, peripheral intravenous starts and skin punctures; and a significant reduction (P<0.05) in need for other devices, number of emergency department visits, emergency department visits resulting in hospital admissions, and total admissions. Adverse events were graded as mild (n=18), moderate (n=6) and severe (n=0). Port-a-cath placement in children with medical complexity with neurologic impairment significantly reduced all peripheral intravenous attempts, peripheral intravenous starts, skin punctures, total number of emergency department visits, visits culminating in admission, and total number of inpatient admissions. Advantages must be considered against potential port-a-cath-related adverse events.

Central venous catheter-associated thrombosis in children with congenital hyperinsulinism

SummaryCongenital hyperinsulinism (CHI) is an important cause of severe hypoglycaemia in infancy. To correct hypoglycaemia, high concentrations of dextrose are often required through a central venous catheter (CVC) with consequent risk of thrombosis. We describe a series of six cases of CHI due to varying aetiologies from our centre requiring CVC for the management of hypoglycaemia, who developed thrombosis in association with CVC. We subsequently analysed the incidence and risk factors for CVC-associated thrombosis, as well as the outcomes of enoxaparin prophylaxis. The six cases occurred over a 3-year period; we identified an additional 27 patients with CHI who required CVC insertion during this period (n = 33 total), and a separate cohort of patients with CHI and CVC who received enoxaparin prophylaxis (n = 7). The incidence of CVC-associated thrombosis was 18% (6/33) over the 3 years, a rate of 4.2 thromboses/1000 CVC days. There was no difference in the frequency of genetic mutations or focal CHI in those that developed thromboses. However, compound heterozygous/homozygous potassium ATP channel mutations correlated with thrombosis (R2 = 0.40, P = 0.001). No difference was observed in CVC duration, high concentration dextrose or glucagon infused through the CVC. In patients receiving enoxaparin prophylaxis, none developed thrombosis or bleeding complications. The characteristics of these patients did not differ significantly from those with thrombosis not on prophylaxis. We therefore conclude that CVC-associated thrombosis can occur in a significant proportion (18%) of patients with CHI, particularly in severe CHI, for which anticoagulant prophylaxis may be indicated.Learning points:CVC insertion is one of the most significant risk factors for thrombosis in the paediatric population.Risk factors for CVC-associated thrombosis include increased duration of CVC placement, malpositioning and infusion of blood products.To our knowledge, this is the first study to evaluate CVC-associated thrombosis in patients with congenital hyperinsulinism (CHI).The incidence of CVC-associated thrombosis development is significant (18%) in CHI patients and higher compared to other neonates with CVC. CHI severity may be a risk factor for thrombosis development.Although effective prophylaxis for CVC-associated thrombosis in infancy is yet to be established, our preliminary experience suggests the safety and efficacy of enoxoaparin prophylaxis in this population and requires on-going evaluation.

A hospital-wide reduction in central line–associated bloodstream infections through systematic quality improvement initiative and multidisciplinary teamwork

Few data are available on hospital-wide incidence of central line-associated bloodstream infection (CLABSI) rates in patients with central venous catheter (CVC) in China, where many systemic obstacles holding back evidence-based guidelines implementation exist. This study was conducted prospectively in 2 phases. The baseline and intervention phases were performed in a teaching hospital in China, between January 2017 and October 2018. A systematic quality improvement (SQI) and multidisciplinary teamwork (MDT) CLABSI infection control program was introduced in the intervention phase. In the intensive care units (ICUs) and non-ICUs, CLABSIs were continuously monitored, data collected, then analyzed. After intervention, the CLABSI rate decreased from 2.84-0.56 per 1,000 CVC days in ICUs (P < .001), and from 0.82-0.47 per 1,000 CVC days in non-ICUs (P = .003). The length of time until CLABSI occurrence increased from 8.72-13.60 days in ICUs (P = .046), and from 10.00-12.00 days in non-ICUs (P = .048). The number of multidrug-resistant bacteria isolated from CLABSI episodes decreased both in ICUs and in non-ICUs. The SQI and MDT CLABSI infection control program is effective in reducing hospital-wide CLABSI in patients with CVC, both in ICUs and in non-ICUs.

