FW: Controversies in Hospital Infection Prevention

[Michael Wishart]

I think is very much worthy of further consideration. In the Australian context, many acute ICUs have a policy of central line access as a criteria of admission to ICU. But if we can appropriately reduce the number of central lines inserted, we could indeed reduce the risk of CLABSI to that patient group..

Comments anyone? Any epidemiologists/statisticians out there who have a view on this?

Cheers
Michael

Michael Wishart
Infection Control Coordinator

A 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
[cid:image001.png@01D01926.61F1C2B0]
P Please consider the environment before printing this email

From: noreply+feedproxy@google.com [mailto:noreply+feedproxy@google.com]
Sent: Sunday, 25 October 2015 4:34 PM
To: Michael Wishart
Subject: Controversies in Hospital Infection Prevention

Controversies in Hospital Infection Prevention

________________________________

Denominators matter

Posted: 24 Oct 2015 07:12 PM PDT

Let’s perform a thought experiment. At St. Eligius Hospital there are two ICUs. These two ICUs have the same number of beds, the same number of patient days (12,000/year), and the same case mix index. In fact, they’re essentially identical, except that ICU A has an annual CLABSI rate of 2.7/1,000 central line days and ICU B has a CLABSI rate of 5.0/1,000 central line days. Which ICU is better performing with regards to CLABSI? Well, without any other data to consider, we’d be greatly tempted to conclude that ICU A is the better performer since it’s CLABSI rate is nearly one-half that of ICU B. Now, let’s add another piece of information: ICU B focused on reducing central line placement as a safety intervention–so at year’s end, ICU A had 7,500 central line days and ICU B had 3,000 central line days. This means that ICU A finished the year with 20 CLABSIs, and ICU B had 15. Now it’s clear that ICU B is the better performer despite having the higher rate.

This is not just a theoretical problem. During my first rotation on the Infectious Diseases Consultation Service at the University of Iowa last year, I was struck by the low prevalence of central lines in the medical ICU. Turns out my perception was spot on–when I looked at our NHSN data, I saw that 3 of our 5 adult ICUs have central line utilization ratios less than the 15th percentile nationally. This is not an accidental occurrence; clinicians in those ICUs have worked hard to avoid placement of devices that are associated with infection. The problem is that the central lines that do get placed in these units are concentrated in a group of patients that are sicker and more likely to develop CLABSI, since the less sick patients will be managed without a central line. Moreover, the denominator is reduced. And the result is higher CLABSI rates. Here, no good deed goes unpunished.

But there’s an easy fix. Instead of using device days as the denominator, use patient days. In our thought experiment, we would see that ICU A would have a CLABSI rate of 1.7/1,000 patient days and ICU B would have a rate of 1.2/1,000 patient days. The better performer (ICU B) will now have the lower rate, as expected. Makes sense, no? CDC should move to address this given the financial penalties hospitals now face based on CLABSI rates. Changing the denominator would provide an incentive for hospitals to aggressively reduce device insertion. And since NHSN has collected patient days for decades, there would be no loss of long-term trending. Lastly, use of patient-days as a denominator produces a patient-centered metric. Think about it: do we really care what fraction of catheters become infected? No! Our focus should be on what fraction of and how many patients become infected, which is also more intuitive for providers at the sharp edge of patient care.

You are subscribed to email updates from Controversies in Hospital Infection Prevention.
To stop receiving these emails, you may unsubscribe now.

Email delivery powered by Google

______________________________________________________________________
For the purposes of protecting the integrity and security of the SVHA network and the information held on it, all emails to and from any email address on the svha.org.au domain (or any other domain of St Vincents Health Australia Limited or any of its related bodies corporate) (an SVHA Email Address) will pass through and be scanned by the Symantec.cloud anti virus and anti spam filter service. These services may be provided by Symantec from locations outside of Australia and, if so, this will involve any email you send to or receive from an SVHA Email Address being sent to and scanned in those locations.

MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.

The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.

Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.

Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au

To send a message to the list administrator send an email to aicalist-request@aicalist.org.au.

You can unsubscribe from this list be sending ‘signoff aicalist’ (without the quotes) to listserv@aicalist.org.au

[Claire Rickard]

Hi Michael, it is indeed very interesting. 2 comments:

– What were they using for venous access instead?? – while some could have
been managed on oral treatment – are they using a lot more PIVs and
midlines, thus ‘hiding’ the risk of infection there?

What results would we see for those 2 ICUs if they were reporting CABSI in
ALL vascular access devices – including arterial lines..

Now that research is coming out showing (a) we don’t have to remove
non-symptomatic PIVs at 4 days, and (b) the risk of thromobosis/CLABS in
PICCs is greater than initially thought – we are seeing a switch back in
use to PIVs and Midlines. So that means some of our infections will move to
those lines. Hopefully less, but more than we have traditionally had in
those devices.

By the way, doing the “pre-post- type studies, it would be easy for a
hospital in 5 years to conclude “we have seen more PIV infections since we
started using them longer”, when this is actually due to less PICC/CVC use,
in sicker more at risk patients. An RCT would control for changes in
general policy/practice such as the above that happen over time, and thus
that kind of incorrect conclusion, ..in fact Ricard (no relation LOL did a
PIV vs CVC trial in ICU a couple of years back). (Abstract below, although
note that many of what they called PIV “Serious complications” were
difficult insertions and they did not use ultrasound, so maybe that would
have helped…).

– Secondly, their comment that the actual event numbers showed ICU B as the
better performs is incorrect – 20/7500 and 15/3000 still converts to 2.7
(ICU A) and 5.0 (ICU B) per 1000 days.

