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Hospital in partnership implements an ultrasound method to perform peripheral venous cannulations, performing the method for 124 patients with a success rate of 97.6 per cent

Challenge

    • Hospital failed to comply with the Centers for Disease Control and Prevention (CDC) recommendations for prompt removal of the central venous catheter (CVC), due to inadequate or difficult peripheral venous access
    • During the first surveillance period (2015), Catheter-Related Bloodstream Infections (CR-BSIs) accounted for 21 (48.8%) incidents and 15.93 instances (9.9-24.3)/1000 CVC-days
    • Improve compliance to CDC’s evidence-based procedures for CVC

Action

    • Implemented ultrasound-guided peripheral venous cannulation (UGPVC) method to reduce CR-BSIs incidents in ICU
    • Combined the five evidence-based procedures recommended by the CDC together with the UGPVC method to increase the compliance with the Category IA recommendation for removal of the intravascular catheter

Result

    • Resulted in UGPVC being performed for 124 patients, with a success rate of 97.6%
    • 104 (86%) out of 121 successful trials were placed on the 1st and 2nd attempts
    • Resulted in CR-BSIs being the least commonly encountered type of infection accounting for 4 (16.7%) incidents
    • Incidence rate per 1000 devices-days was reduced by 11.7/1000 devices days in the second surveillance period (2016)

* Please provide a brief outline of your work.

 In a way to reduce Catheter-Related Bloodstream Infections incidence in ICU, we attempted to implement CDCs evidence-based procedures recommended for central venous catheter. We failed to comply with the recommendation for prompt removal of the central venous catheter, due to the frequently encountered inadequate, or difficulties on establishing peripheral venous access.

We incorporated ultrasound-guided peripheral venous cannulation (UGPVC) method as a supplementary intervention to CDCs recommendations end examined their effect the subsequent year. Significant reduction on CR-BSI incidence rate out of the expected range was found. UGPVC could be considered as an enhancing reminder to Category IA recommendation for reduction CVC exposure.

 * Please describe the actions you took to achieve your result.

 The majority of serious Catheter-Related Bloodstream Infections are associated with central venous catheters placed in intensive care units and are considered to be one of the most costly and lethal type of Healthcare-Associated Infections (HAIs) with reported mortality of 12%-25%.

Keystone Michigan ICU cohort study has effected a reduction up to 66%, by targeting clinicians compliance, on the five evidence based procedures recommended by the CDC (hand hygiene, maximum barrier precautions, chlorhexidine site disinfection, avoiding the femoral site, and promptly removing unnecessary central venous catheters).

Based on infection data recorded on patients admitted in our ICU, CR-BSIs were found to be the most prevalent among all device-associated infections. We assumed that CVC utilisation ratios (UR) and extended duration of use were probably additively responsible for the high CR-BSIs prevalence, as they were higher than reported in several studies. In a way to reduce their incidence, we implemented CDCs evidence-based procedures.

Although the clinicians’ (nurses & physicians) compliance were adequately reminded by unit-based safety check lists, difficulties were found on adequately fulfilling the recommendation for removal the intravascular catheter as soon as it was no longer necessary. Reason for failing was the inadequate, or difficult peripheral venous access (paucity or absence of visible or palpable peripheral veins due to obesity, underweight or edema). Inadequate, or difficult peripheral venous access is also a common indication for CVC placement.

Accordingly, we decided to implement an ultrasound-guided peripheral venous cannulation (UGPVC) method as a supplementary intervention to CDCs evidence-based procedures in order to fully comply with the recommendation of removal the unnecessary intravascular catheter or avoid unnecessary placement.

The use of UGPVC method, can be very helpful in both of the cases, it is very well described and increasingly used in the literature and clinical practice. Randomized trials and observational studies have found that it can reduce the risk of misplacement when difficulty is expected or when the traditional technique has no results.

The aim of the study was the elimination of the inadequate, or difficult peripheral venous access as an indication of CVC use (avoid unnecessary placement or prompt removal) using a reminder for UGPVC method as a supplementary intervention to CDCs recommendations and examine their effect the subsequent year.

 * Please list the most significant results

 UGPVC was performed for 124 patients, with a success rate of 97.6%, 104(86%) out of 121 successful trials were placed on the 1st and 2nd attempts. During the first surveillance period(2015), CR-BSIs was the most commonly encountered type of infection accounting for 21(48.8%) incidents and 15.93 instances (9.9-24.3)/1000 CVC-days.

During the second surveillance period(2016), CR-BSIs was the least commonly encountered type of infection accounting for 4(16.7%) incidents. Incidence rate per 1000 devices-days was reduced by 11.7 per 1000 devices days in the second surveillance period.

There was a reduction of 74% in the rate(RR=0.26, 95%C.I.:0.06-0.77). Reduction appears to be more than that appears in Keystone Michigan study (66%).

 * Describe how your project has spread to other teams, departments or organisations

 The results of the intervention were presented to the scientific committee of the Nursing Department of the Cyprus University of Technology. The committee decided to incorporate the specific methodology of the intervention into their postgraduate program in Advanced and Emergency Critical Care, with the perspective to influence all ICU healthcare facilities in Cyprus.

The aforementioned MSc program is the only ICU related title offered, with participants from all the ICUs in the Republic of Cyprus. Theoretical training will be a part of the program and practical training will be offered in situ at the candidates’ work of place.

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Key individuals

Iordanou Stelios