SUN-057 Reducing Central Venous Catheter Burden in Haemodialysis Patients: The Impact of Changing Practice within an Australian Renal Unit

Despite varying worldwide practice, renal guidelines suggest minimisation of central venous catheter (CVC) use for dialysis access in haemodialysis (HD) patients as CVCs may lead to increases in morbidity and mortality. Few prospective studies have described the impact of renal unit initiatives aimed at reducing catheter burden and their potential effect on patient survival. We present data from a 10 year observational cohort study in an adult tertiary renal unit in Sydney, Australia. Initiatives introduced included; regular review of data regarding CVC infection rates and CVC exposure within the unit, appointment of a vascular access nurse specialist and regular multi-disciplinary team meetings between renal physicians, vascular surgeons and dialysis co-ordinators. Eligible patients over 18 years of age who required HD and did not have a functioning dialysis access, thereby requiring a CVC, were included. Patients were classified by treating physician into one of 4 groups based upon reason for CVC insertion. Patients believed to have acute kidney injury (AKI) and expected to recover to dialysis independence were classified as AKI; patients starting maintenance dialysis without a permanent access in place were classified as end stage kidney disease (ESKD); patients with failure of an existing HD access were classified as HD failure and patients transferring from peritoneal dialysis (PD) without an HD access were classified as PD failure. Prospective data were collected over 10 years on all patients and CVCs and linked to administrative health and registry data. Descriptive and survival analyses were performed and have been censored for transplantation. The study cohort included 557 patients and 1067 CVCs. The median patient age was 71.7 years [59.3-78.6]. The reasons for initial CVC insertion were; AKI (246 patients, 44% of total), ESKD (182, 33%), HD failure (84, 15%) and PD failure (45, 8%). Despite this, the majority of CVCs were required for HD failure (368, 35%), followed by AKI (338, 32%), ESKD (272, 25%) and PD failure (89, 8%). Over the data collection period the reasons for initial CVC placement changed. From 2005 to 2015 the proportion of patients requiring an initial CVC due to ESKD fell from 23% to 18%, whereas the proportion resulting from AKI rose from 27% to 59%. Total CVC days increased across the study period from 4859 days in 2005 to 5445 days in 2015, however days attributed to ESKD, HD failure and PD failure fell (1554 to 1200, 2330 to 2026, 595 to 542 respectively) (Figure 1). Use of tunnelled CVCs rose from 61% to 80%. Rates of CVC infection, classified as either a confirmed bacteraemia or the removal of a CVC due to suspicion of infection, fell from 5.76/1000 catheter days to 0.37/1000 catheter days. This prospective study describes how simple initiatives introduced in an Australian renal unit may reduce CVC burden and mitigate CVC associated infection rates.

Central Line-associated Bloodstream Infections in Cancer Patients: An Experience from a Tertiary Care Cancer Centre

AbstractIntroduction: Central venous catheters (CVCs) implanted in patients with malignancies may often be associated with local or central line-associated bloodstream infections (CLABSI), which are a major source of morbidity and rarely mortality, making such patients’ care difficult and complicated. Materials and Methods: This retrospective study is a single-centre’s experience including both paediatric and adult patients with malignancy, who had a CVC inserted and were receiving care at cancer centre of our hospital over a period between January 2017 and June 2018. Results: In the period from January 2017 to June 2018, 73 confirmed cases of CLABSIs among cancer patients were included in this study. The rate of CLABSIs was estimated as 2.1 episodes/1000 CVC days. Out of 73 CLABSI cases, Gram-negative bacilli were the predominant causative agents of CLABSI constituting 72.6% (n = 53/73) of isolated organisms, 21.9% (n = 16/73) of infections were caused by Gram-positive cocci while polymicrobial infections accounted for 5.4% (n = 4/73) of these cases. Conclusion: Over the last 20 years, an epidemiologic shift has occurred among CLABSI in cancer patients. These findings should be considered with the development of interventions that will prevent Gram-negative CLABSI after CVC insertion. To our knowledge, this is the first study reporting data on the incidence of CLABSIs in cancer patients at tertiary care hospital from North Indian hospital.