C

Crit Care Med.
2013
Sep;41(9):2108-15.
doi: 10.1097/CCM.0b013e31828a42c5.
Central or peripheral catheters for initial venous access of ICU patients:
a randomized controlled trial.
Ricard JD

1, Salomon L

, Boyer A

, Thiery G

, Meybeck A

, Roy C

, Pasquet B

, Le Mire E

, Dreyfuss D

.
Author information

Abstract
OBJECTIVES:

The vast majority of ICU patients require some form of venous access. There
are no evidenced-based guidelines concerning the use of either central or
peripheral venous catheters, despite very different complications. It
remains unknown which to insert in ICU patients. We investigated the rate
of catheter-related insertion or maintenance complications in two
strategies: one favoring the central venous catheters and the other
peripheral venous catheters.
DESIGN:

Multicenter, controlled, parallel-group, open-label randomized trial.
SETTING:

Three French ICUs.
PATIENTS:

Adult ICU patients with equal central or peripheral venous access
requirement.
INTERVENTION:

Patients were randomized to receive central venous catheters or peripheral
venous catheters as initial venous access.
MEASUREMENTS AND RESULTS:

The primary endpoint was the rate of major catheter-related complications
within 28 days. Secondary endpoints were the rate of minor catheter-related
complications and a composite score-assessing staff utilization and time
spent to manage catheter insertions. Analysis was intention to treat. We
randomly assigned 135 patients to receive a central venous catheter and 128
patients to receive a peripheral venous catheter. Major catheter-related
complications were greater in the peripheral venous catheter than in the
central venous catheter group (133 vs 87, respectively, p0.02) although
none of those was life threatening. Minor catheter-related complications
were 201 with central venous catheters and 248 with peripheral venous catheters
(p0.06). 46% (60/128) patients were managed throughout their ICU stay with
peripheral venous catheters only. There were significantly more peripheral
venous catheter-related complications per patient in patients managed
solely with peripheral venous catheter than in patients that received
peripheral venous catheter and at least one central venous catheter: 1.92
(121/63) versus 1.13 (226/200), p<0.005. There was no difference in central
venous catheter-related complications per patient between patients
initially randomized to peripheral venouscatheters but subsequently
crossed-over to central venous catheter and patients randomized to the
central venous catheter group. Kaplan-Meier estimates of survival
probability did not differ between the two groups.
CONCLUSION:

In ICU patients with equal central or peripheral venous access requirement,
central venous catheters should preferably be inserted: a strategy
associated with less major complications

Claire Rickard
RN PhD FAAHMS FACN, Professor, NHMRC Centre of Research Excellence in
Nursing Interventions in Hospitalised Patients, Menzies Health Institute
Queensland
Director, Alliance for Vascular Access Teaching and Research (AVATAR)
Visiting Scholar, Princess Alexandra, Prince Charles, and Royal Brisbane &
Women's Hospitals
Honorary Professor, University of Manchester

On 26 October 2015 at 07:58, Michael Wishart
wrote:

> I think is very much worthy of further consideration. In the Australian
> context, many acute ICUs have a policy of central line access as a
> criteria of admission to ICU. But if we can appropriately reduce the number
> of central lines inserted, we could indeed reduce the risk of CLABSI to
> that patient group..
>
>
>
> Comments anyone? Any epidemiologists/statisticians out there who have a
> view on this?
>
>
>
> Cheers
>
> Michael
>
>
>
>
>
> *Michael Wishart*
>
> Infection Control Coordinator
>
>
> *A *627 Rode Road, Chermside QLD 4032
> *P *(07) 3326 3068 | *F *(07) 3607 2226 | *E *
> michael.wishart@svha.org.au | *W * http://www.hsnph.org.au
> [image: cid:image001.png@01D01926.61F1C2B0]
> P *Please consider the environment before printing this email*
>
>
>
> *From:* noreply+feedproxy@google.com [mailto:noreply+feedproxy@google.com]
>
> *Sent:* Sunday, 25 October 2015 4:34 PM
> *To:* Michael Wishart
> *Subject:* Controversies in Hospital Infection Prevention
>
>
> Controversies in Hospital Infection Prevention
>
> ——————————
>
> *Denominators matter*
>
>
> Posted: 24 Oct 2015 07:12 PM PDT
>
>
> Let’s perform a thought experiment. At *St. Eligius Hospital*
> there are two ICUs. These
> two ICUs have the same number of beds, the same number of patient days
> (12,000/year), and the same case mix index. In fact, they’re essentially
> identical, except that ICU A has an annual CLABSI rate of 2.7/1,000 central
> line days and ICU B has a CLABSI rate of 5.0/1,000 central line days. Which
> ICU is better performing with regards to CLABSI? Well, without any other
> data to consider, we’d be greatly tempted to conclude that ICU A is the
> better performer since it’s CLABSI rate is nearly one-half that of ICU B.
> Now, let’s add another piece of information: ICU B focused on reducing
> central line placement as a safety intervention–so at year’s end, ICU A
> had 7,500 central line days and ICU B had 3,000 central line days. This
> means that ICU A finished the year with 20 CLABSIs, and ICU B had 15. Now
> it’s clear that ICU B is the better performer despite having the higher
> rate.
>
> This is not just a theoretical problem. During my first rotation on the
> Infectious Diseases Consultation Service at the University of Iowa last
> year, I was struck by the low prevalence of central lines in the medical
> ICU. Turns out my perception was spot on–when I looked at our NHSN data, I
> saw that 3 of our 5 adult ICUs have central line utilization ratios less
> than the 15th percentile nationally. This is not an accidental occurrence;
> clinicians in those ICUs have worked hard to avoid placement of devices
> that are associated with infection. The problem is that the central lines
> that do get placed in these units are concentrated in a group of patients
> that are sicker and more likely to develop CLABSI, since the less sick
> patients will be managed without a central line. Moreover, the denominator
> is reduced. And the result is higher CLABSI rates. Here, no good deed goes
> unpunished.
>
> But there’s an easy fix. Instead of using device days as the denominator,
> use patient days. In our thought experiment, we would see that ICU A would
> have a CLABSI rate of 1.7/1,000 patient days and ICU B would have a rate of
> 1.2/1,000 patient days. The better performer (ICU B) will now have the
> lower rate, as expected. Makes sense, no? CDC should move to address this
> given the financial penalties hospitals now face based on CLABSI rates.
> Changing the denominator would provide an incentive for hospitals to
> aggressively reduce device insertion. And since NHSN has collected patient
> days for decades, there would be no loss of long-term trending. Lastly, use
> of patient-days as a denominator produces a patient-centered metric. Think
> about it: do we really care what fraction of catheters become infected? No!
> Our focus should be on what fraction of and how many *patients* become
> infected, which is also more intuitive for providers at the sharp edge of
> patient care.
>
>
>
>
> [image: Image removed by sender.]
>
>
>
> You are subscribed to email updates from Controversies in Hospital
> Infection Prevention .
> To stop receiving these emails, you may unsubscribe now
>
> .
>
> Email delivery powered by Google
>
>
>
> ______________________________________________________________________
> For the purposes of protecting the integrity and security of the SVHA
> network and the information held on it, all emails to and from any email
> address on the svha.org.au domain (or any other domain of St Vincents
> Health Australia Limited or any of its related bodies corporate) (an SVHA
> Email Address) will pass through and be scanned by the Symantec.cloud anti
> virus and anti spam filter service. These services may be provided by
> Symantec from locations outside of Australia and, if so, this will involve
> any email you send to or receive from an SVHA Email Address being sent to
> and scanned in those locations.
> MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO
> NOT REPRESENT THE OPINION OF ACIPC.
>
> The use of trade/product/commercial brand names through the list is
> discouraged by ACIPC. If you wish to discuss specific reference to products
> or services by brand or commercial names, please do this outside the list.
>
> Archive of all messages are available at http://aicalist.org.au/archives
> – registration and login required.
>
> Replies to this message will be directed back to the list. To create a new
> message send an email to aicalist@aicalist.org.au
>
> To send a message to the list administrator send an email to
> aicalist-request@aicalist.org.au.
>
> You can unsubscribe from this list be sending ‘signoff aicalist’ (without
> the quotes) to listserv@aicalist.org.au
>

MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.

The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.

Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.

Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au

To send a message to the list administrator send an email to aicalist-request@aicalist.org.au.

You can unsubscribe from this list be sending ‘signoff aicalist’ (without the quotes) to listserv@aicalist.org.au

[Claire Rickard]

aha thanks Rebecca, now I see they had mentioned ICU days higher up in the
para…..
there’s nothing like making a mistake on a national mailing list 😀
C

Claire Rickard
RN PhD FAAHMS FACN, Professor, NHMRC Centre of Research Excellence in
Nursing Interventions in Hospitalised Patients, Menzies Health Institute
Queensland
Director, Alliance for Vascular Access Teaching and Research (AVATAR)
Visiting Scholar, Princess Alexandra, Prince Charles, and Royal Brisbane &
Women’s Hospitals
Honorary Professor, University of Manchester

On 26 October 2015 at 10:52, McCann, Rebecca wrote:

> Hi Michael
>
>
>
> I think Claire has missed that the second rates were calculated using the
> 12,000 patient days both units had .
>
>
>
> Kind Regards
>
>
>
> Rebecca
>
>
>
>
>
> *R**ebecca McCann Program Manager *
> Healthcare Associated Infection Unit (HAIU)
> Communicable Disease Control Directorate Department of Health
> Grace Vaughan House
> 227 Stubbs Terrace
> SHENTON PARK WA 6008
> T:08 9388 4859 M:0439 920 819 F:08 9388 4888
> E:rebecca.mccann@health.wa.gov.au
>
>
> The contents of this e-mail transmission are intended for the named
> recipients only and may contain confidential and/or privileged
> information. If you received this message in error, you must not copy,
> duplicate, forward, print or otherwise distribute any information contained
> herein, but must ensure that this e-mail is permanently deleted and advise
> the sender immediately.
>
>
>
>
>
> *From:* ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] *On
> Behalf Of *Claire Rickard
> *Sent:* Monday, 26 October 2015 6:42 AM
> *To:* AICALIST@AICALIST.ORG.AU
> *Subject:* Re: [ACIPC_Infexion_Connexion] FW: Controversies in Hospital
> Infection Prevention
>
>
>
> Hi Michael, it is indeed very interesting. 2 comments:
>
>
>
> – What were they using for venous access instead?? – while some could have
> been managed on oral treatment – are they using a lot more PIVs and
> midlines, thus ‘hiding’ the risk of infection there?
>
>
>
> What results would we see for those 2 ICUs if they were reporting CABSI in
> ALL vascular access devices – including arterial lines..
>
>
>
> Now that research is coming out showing (a) we don’t have to remove
> non-symptomatic PIVs at 4 days, and (b) the risk of thromobosis/CLABS in
> PICCs is greater than initially thought – we are seeing a switch back in
> use to PIVs and Midlines. So that means some of our infections will move to
> those lines. Hopefully less, but more than we have traditionally had in
> those devices.
>
>
>
> By the way, doing the “pre-post- type studies, it would be easy for a
> hospital in 5 years to conclude “we have seen more PIV infections since we
> started using them longer”, when this is actually due to less PICC/CVC use,
> in sicker more at risk patients. An RCT would control for changes in
> general policy/practice such as the above that happen over time, and thus
> that kind of incorrect conclusion, ..in fact Ricard (no relation LOL did a
> PIV vs CVC trial in ICU a couple of years back). (Abstract below, although
> note that many of what they called PIV “Serious complications” were
> difficult insertions and they did not use ultrasound, so maybe that would
> have helped…).
>
>
>
> – Secondly, their comment that the actual event numbers showed ICU B as
> the better performs is incorrect – 20/7500 and 15/3000 still converts to
> 2.7 (ICU A) and 5.0 (ICU B) per 1000 days.
>
>
>
> C
>
>
>
>
>
> Crit Care Med.
> 2013 Sep;41(9):2108-15.
> doi: 10.1097/CCM.0b013e31828a42c5.
> Central or peripheral catheters for initial venous access of ICU patients:
> a randomized controlled trial.
>
> Ricard JD
>
> 1, Salomon L
>
> , Boyer A
>
> , Thiery G
>
> , Meybeck A
>
> , Roy C
>
> , Pasquet B
>
> , Le Mire E
>
> , Dreyfuss D
>
> .
> Author information
>
> Abstract
> OBJECTIVES:
>
> The vast majority of ICU patients require some form of venous access.
> There are no evidenced-based guidelines concerning the use of either
> central or peripheral venous catheters, despite very different
> complications. It remains unknown which to insert in ICU patients. We
> investigated the rate of catheter-related insertion or maintenance
> complications in two strategies: one favoring the central venous catheters
> and the other peripheral venous catheters.
> DESIGN:
>
> Multicenter, controlled, parallel-group, open-label randomized trial.
> SETTING:
>
> Three French ICUs.
> PATIENTS:
>
> Adult ICU patients with equal central or peripheral venous access
> requirement.
> INTERVENTION:
>
> Patients were randomized to receive central venous catheters or
> peripheralvenous catheters as initial venous access.
> MEASUREMENTS AND RESULTS:
>
> The primary endpoint was the rate of major catheter-related complications
> within 28 days. Secondary endpoints were the rate of minor catheter-related
> complications and a composite score-assessing staff utilization and time
> spent to manage catheter insertions. Analysis was intention to treat. We
> randomly assigned 135 patients to receive a central venous catheter and 128
> patients to receive a peripheral venous catheter. Major catheter-related
> complications were greater in the peripheral venous catheter than in the
> central venous catheter group (133 vs 87, respectively, p0.02) although
> none of those was life threatening. Minor catheter-related complications
> were 201 with central venous catheters and 248 with
> peripheral venous catheters (p0.06). 46% (60/128) patients were managed
> throughout their ICU stay with peripheral venous catheters only. There were
> significantly more peripheral venous catheter-related complications per
> patient in patients managed solely with peripheral venous catheter than in
> patients that received peripheral venous catheter and at least one
> central venous catheter: 1.92 (121/63) versus 1.13 (226/200), p There was no difference in central venous catheter-related complications
> per patient between patients initially randomized to
> peripheral venouscatheters but subsequently crossed-over to
> central venous catheter and patients randomized to the
> central venous catheter group. Kaplan-Meier estimates of survival
> probability did not differ between the two groups.
> CONCLUSION:
>
> In ICU patients with equal central or peripheral venous access
> requirement, central venous catheters should preferably be inserted: a
> strategy associated with less major complications
>
>
>
>
> Claire Rickard
>
> RN PhD FAAHMS FACN, Professor, NHMRC Centre of Research Excellence in
> Nursing Interventions in Hospitalised Patients, Menzies Health Institute
> Queensland
>
> Director, Alliance for Vascular Access Teaching and Research (AVATAR)
>
> Visiting Scholar, Princess Alexandra, Prince Charles, and Royal Brisbane &
> Women’s Hospitals
>
> Honorary Professor, University of Manchester
>
> Assistant: Jo.Wright@griffith.edu.au Tel: +61 7 3735 4886
>
>
>
>
>
>
>
> On 26 October 2015 at 07:58, Michael Wishart
> wrote:
>
> I think is very much worthy of further consideration. In the Australian
> context, many acute ICUs have a policy of central line access as a
> criteria of admission to ICU. But if we can appropriately reduce the number
> of central lines inserted, we could indeed reduce the risk of CLABSI to
> that patient group..
>
>
>
> Comments anyone? Any epidemiologists/statisticians out there who have a
> view on this?
>
>
>
> Cheers
>
> Michael
>
>
