Abstract

Introduction: Blood cultures are critical values for identifying the source of an infection in patients seeking medical treatment for an acute illness. False-positive cultures can negatively influence patient care when physicians use inaccurate information to prescribe treatment. Inaccurate prescribed treatment negatively influences the quality of patient care related to prolonged medical treatment and hospital stay and unnecessary repetition of diagnostic tests.

Purpose: The purpose of this project was to determine if blood culture contamination rates would be decreased if improved availability of CHG products was provided in all emergency department patient care areas would reduce the contamination rates of blood cultures.

Methodology: The Theory of Planned Behavior provided the theoretical framework for this descriptive correlational project to examine barriers to following the procedural guidelines to cleanse venipuncture sites with a chlorhexidine gluconate (CHG) product before venipuncture Alcohol preparation pads were removed from the emergency department and a CHG product packaged similar to the alcohol preparation pads was placed in the department procedure trays and bedside carts.

Results: During the first 2 weeks of the pilot project, blood culture contamination rates were reduced from 4.5% to 1.5%. The following month, rates remained low at 1.9%.

Conclusion: Placement of CHG products at the bedside will improve patient safety and quality of care by reducing the incidence of inaccurate diagnosis and treatment based on false-positive blood cultures.

Abstract

Background: Children with special health care needs (CSHCN) are predicted to be at particular risk for difficult peripheral venous access (PVA). Near infrared (NIR) technology is a noninvasive method that reveals vessels that are otherwise not visible to the eye. Our primary objective was to determine whether PVA success improved with NIR when compared with traditional visualization/palpation, specifically in CSHCN.

Methods: A retrospective analysis of all patients requiring PVA insertions by the vascular access team at a 350-bed tertiary children's hospital from July 2013 until June 2014 were included. Independent variables included age, gender, ethnicity, CSHCN status and modality used (NIR, ultrasound guidance, transillumination, or none). The primary outcome was subjective difficulty, PVA success, and number of attempts required. The effect of NIR and CSHCN was analyzed using χ ² test.

Results: Data were gathered on 7896 PVA placements in children. Out of these, 6071 children were deemed to have special health care needs. CSHCN had subjectively difficult access 88% of the time compared with non-CSHCN at 74.7% (P < 0.0001). CSHCN status lowered intravenous access success rates from 91.4% to 87.5% (P < 0.0001). The use of NIR significantly increased intravenous access success rates when compared with visualization or palpation (26% vs 19.6%; P < 0.0001). Modality had a statistically significant effect on the number of attempts (P < 0.0001), but only a slight clinical significance (NIR, up to 1–4 attempts and ultrasound or transillumination combined, 1–6 attempts).

Conclusions: NIR decreases the number of attempts and improve overall success rates in acquiring PVA in CSHCN. Further studies on maximizing PVA success in this patient population are warranted.

Abstract

Background: Vascular access (VA) is essential for successful hemodialysis (HD) but its provision poses significant challenges to renal services. This study aimed to report the long-term outcomes for different types of first permanent VA, and identify factors that affected outcomes in a cohort of patients undergoing HD at a single renal unit.

Methods: Data recorded before April 1, 2013, were collected on factors related to patient characteristics and VA management. Univariate analysis of VA survival was undertaken using the Kaplan-Meier method with log-rank testing used to test for differences between subgroups. Secondary outcomes included VA complication and intervention rates.

Results: Of those first permanent VA attempts (n = 103), 26.2% were radiocephalic arteriovenous fistulae (RCAVF), 54.4% were brachiocephalic arteriovenous fistulae (BCAVF), 10.7% were transposed basilic arteriovenous fistulae (TBAVF), and the remaining 8.7% were polytetrafluoroethylene forearm loop arteriovenous grafts (AVG). Overall cumulative secondary VA survival rates at 6, 12, and 24 months were 90.9%, 82.8%, and 73.4%, respectively. Complication rates for RCAVF, BCAVF, TBAVF, and AVG were 0.5, 1.2, 4.5, and 2.6 per patient year on HD, respectively. Intervention rates for RCAVF, BCAVF, TBAVF, and AVG were 0.4, 0.8, 2.9, and 2.1 per patient year on HD, respectively. A primary renal diagnosis of diabetes (P = 0.022), use of temporary central venous catheter (P = 0.003) or rope-ladder needling (P = 0.013), and the use of TBAVF or AVG (P < 0.001) were predictive of significantly poorer VA survival.

Conclusions: RCAVF and BCAVF were associated with significantly superior outcomes compared with TBAVF and AVG in terms of complication and intervention rates, and long-term survival.

Abstract

Background: The safety of power-injectable implanted arm ports is well established, but there is insufficient data to conclude that image quality of computed tomography resulting from contrast introduced via the port is of equal quality to images derived from contrast introduced via traditional peripheral access. The objective of this study was to determine whether the image quality of computed tomography pulmonary embolism and computed tomography aorta studies would differ when injecting contrast via an implanted arm port vs a peripheral intravenous site. We hypothesized that injecting via an implanted arm port would produce better-quality images, the result of more appropriate timing and less streak artifact.

Methods: Scans from a provincial database search for patients who underwent a computed tomography pulmonary embolism or aorta study with contrast injection via the implanted arm port and thin section images available, were reviewed (pulmonary embolism studies n = 3, aorta studies n = 3). Only a limited number of patients were available for review because there are currently few patients with these ports in place and we limited evaluation to thin section images. Comparison was made with 6 control patients who did not have a port and had received a peripheral arm intravenous contrast injection for these study types. Objective measurements included signal-to-noise ratio and contrast-to-noise ratio of the pulmonary arteries (4 sites) and aorta (2 sites) as appropriate for scan type. Subjective analysis of image quality was performed by 2 radiologists.

Results: Although sample size was limited, the implanted arm port group had similar or higher mean signal-to-noise ratio and contrast-to-noise ratio values at all sites. Subjective assessments showed the implanted arm port group to have similar or better opacification and diagnostic confidence; similar or less streak artifact was also observed at each of the sites.

Conclusions: These exploratory results suggest that studies with implanted arm port injection can generate high-quality images on both objective and subjective assessment, similar to, or possibly better than, images generated from usual peripheral intravenous access for contrast injection.

Abstract

Purpose: Forearm loop arteriovenous grafts (AVGs) are an effective way to grant permanent vascular access in end-stage renal disease patients undergoing hemodialysis. A common postoperative complication with this procedure is forearm swelling. Distal vein ligation is believed to reduce postoperative venous hypertension and forearm swelling. There have been no previous randomized controlled trials comparing the efficacy of AVGs with and without distal vein ligation.

Methods: A pilot study was performed as a randomized controlled trial. End-stage renal disease patients who required AVG construction were recruited and randomly assigned to either the distal vein ligation group or the nondistal vein ligation group. Forearm swelling, graft patency, and graft thrombosis were recorded and compared.

Results: The nonligation and ligation groups consisted of 30 and 31 patients, respectively. Forearm swelling at both the proximal and distal areas was nonsignificantly higher in the nonligation group than in the ligation group. The success rate of cannulation of the graft was 77% in both groups. The first cannulation time was somewhat shorter in the ligation group than in the nonligation group (57 vs 63 days; P = .282). There was no difference in graft thrombosis between the 2 groups (8 and 6 patients, respectively, in the nonligation and ligation groups).

Conclusions: AVGs can be performed with or without distal vein ligation.