Incidence of and risk factors for venous thrombosis in children with percutaneous non-tunnelled central venous catheters

BackgroundVenous thrombosis (VT) in children is often associated with a central venous catheter (CVC). We aimed to determine the incidence of VT associated with percutaneous non-tunnelled CVCs in a general paediatric population, and to identify risk factors for VT in this cohort. MethodsObservational, prospective study enrolling consecutive patients at a tertiary multi-disciplinary paediatric hospital. A total of 211 percutaneous, non-tunnelled CVCs were analysed. Data regarding potential risk factors for CVC-related VT were collected. Compression ultrasonography with colour Doppler was used to diagnose VT. ResultsOverall, 30.3% of children developed CVC-related VT, with an incidence rate of 29.6 (confidence interval, 22.5–36.9) cases/1000 CVC days. Upper body CVC location, multiple lumen CVCs, and male gender were independent risk factors for VT in multivariate analysis. All upper body VTs were in the internal jugular vein (IJV). The occurrence of CVC-related VT did not affect length of paediatric ICU or hospital stay. In patients with VT, femoral CVCs, young age, paediatric ICU admission, and a ratio of CVC/vein diameter >0.33 were associated with VT being symptomatic, occlusive, or both. IJV VT was often asymptomatic and non-occlusive. ConclusionsPaediatric non-tunnelled CVCs are frequently complicated by VT. Avoiding IJV CVCs and multiple lumen catheters could potentially reduce the overall risk of VT. However, IJV VT was more likely to be smaller and asymptomatic compared with femoral vein VT. More data are needed on the risk of complications from smaller, asymptomatic VT compared with the group of VT with symptoms or vein occlusion. Femoral vein CVCs and CVC/vein diameter >0.33 could be modifiable risk factors for VT with larger thrombotic mass. Clinical trial registrationACTRN12615000442505.

Catheter-associated bloodstream infections

Each year an estimated quarter million central venous catheters (CVCs) are inserted in the UK for monitoring, delivery of drugs or intravenous feeding and blood sampling in patients receiving critical care. CVCs are indispensable, but the reported rate of catheter associated bloodstream infection (CA-BSI) is high with an incidence varying between 0.46 and 26.5 per 1000 CVC days. CA-BSI is an important cause of adverse clinical outcome, with associated morbidity and mortality, and an additional increased economic cost to the National Health Service. Of any clinical specialty Paediatric Intensive Care Units (PICUs) have one of the highest rates of hospital acquired bloodstream infection (BSI), with an estimated 70% caused by CVCs.

Central Line-Associated Bloodstream Infections in Children With Hematologic and Oncologic Diseases: First Prevalence Results From a University Hospital.

Central line-associated bloodstream infections (CLABSIs) are still a major cause of morbidity and mortality in pediatric hematology-oncology patients in many countries. This cross-sectional study was a retrospective review of CLABSI in inpatient pediatric hematology-oncology cases with long-term central venous catheter at the Pediatric Hematology Department from January 2013 to June 2014. Characteristics of CLABSI events in pediatric patients with hematologic malignancies and related nonmalignant hematologic conditions are documented. CLABSI developed in 61.8% (n = 21) of the 34 hospitalized patients included in the study. The CLABSI rate was 7.8 per 1,000 inpatient central venous catheter days. Coagulase-negative staphylococci was the predominant pathogen in 47.6% of the patients with CLABSI. The high rate of CLABSI requires prevention strategies to reduce CLABSI immediately. This study provides guidance in prioritizing strategies for reducing rates of infection.

Increased Incidence of Central Venous Catheter-Related Infection in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intra-Peritoneal Chemotherapy.

Background: Cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) is a complex surgical intervention with associated risks. Central venous catheter (CVC) line sepsis is one of a number of potential morbidities. The aim of this study was to calculate the incidence of catheter-related infection (CRI) in a CRS and HIPEC patient population and to assess its influence on length of hospital stay. Methods: Data were collected on consecutive patients who underwent CRS HIPEC between August 2013 and October 2017. Data included patient demographics, timing of CVC insertion/removal, time spent in critical care, and CVC tip/blood culture results. Charts were reviewed for patients with both positive CVC culture and positive blood cultures to assess for evidence of catheter related infection and systemic inflammatory response syndrome (SIRS). Results: Data on 100 consecutive CRS HIPEC operations performed between August 2013 and October 2017 was analyzed. There were 11 CRIs in 100 CVCs, resulting in a CRI rate of 16.2 per 1,000 CVC days. Patients within the CRI group had a longer high-dependency unit (HDU) stay compared with the non-septic group (6 days vs. 4.07 days, p < 0.05). The CVC duration for the CRI and non-CRI group was 8.4 and 7.6 days, respectively (p = 0.12). The CRI group also had an increased total hospital length of stay (LOS; 20.8 days vs. 15.4 days, p < 0.05). On average, CRIs occurred eight days post-operative and four days post-HDU discharge. There was no association identified with longer CVC duration (p = 0.34). There has been an annual decline in CRI rates in CRS and HIPEC patients over the duration of the study period from 19.1 per 1,000 CVC days in 2016 to 8.2 per 1,000 CVC days in 2017. Conclusion: This is the first study to report on CRI rates in patients undergoing CRS and HIPEC. The CRI rate of 16.2 per 1,000 CVC days is higher than the overall national figure of 5.2 per 1,000 for CVC lines inserted in the operating room. Patients who developed line sepsis had longer HDU and longer overall hospital stay. Catheter-related infection was noted post-HDU discharge in all cases. Implementation of a CVC care bundle in the later years of the study period coincided with a reduction in CRI rates.