>
>
>
> *Michael Wishart*
>
> Infection Control Coordinator
>
>
> *A *627 Rode Road, Chermside QLD 4032
> *P *(07) 3326 3068 | *F *(07) 3607 2226 | *E *
> michael.wishart@svha.org.au | *W * http://www.hsnph.org.au
>
> P *Please consider the environment before printing this email*
>
>
>
> *From:* noreply+feedproxy@google.com [mailto:noreply+feedproxy@google.com]
>
> *Sent:* Sunday, 25 October 2015 4:34 PM
> *To:* Michael Wishart
> *Subject:* Controversies in Hospital Infection Prevention
>
>
> Controversies in Hospital Infection Prevention
>
> ——————————
>
> *Denominators matter*
>
>
> Posted: 24 Oct 2015 07:12 PM PDT
>
>
> Let’s perform a thought experiment. At *St. Eligius Hospital*
> there are two ICUs. These
> two ICUs have the same number of beds, the same number of patient days
> (12,000/year), and the same case mix index. In fact, they’re essentially
> identical, except that ICU A has an annual CLABSI rate of 2.7/1,000 central
> line days and ICU B has a CLABSI rate of 5.0/1,000 central line days. Which
> ICU is better performing with regards to CLABSI? Well, without any other
> data to consider, we’d be greatly tempted to conclude that ICU A is the
> better performer since it’s CLABSI rate is nearly one-half that of ICU B.
> Now, let’s add another piece of information: ICU B focused on reducing
> central line placement as a safety intervention–so at year’s end, ICU A
> had 7,500 central line days and ICU B had 3,000 central line days. This
> means that ICU A finished the year with 20 CLABSIs, and ICU B had 15. Now
> it’s clear that ICU B is the better performer despite having the higher
> rate.
>
> This is not just a theoretical problem. During my first rotation on the
> Infectious Diseases Consultation Service at the University of Iowa last
> year, I was struck by the low prevalence of central lines in the medical
> ICU. Turns out my perception was spot on–when I looked at our NHSN data, I
> saw that 3 of our 5 adult ICUs have central line utilization ratios less
> than the 15th percentile nationally. This is not an accidental occurrence;
> clinicians in those ICUs have worked hard to avoid placement of devices
> that are associated with infection. The problem is that the central lines
> that do get placed in these units are concentrated in a group of patients
> that are sicker and more likely to develop CLABSI, since the less sick
> patients will be managed without a central line. Moreover, the denominator
> is reduced. And the result is higher CLABSI rates. Here, no good deed goes
> unpunished.
>
> But there’s an easy fix. Instead of using device days as the denominator,
> use patient days. In our thought experiment, we would see that ICU A would
> have a CLABSI rate of 1.7/1,000 patient days and ICU B would have a rate of
> 1.2/1,000 patient days. The better performer (ICU B) will now have the
> lower rate, as expected. Makes sense, no? CDC should move to address this
> given the financial penalties hospitals now face based on CLABSI rates.
> Changing the denominator would provide an incentive for hospitals to
> aggressively reduce device insertion. And since NHSN has collected patient
> days for decades, there would be no loss of long-term trending. Lastly, use
> of patient-days as a denominator produces a patient-centered metric. Think
> about it: do we really care what fraction of catheters become infected? No!
> Our focus should be on what fraction of and how many *patients* become
> infected, which is also more intuitive for providers at the sharp edge of
> patient care.
>
>
>
>
>
>
> You are subscribed to email updates from Controversies in Hospital
> Infection Prevention .
> To stop receiving these emails, you may unsubscribe now
>
> .
>
> Email delivery powered by Google
>
>
>
>
> ______________________________________________________________________
> For the purposes of protecting the integrity and security of the SVHA
> network and the information held on it, all emails to and from any email
> address on the svha.org.au domain (or any other domain of St Vincents
> Health Australia Limited or any of its related bodies corporate) (an SVHA
> Email Address) will pass through and be scanned by the Symantec.cloud anti
> virus and anti spam filter service. These services may be provided by
> Symantec from locations outside of Australia and, if so, this will involve
> any email you send to or receive from an SVHA Email Address being sent to
> and scanned in those locations.
>
> MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO
> NOT REPRESENT THE OPINION OF ACIPC.
>
> The use of trade/product/commercial brand names through the list is
> discouraged by ACIPC. If you wish to discuss specific reference to products
> or services by brand or commercial names, please do this outside the list.
>
> Archive of all messages are available at http://aicalist.org.au/archives
> – registration and login required.
>
> Replies to this message will be directed back to the list. To create a new
> message send an email to aicalist@aicalist.org.au
>
> To send a message to the list administrator send an email to
> aicalist-request@aicalist.org.au.
>
> You can unsubscribe from this list be sending ‘signoff aicalist’ (without
> the quotes) to listserv@aicalist.org.au
>
>
>
> MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO
> NOT REPRESENT THE OPINION OF ACIPC.
>
> The use of trade/product/commercial brand names through the list is
> discouraged by ACIPC. If you wish to discuss specific reference to products
> or services by brand or commercial names, please do this outside the list.
>
> Archive of all messages are available at http://aicalist.org.au/archives
> – registration and login required.
>
> Replies to this message will be directed back to the list. To create a new
> message send an email to aicalist@aicalist.org.au
>
> To send a message to the list administrator send an email to
> aicalist-request@aicalist.org.au.
>
> You can unsubscribe from this list be sending ‘signoff aicalist’ (without
> the quotes) to listserv@aicalist.org.au
> MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO
> NOT REPRESENT THE OPINION OF ACIPC.
>
> The use of trade/product/commercial brand names through the list is
> discouraged by ACIPC. If you wish to discuss specific reference to products
> or services by brand or commercial names, please do this outside the list.
>
> Archive of all messages are available at http://aicalist.org.au/archives
> – registration and login required.
>
> Replies to this message will be directed back to the list. To create a new
> message send an email to aicalist@aicalist.org.au
>
> To send a message to the list administrator send an email to
> aicalist-request@aicalist.org.au.
>
> You can unsubscribe from this list be sending ‘signoff aicalist’ (without
> the quotes) to listserv@aicalist.org.au
>

MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.

The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.

Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.

Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au

To send a message to the list administrator send an email to aicalist-request@aicalist.org.au.

You can unsubscribe from this list be sending ‘signoff aicalist’ (without the quotes) to listserv@aicalist.org.au

[Kevin Kavanagh]

I goes without saying that if you use less central lines then you will get
less central line infections. However, it you then are using peripheral
lines, additional problems can arise from decreased patient mobility,
vascular inflammation and if a chemotheraputic agent is used, even tissue
necrosis.

We also looked at improvement in rates of CLABSIs over four years using
different denominators (patient discharge and line days) each one used in
a large data set.(Partnership for patients vs NHSN). There was no
difference in the improvement observed using these two metics. This is
probably because the vast majority of CLABSIs can be prevented.

This situation is unlike CAUTIs where the two data sets gave markedly
different results.

Kevin

Kevin Kavanagh, MD
Health Watch USA
Lexington KY, USA
606-875-3642

On Sun, Oct 25, 2015 at 9:16 PM, Claire Rickard
wrote:

> aha thanks Rebecca, now I see they had mentioned ICU days higher up in the
> para…..
> there’s nothing like making a mistake on a national mailing list 😀
> C
>
>
> Claire Rickard
> RN PhD FAAHMS FACN, Professor, NHMRC Centre of Research Excellence in
> Nursing Interventions in Hospitalised Patients, Menzies Health Institute
> Queensland
> Director, Alliance for Vascular Access Teaching and Research (AVATAR)
> Visiting Scholar, Princess Alexandra, Prince Charles, and Royal Brisbane &
> Women’s Hospitals
> Honorary Professor, University of Manchester
> Assistant: Jo.Wright@griffith.edu.au Tel: +61 7 3735 4886
>
>
>
>
> On 26 October 2015 at 10:52, McCann, Rebecca Rebecca.McCann@health.wa.gov.au> wrote:
>
>> Hi Michael
>>
>>
>>
>> I think Claire has missed that the second rates were calculated using the
>> 12,000 patient days both units had .
>>
>>
>>
>> Kind Regards
>>
>>
>>
>> Rebecca
>>
>>
>>
>>
>>
>> *R**ebecca McCann Program Manager *
>> Healthcare Associated Infection Unit (HAIU)
>> Communicable Disease Control Directorate Department of Health
>> Grace Vaughan House
>> 227 Stubbs Terrace
>> SHENTON PARK WA 6008
>> T:08 9388 4859 M:0439 920 819 F:08 9388 4888
>> E:rebecca.mccann@health.wa.gov.au
>>
>>
>> The contents of this e-mail transmission are intended for the named
>> recipients only and may contain confidential and/or privileged
>> information. If you received this message in error, you must not copy,
>> duplicate, forward, print or otherwise distribute any information contained
>> herein, but must ensure that this e-mail is permanently deleted and advise
>> the sender immediately.
>>
>>
>>
>>
>>
>> *From:* ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] *On
>> Behalf Of *Claire Rickard
>> *Sent:* Monday, 26 October 2015 6:42 AM
>> *To:* AICALIST@AICALIST.ORG.AU
>> *Subject:* Re: [ACIPC_Infexion_Connexion] FW: Controversies in Hospital
>> Infection Prevention
>>
>>
>>
>> Hi Michael, it is indeed very interesting. 2 comments:
>>
>>
>>
>> – What were they using for venous access instead?? – while some could
>> have been managed on oral treatment – are they using a lot more PIVs and
>> midlines, thus ‘hiding’ the risk of infection there?
>>
>>
>>
>> What results would we see for those 2 ICUs if they were reporting CABSI
>> in ALL vascular access devices – including arterial lines..
>>
>>
>>
>> Now that research is coming out showing (a) we don’t have to remove
>> non-symptomatic PIVs at 4 days, and (b) the risk of thromobosis/CLABS in
>> PICCs is greater than initially thought – we are seeing a switch back in
>> use to PIVs and Midlines. So that means some of our infections will move to
>> those lines. Hopefully less, but more than we have traditionally had in
>> those devices.
>>
>>
>>
>> By the way, doing the “pre-post- type studies, it would be easy for a
>> hospital in 5 years to conclude “we have seen more PIV infections since we
>> started using them longer”, when this is actually due to less PICC/CVC use,
>> in sicker more at risk patients. An RCT would control for changes in
>> general policy/practice such as the above that happen over time, and thus
>> that kind of incorrect conclusion, ..in fact Ricard (no relation LOL did a
>> PIV vs CVC trial in ICU a couple of years back). (Abstract below, although
>> note that many of what they called PIV “Serious complications” were
>> difficult insertions and they did not use ultrasound, so maybe that would
>> have helped…).
>>
>>
>>
>> – Secondly, their comment that the actual event numbers showed ICU B as
>> the better performs is incorrect – 20/7500 and 15/3000 still converts to
>> 2.7 (ICU A) and 5.0 (ICU B) per 1000 days.
>>
>>
>>
>> C
>>
>>
>>
>>
>>
>> Crit Care Med.
>> 2013 Sep;41(9):2108-15.
>> doi: 10.1097/CCM.0b013e31828a42c5.
>> Central or peripheral catheters for initial venous access of ICU
>> patients: a randomized controlled trial.
>>
>> Ricard JD
>>
>> 1, Salomon L
>>
>> , Boyer A
>>
>> , Thiery G
>>
>> , Meybeck A
>>
>> , Roy C
>>
>> , Pasquet B
>>
>> , Le Mire E
>>
>> , Dreyfuss D
>>
>> .
>> Author information
>>
>> Abstract
>> OBJECTIVES:
>>
>> The vast majority of ICU patients require some form of venous access.
>> There are no evidenced-based guidelines concerning the use of either
>> central or peripheral venous catheters, despite very different
>> complications. It remains unknown which to insert in ICU patients. We
>> investigated the rate of catheter-related insertion or maintenance
>> complications in two strategies: one favoring the central venous catheters
>> and the other peripheral venous catheters.
>> DESIGN:
>>
>> Multicenter, controlled, parallel-group, open-label randomized trial.