Two-Year Outcomes of Early Cannulation Arteriovenous Grafts for End-Stage Renal Disease

Almost 80% of patients with end-stage renal disease (ESRD) initiate dialysis via a central venous catheter (CVC). CVCs are associated with multiple complications and a high cost of care. The purpose of our project is to determine the impact of early cannulation arteriovenous grafts (ECAVGs) on quality of care and costs. The dialysis access modality, complications, secondary interventions, hospital outcomes, and detailed costs were tracked for 397 sequential patients who underwent access creation between July 2014 and October 2018. Complications were grouped into deep vein thrombosis, line infections, sepsis, pneumothorax, and other. Secondary interventions included angioplasty, angioplasty and stent grafting, thrombectomy, surgical revision, and explantation. Hospital outcomes included length of stay, inpatient mortality, 30-day readmission, and discharge disposition. Costs included supplies, medications, laboratory tests, labor, and other direct costs. All variables were measured at the time of the index procedure, 30days, 90days, 180days, 270days, 1 year, 18months, and 2 years. There were 131 patients who underwent arteriovenous fistula (AVF) and 266 who received ECAVG for dialysis access. The total cost of care per patient was $17,523 for AVF and $5,894 for ECAVG at 1 year (P<0.01). Primary-assisted patency for AVF was 49.3% versus 81.4% for ECAVG (P=0.027), and secondary-assisted patency for AVF was 63.8% versus 85.4% for ECAVG at 1 year (P=0.011). There was a survival advantage for ECAVGs at 1 year (78.6% for AVF vs 85.0% for ECAVG, P=0.034). Patients who received ECAVG had fewer CVC days (2.3% vs 19.1% for AVF, P<0.001), fewer complications (1.6% vs. 21.5% for AVF, P<0.001), and fewer secondary interventions (17.0% vs 52.5% for AVF, P<0.001). This is the first study on patients with ESRD to report detailed outcomes and cost analysis as it relates to AVF versus ECAVG. ECAVGs have an advantage over AVFs due to lower overall cost and better clinical outcomes at 1 year. Implementation of an urgent start dialysis access program centered around ECAVGs may help achieve the national goal of better health care at a lower cost for patients with ESRD.

236 Nutrition Support through Sedative Procedures: A Retrospective Comparison of Feeding Methods in Pediatric Burn Patients

The hypermetabolic response to thermal trauma increases nutritional risk in pediatric burn patients. Interruption of feedings due to necessary clinical procedures leads to calorie and protein deficits, a constant challenge for the clinician. New methods for providing nutrition support that are safe and effective are needed. The objective of this study was to evaluate the nutritional and clinical outcomes associated with post pyloric enteral nutrition (EN) provided throughout sedation in pediatric burn patients as compared to a current standard of care of using parenteral nutrition (PN). A retrospective medical record review, grouping patients based on the type of nutrition support (EN or PN) received throughout sedative procedures was conducted. Sedative procedures included bedside dressing changes and operating room visits. Nutritional outcomes examined included: percent calorie goal achieved, percent protein goal achieved, and nil per os (NPO) hours. NPO hours refers to withholding any form of EN. Clinical outcomes included: intensive care unit (ICU) length of stay (LOS); total LOS; days on mechanical ventilation; days to wound closure; central venous catheter (CVC) days; hyperglycemic events; EN intolerance; and line infection. Statistical analysis was performed using repeated measures of ANOVA. Patients receiving PN had on average 13 more NPO hours than the EN group (p=.000), and a mean difference of 1 more hyperglycemic event (p=.03). There was an average of 1.6 more tube feeding intolerance events in the EN group, when compared to the PN group (p=0.01). There was no statistical significance between the EN and PN group in percent calories and protein goals achieved, wound closure days, LOS, ICU LOS, CVC days, or days on mechanical ventilation. Continued enteral nutrition support through sedation allowed patients to meet their goal calorie and protein requirements without adverse clinical outcomes. Parenteral nutrition can also be used safely in order to minimize nutritional deficits due to NPO time when unable to feed intraoperatively. This work describes an effective feeding method that can be used to avoid nutritional deficits in patients during sedative procedures.

Outcomes in Medical Intensive Care Patients Housed in Geographically Distant Units.

The purpose of this study is to determine whether in patients admitted to a medical intensive care unit (ICU) service there are outcome differences between those in a medical ICU bed ("home") and a geographically distant subspecialty ICU bed ("overflow"). We performed a retrospective cohort study of 4091 patients admitted to a medical ICU of a large tertiary-care urban teaching hospital. Depending on bed availability, some patients were housed in surgical or cardiac subspecialty ICUs while still being cared for by the primary medical ICU service. We assessed the association of these overflow patients with readmission rates and ICU and hospital length of stay (LOS). Potential differences in care was assessed by measuring the number of central line days, urinary catheter days, and ventilator days. Of the 4091 consecutive patients admitted to the medical ICU, 362 (9%) were housed in an overflow ICU and 3729 (91%) were home patients. There was no difference in demographics, patient characteristics, ICU admission diagnosis, or risk of mortality between the 2 groups. Compared to home patients, overflow patients had a higher rate of readmission to the ICU (10.5% vs 6.63% respectively P = .006), a slightly shorter ICU LOS (median 2 [interquartile range, IQR: 1-4] days versus home group of 2 [IQR: 1-5] days; P = .001), and a slightly longer hospital LOS (overflow 7 [IQR: 4-17] days vs home 7 [IQR: 4-13] days, P = .001). There was no differences in number of central venous catheter days, urinary catheter days, ventilator days, or mortality. Medical ICU patients who are housed in ICUs geographically distant from the primary team's location have increased morbidity when compared to patients admitted to the home ICU. However, there are no differences in number of central venous catheter days, urinary catheter days, ventilator days, or mortality.

Healthcare-associated infection in the Grey’s Hospital paediatric intensive care unit: does an Infection Control Programme work?

Background: Healthcare-associated infections are an important cause of morbidity and mortality globally. Grey’s Hospital introduced an Infection Control Programme in August 2016, which included Best Care Always bundles for reducing the occurrence of central line-associated bloodstream infections, catheter-associated urinary tract infections and ventilatorassociated pneumonia. Methods: An observational before–after quasi-experiment was conducted retrospectively reviewing healthcare-associated infection rates in the Grey’s Hospital paediatric intensive care unit a year prior to (August 2015 to July 2016) and after (September 2016 to August 2017) implementation of an Infection Control Programme.Results: There was an absolute decrease in healthcare-associated infection from 102 to 81 and a statistically significant decrease in bloodstream infections per 1 000 central venous catheter days from 36/1 000–15/1 000 after intervention (RR 0.42, 95% CI 0.23–0.79, p = 0.004). The rate of healthcare-associated infection decreased from 23/100 admissions prior to the intervention to 20/100 admissions after the intervention (RR 0.87, 95% CI 0.51–1.48, p = 0.61) and from 40/1 000 patient days to 32/1 000 patient days (RR 0.80, 95% CI 0.51–1.26, p = 0.34). Reductions in healthcare-associated infection were also seen in bloodstream infections and urinary tract infections.Conclusion: The observed downward trend in overall healthcare-associated infections, bloodstream infections and urinary tract infections did not reach statistical significance except for bloodstream infections per 1 000 central venous catheter days. Further research or audit is needed to ascertain reasons for this less than expected decrease in healthcare-associated infections. In the meantime, meticulous adherence to bundles should be encouraged.