>> SETTING:
>>
>> Three French ICUs.
>> PATIENTS:
>>
>> Adult ICU patients with equal central or peripheral venous access
>> requirement.
>> INTERVENTION:
>>
>> Patients were randomized to receive central venous catheters or
>> peripheralvenous catheters as initial venous access.
>> MEASUREMENTS AND RESULTS:
>>
>> The primary endpoint was the rate of major catheter-related complications
>> within 28 days. Secondary endpoints were the rate of minor catheter-related
>> complications and a composite score-assessing staff utilization and time
>> spent to manage catheter insertions. Analysis was intention to treat. We
>> randomly assigned 135 patients to receive a central venous catheter and 128
>> patients to receive a peripheral venous catheter. Major catheter-related
>> complications were greater in the peripheral venous catheter than in the
>> central venous catheter group (133 vs 87, respectively, p0.02) although
>> none of those was life threatening. Minor catheter-related complications
>> were 201 with central venous catheters and 248 with
>> peripheral venous catheters (p0.06). 46% (60/128) patients were managed
>> throughout their ICU stay with peripheral venous catheters only. There were
>> significantly more peripheral venous catheter-related complications per
>> patient in patients managed solely with peripheral venous catheter than in
>> patients that received peripheral venous catheter and at least one
>> central venous catheter: 1.92 (121/63) versus 1.13 (226/200), p> There was no difference in central venous catheter-related complications
>> per patient between patients initially randomized to
>> peripheral venouscatheters but subsequently crossed-over to
>> central venous catheter and patients randomized to the
>> central venous catheter group. Kaplan-Meier estimates of survival
>> probability did not differ between the two groups.
>> CONCLUSION:
>>
>> In ICU patients with equal central or peripheral venous access
>> requirement, central venous catheters should preferably be inserted: a
>> strategy associated with less major complications
>>
>>
>>
>>
>> Claire Rickard
>>
>> RN PhD FAAHMS FACN, Professor, NHMRC Centre of Research Excellence in
>> Nursing Interventions in Hospitalised Patients, Menzies Health Institute
>> Queensland
>>
>> Director, Alliance for Vascular Access Teaching and Research (AVATAR)
>>
>> Visiting Scholar, Princess Alexandra, Prince Charles, and Royal Brisbane
>> & Women’s Hospitals
>>
>> Honorary Professor, University of Manchester
>>
>> Assistant: Jo.Wright@griffith.edu.au Tel: +61 7 3735 4886
>>
>>
>>
>>
>>
>>
>>
>> On 26 October 2015 at 07:58, Michael Wishart
>> wrote:
>>
>> I think is very much worthy of further consideration. In the Australian
>> context, many acute ICUs have a policy of central line access as a
>> criteria of admission to ICU. But if we can appropriately reduce the number
>> of central lines inserted, we could indeed reduce the risk of CLABSI to
>> that patient group..
>>
>>
>>
>> Comments anyone? Any epidemiologists/statisticians out there who have a
>> view on this?
>>
>>
>>
>> Cheers
>>
>> Michael
>>
>>
>>
>>
>>
>> *Michael Wishart*
>>
>> Infection Control Coordinator
>>
>>
>> *A *627 Rode Road, Chermside QLD 4032
>> *P *(07) 3326 3068 | *F *(07) 3607 2226 | *E *
>> michael.wishart@svha.org.au | *W * http://www.hsnph.org.au
>>
>> P *Please consider the environment before printing this email*
>>
>>
>>
>> *From:* noreply+feedproxy@google.com [mailto:noreply+feedproxy@google.com]
>>
>> *Sent:* Sunday, 25 October 2015 4:34 PM
>> *To:* Michael Wishart
>> *Subject:* Controversies in Hospital Infection Prevention
>>
>>
>> Controversies in Hospital Infection Prevention
>>
>> ——————————
>>
>> *Denominators matter*
>>
>>
>> Posted: 24 Oct 2015 07:12 PM PDT
>>
>>
>> Let’s perform a thought experiment. At *St. Eligius Hospital*
>> there are two ICUs. These
>> two ICUs have the same number of beds, the same number of patient days
>> (12,000/year), and the same case mix index. In fact, they’re essentially
>> identical, except that ICU A has an annual CLABSI rate of 2.7/1,000 central
>> line days and ICU B has a CLABSI rate of 5.0/1,000 central line days. Which
>> ICU is better performing with regards to CLABSI? Well, without any other
>> data to consider, we’d be greatly tempted to conclude that ICU A is the
>> better performer since it’s CLABSI rate is nearly one-half that of ICU B.
>> Now, let’s add another piece of information: ICU B focused on reducing
>> central line placement as a safety intervention–so at year’s end, ICU A
>> had 7,500 central line days and ICU B had 3,000 central line days. This
>> means that ICU A finished the year with 20 CLABSIs, and ICU B had 15. Now
>> it’s clear that ICU B is the better performer despite having the higher
>> rate.
>>
>> This is not just a theoretical problem. During my first rotation on the
>> Infectious Diseases Consultation Service at the University of Iowa last
>> year, I was struck by the low prevalence of central lines in the medical
>> ICU. Turns out my perception was spot on–when I looked at our NHSN data, I
>> saw that 3 of our 5 adult ICUs have central line utilization ratios less
>> than the 15th percentile nationally. This is not an accidental occurrence;
>> clinicians in those ICUs have worked hard to avoid placement of devices
>> that are associated with infection. The problem is that the central lines
>> that do get placed in these units are concentrated in a group of patients
>> that are sicker and more likely to develop CLABSI, since the less sick
>> patients will be managed without a central line. Moreover, the denominator
>> is reduced. And the result is higher CLABSI rates. Here, no good deed goes
>> unpunished.
>>
>> But there’s an easy fix. Instead of using device days as the denominator,
>> use patient days. In our thought experiment, we would see that ICU A would
>> have a CLABSI rate of 1.7/1,000 patient days and ICU B would have a rate of
>> 1.2/1,000 patient days. The better performer (ICU B) will now have the
>> lower rate, as expected. Makes sense, no? CDC should move to address this
>> given the financial penalties hospitals now face based on CLABSI rates.
>> Changing the denominator would provide an incentive for hospitals to
>> aggressively reduce device insertion. And since NHSN has collected patient
>> days for decades, there would be no loss of long-term trending. Lastly, use
>> of patient-days as a denominator produces a patient-centered metric. Think
>> about it: do we really care what fraction of catheters become infected? No!
>> Our focus should be on what fraction of and how many *patients* become
>> infected, which is also more intuitive for providers at the sharp edge of
>> patient care.
>>
>>
>>
>>
>>
>>
>> You are subscribed to email updates from Controversies in Hospital
>> Infection Prevention .
>> To stop receiving these emails, you may unsubscribe now
>>
>> .
>>
>> Email delivery powered by Google
>>
>>
>>
>>
>> ______________________________________________________________________
>> For the purposes of protecting the integrity and security of the SVHA
>> network and the information held on it, all emails to and from any email
>> address on the svha.org.au domain (or any other domain of St Vincents
>> Health Australia Limited or any of its related bodies corporate) (an SVHA
>> Email Address) will pass through and be scanned by the Symantec.cloud anti
>> virus and anti spam filter service. These services may be provided by
>> Symantec from locations outside of Australia and, if so, this will involve
>> any email you send to or receive from an SVHA Email Address being sent to
>> and scanned in those locations.
>>
>> MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO
>> NOT REPRESENT THE OPINION OF ACIPC.
>>
>> The use of trade/product/commercial brand names through the list is
>> discouraged by ACIPC. If you wish to discuss specific reference to products
>> or services by brand or commercial names, please do this outside the list.
>>
>> Archive of all messages are available at http://aicalist.org.au/archives
>> – registration and login required.
>>
>> Replies to this message will be directed back to the list. To create a
>> new message send an email to aicalist@aicalist.org.au
>>
>> To send a message to the list administrator send an email to
>> aicalist-request@aicalist.org.au.
>>
>> You can unsubscribe from this list be sending ‘signoff aicalist’ (without
>> the quotes) to listserv@aicalist.org.au
>>
>>
>>
>> MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO
>> NOT REPRESENT THE OPINION OF ACIPC.
>>
>> The use of trade/product/commercial brand names through the list is
>> discouraged by ACIPC. If you wish to discuss specific reference to products
>> or services by brand or commercial names, please do this outside the list.
>>
>> Archive of all messages are available at http://aicalist.org.au/archives
>> – registration and login required.
>>
>> Replies to this message will be directed back to the list. To create a
>> new message send an email to aicalist@aicalist.org.au
>>
>> To send a message to the list administrator send an email to
>> aicalist-request@aicalist.org.au.
>>
>> You can unsubscribe from this list be sending ‘signoff aicalist’ (without
>> the quotes) to listserv@aicalist.org.au
>> MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO
>> NOT REPRESENT THE OPINION OF ACIPC.
>>
>> The use of trade/product/commercial brand names through the list is
>> discouraged by ACIPC. If you wish to discuss specific reference to products
>> or services by brand or commercial names, please do this outside the list.
>>
>> Archive of all messages are available at http://aicalist.org.au/archives
>> – registration and login required.
>>
>> Replies to this message will be directed back to the list. To create a
>> new message send an email to aicalist@aicalist.org.au
>>
>> To send a message to the list administrator send an email to
>> aicalist-request@aicalist.org.au.
>>
>> You can unsubscribe from this list be sending ‘signoff aicalist’ (without
>> the quotes) to listserv@aicalist.org.au
>>
>
> MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO
> NOT REPRESENT THE OPINION OF ACIPC.
>
> The use of trade/product/commercial brand names through the list is
> discouraged by ACIPC. If you wish to discuss specific reference to products
> or services by brand or commercial names, please do this outside the list.
>
> Archive of all messages are available at http://aicalist.org.au/archives
> – registration and login required.
>
> Replies to this message will be directed back to the list. To create a new
> message send an email to aicalist@aicalist.org.au
>
> To send a message to the list administrator send an email to
> aicalist-request@aicalist.org.au.
>
> You can unsubscribe from this list be sending ‘signoff aicalist’ (without
> the quotes) to listserv@aicalist.org.au
>

—
*Confidentiality Notice: This e-mail is intended only for the addressee
named above. It may contain information that is privileged, confidential,
or otherwise protected from use and disclosure. If you are not the intended
recipient, you are hereby notified that any review, disclosure, copying, or
dissemination of this transmission, or taking of any action in reliance on
its contents, or other use is strictly prohibited. If you have received
this transmission in error, please reply to the sender listed above
immediately and permanently delete this message from your inbox. Thank you
for your cooperation.*

MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.

The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.

Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.

Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au

To send a message to the list administrator send an email to aicalist-request@aicalist.org.au.

You can unsubscribe from this list be sending ‘signoff aicalist’ (without the quotes) to listserv@aicalist.org.au

[Author]

Posts