The Importance of Patients and Caregivers Education to Prevent Central Line Associated Bloodstream Infections in Children with Malignancies: A Single Center Experience

▪BackgroundLong-term placement of central venous catheters (CVCs) is common in children with malignancies. The optimization of antiseptic protocols, together with proper manipulation by well-trained nursing staff, has lowered the incidence of central line associated bloodstream infections (CLABSI). Furthermore, actual chemotherapeutic protocols aim to avoid extensive inpatient hospitalizations.However, self-management of CVCs is not simple: it requires adequate materials and an appropriate education of patients and caregivers. Therefore, the influence of social factors, such as language barriers, may be stronger than expected, especially in tertiary level institutions that act in multicultural settings.MethodsWe retrospectively analyzed patients who were admitted at our hematology-oncology service and who inserted any type of CVC between November 2012 and May 2018. Only patients with a complete and certified history of the CVC status from our experienced nurses were included.Cultural and linguistic barriers (CLB) were defined as patients and families who did not speak Italian as mother tongue together with presence of important social or cultural issues that impaired proper CVC management. Furthermore, patients were stratified according to the presence of CLB (CLB+ versus CLB-). The diagnosis of CLABSI was made according to Center for Disease Prevention and Control Criteria (Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and non-central line-associated Bloodstream Infection). January 2018). A complete antibiogram was available in all cases of CLABSI.Density of infection, defined as number of events/ 1000 CVC days, was calculated as CLABSIs x 1000 / number of central line days. The following risk factors were considered for CLABSI: presence of CLB, total days of CVC placement, total days with CVC spent as an outpatient (outpatient days), ratio between outpatient and inpatient days (O/I days), number of outpatient accesses, type of CVC, neutropenia, underlying disease, hematopoietic stem cell transplantation (HSCT) and type of HSCT. Chi-squared test was used to assess differences for categorical variables and Yates' correction was considered when appropriate. Pearson and Spearman rank correlation tests were applied.Results and DiscussionThirty-seven patients and 45 CVC were included in this study. We observed 8 cases of CLABSI out of 10209 days of catheterization thus the density of infection was 0.78/1000 catheters days.Four patients had CLB and 3 of them developed CLABSI, accounting for 5 out of 8 CLABSI. A significant correlation was observed between the presence of CLB and CLABSI (chi-squared 7.07, p<0.01). Moreover, no difference was observed in O/I days among groups (CLB+ O/I days: 0.75, CLB- O/I days: 0.74, p>0.05). Neither the total days of CVC placement nor the total number of days spent with a CVC as an outpatient were correlated with a higher incidence of CLABSI (Pearson correlation respectively 0.03 and 0.04, p>0.05). Therefore, the outpatient management of CVC alone did not seem to be a risk factor for CLABSI.Noticeable, 75% of patients who developed a CLABSI had a tunneled CVC implanted but a significant correlation between CVC type and CLABSI was not found. Tunneled CVCs were used in nearly 47% of our population; this could partially explain the higher incidence of infections in patients with this type of CVC. According to literature, the highest incidence was observed among neutropenic patients and who was affected by acute lymphoblastic leukemia, although the difference was not statistically relevant. No others significant correlations were observed.ConclusionEven though the number of patients is relative small and differences in the underlying disease may be a confounding element, we found a significant correlation between cultural and linguistic barriers and incidence of CLABSI. Current treatment protocols for many childhood cancers have significantly reduced morbidity and mortality in this group of patients. Thus, it has become particularly important to minimize the risks of complications, included CLABSI, related to therapy. Reducing cultural and language barriers by implementing cultural mediation seems to be a promising way to pursue this objective. At the same time, we trust the importance of CLB is worth deepening with further studies involving a greater number of patients. DisclosuresNo relevant conflicts of interest to declare.

2096. Evaluation of a Midline Catheter Program and Effect on Central Line-Associated Blood Stream Infections

BackgroundCentral line-associated blood stream infections (CLABSI) result in increased patient morbidity. Guidelines recommend against peripheral venous catheters when access is required for longer than 6 days, often leading to central venous catheter (CVCs) placement. To improve vascular access device choice and reduce the potential risk of CLABSIs, we implemented a quality improvement initiative compromised of a new vascular access algorithm with introduction of midline utilization and sought to evaluate the impact of midline use on CLABSI rates.MethodsA prospective quality improvement assessment from October 2017 through March 2018 analyzed the infection rates of midline catheters and CVCs. When a consult was placed for a peripherally inserted central catheter (PICC) that the patient would be evaluated via the vascular access algorithm (Figure 1) for whether they should receive a midline catheter, a PICC or a traditional CVC. The midline catheters, PICCs, and CVCs were monitored for duration of indwell and bloodstream infections consistent with reportable CLABSI definitions.ResultsIn the month prior to implementation, the institutional CLABSI rate was 1.36 per 1,000 CVC (including PICC) days. Since October 2017, there have been 4,588 midline catheter days, with two midline infections, for a cumulative rate over those 6 months of 0.435 midline catheter infections per 1,000 midline days. This was compared with 26,575 CVC days, with 33 documented CLABSIs, for a rate of 1.242 per 1,000 CVC days. Since the vascular algorithm was implemented, the infection rate from the compilation of CVC and midline catheters is 1.12 per 1,000 catheter days.ConclusionThe implementation of a vascular access algorithm including midlines may effectively reduce central line insertions and thereby decrease CLABSIs through appropriate utilization of a lower risk device (midline). Further research into comparing additional risks, benefits, complications and costs of midline catheters and all styles of central venous catheters is warranted. Disclosures All authors: No reported disclosures.

Minimizing central line–associated bloodstream infections in a high-acuity liver transplant intensive care unit

Increases in liver transplant patient perioperative acuity have resulted in frail immunosuppressed patients at elevated risk for nosocomial infections. Avoiding central line-associated bloodstream infections (CLABSIs) is paramount to facilitate transplantation and post-transplant recovery. In 2015, our liver transplant intensive care unit (ICU) CLABSIs accounted for more than 25% of all CLABSI at our institution. We therefore undertook a multidisciplinary collaborative among clinical epidemiology, nursing, transplant surgery, and critical care to eliminate CLABSI events. From 2014-2016, using Lean methodology and plan-do-study-act (PDSA) cycles, 14 interventions were implemented in the liver transplant ICU. Interventions were aimed at infection prevention, care standardization, and team-based monitoring. Implementation used quality improvement methodology including audit and feedback, education, standardization, multidisciplinary stakeholder involvement, and PDSA cycles. Process measures were monitored and audited. CLABSI rates per 1,000 central venous catheter (CVC) days were tracked by clinical epidemiology. During the intervention, 901 CVC catheter audits were completed. Improvements were seen on all process measures, and complete compliance increased from 25%-67%. CLABSI infection rates dropped from 4.2 to 1.8 in 1,000 CVC days, with an average of less than 1 CLABSI per month. This marked a 61.2% annual reduction, which correlated with an estimated $935,000 annual savings. Concerted ongoing multidisciplinary collaboratives are essential to minimize CLABSI and optimize value and quality in a challenging, high-acuity patient population.

Universal decolonization with octenidine: First experiences in a tertiary burn intensive care unit

BackgroundBurn patients are predisposed for nosocomial infections during their stay on a burn intensive care unit. Moreover, several outbreaks affecting burn units for example caused by Methicillin-resistant Staphylococcus aureus (MRSA) have been reported. One attempt to address these challenges is the use of universal decolonization. MethodsIn 2015 we implemented universal decolonization for all burn patients using the antiseptic agent octenidine for intact skin and the nasopharyngeal mucosa. We conducted a retrospective analysis to evaluate the effect of the decolonization on primary, central line (central venous catheter)-associated bloodstream infections (CLABSI), the frequency of nosocomial clusters (4 or more cases with epidemiologic link and identical molecular pattern) with multidrug-resistant bacteria (MDRB) and the incidence of MRSA. ResultsIn the decolonization period a reduction of the incidence of CLABSI, nosocomial MRSA acquisition and the frequency of nosocomial MDRB clusters was observed. The incidence rate of CLABSI decreased from 2/1000 central venous catheter days in the pre-decolonization phase to 0.8/1000 central venous catheter days in the decolonization period, although this was not statistically significant. The implementation was accompanied by several feedback talks and training for the staff. The user experience was positive and no adverse effects occurred. ConclusionOur results show that universal decolonization in burn patients using octenidine is a promising concept to address hospital acquisition of MRSA; occurrence of CLABSI as well as the spread of MDRB causing clusters. It is of high relevance to further assess the value of this measure in terms of reducing CLABSI in burn patients in larger study groups. Therefore further studies including more burn patients guaranteeing adequate sample size are needed.