Highlights

• Gap analysis identified an opportunity for introduction of antimicrobial PICCs to a large community hospital with elevated CLABSI incidence.

• Combined with continued compliance with basic prevention strategies (i.e., use of a central line insertion checklist/insertion bundle) and optimization of device selection and lumen justification, the introduction of an antimicrobial antithrombogenic PICC was associated with a significant reduction in CLABSI.

Abstract

Objective: To reduce the incidence of central line-associated bloodstream infection (CLABSI) in peripherally inserted central catheters (PICC) through the introduction of an antimicrobial (AM) catheter as recommended in evidence-based guidelines and standards.

Design: Quality improvement project comparing incidence of infections pre-implementation and postimplementation of the new catheter.

Setting: A 582-bed community teaching hospital in Northwest Indiana.

Methods: Pre-implementation analysis of surveillance data indicated that 50% of CLABSIs occurred in patients with PICCs in situ. A gap analysis was performed to review institutional practices against evidence-based recommendations. The use of an AM catheter was supported in each of the documents consulted. After introduction of the new device, performance was measured in a prospective manner using standardized Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) surveillance protocols for CLABSI and internal data sources for other measures.

Results: After 30 months of data collection, the PICC CLABSI incidence reduced from a baseline rate of 1.83/1000 PICC days to 0.162/1000 PICC days (91.15% reduction, P = 0.0002).

Conclusion: Combined with continued compliance with basic prevention strategies (i.e., use of a central line insertion checklist/insertion bundle) and optimization of device selection and lumen justification, the introduction of an antimicrobial/antithrombogenic (AM/AT) PICC was associated with a significant reduction in CLABSI.

Highlights

• Optimum TKVO rate for PIVC is unknown.

• We used computer models to simulate saline infusion through a 20-gauge PIVC in 2 veins.

• Low rates (10 mL/h) may not clear the PIVC tip and keep the device patent.

• Increase to >20 mL/h is effective, but 30–40 mL/h appears most effective.

• This additional fluid load must be considered based on the needs of each patient.

Abstract

Background: Evidence to support an optimum continuous to-keep-vein-open (TKVO) infusion rate for peripheral intravenous catheters (PIVCs) is lacking. The aim of this study was to simulate typical TKVO rates, in combination with flushing, to better understand TKVO in relation to PIVC patency.

Methods: We simulated saline infusion through a 20-gauge PIVC in 2 forearm veins (3.3 and 2.2 mm) using computational fluid dynamics under various venous flow rates (velocities 3.7–22.1 cm/s), with a saline flush rate of 1 mL/s and TKVO infusion rates of 10, 20, and 40 mL/h. We determined TKVO efficacy using the stream of saline clearing the stasis region at the device tip and the shear stress acting on the vein.

Results: At 10 mL/h TKVO rate, blood stasis occurs around the PIVC tip as saline is pulled into the faster-moving venous blood flow, creating the blood recirculation (stasis) zone at the device tip. When TKVO increases >20 mL/h, this stasis diminishes, and the likelihood of patency increases. Shear stress on the vein is negligible during TKVO but increases 10- to 19-fold when flushing the small and large veins investigated here.

Conclusions: Low TKVO rates (10 mL/h) may not clear the PIVC tip and keep the device patent. Based on our simulations, we propose a TKVO rate of at least 20 mL/h could be used in practice; however, 30–40 mL/h appears most effective across different venous flow rates and peripheral vein sizes. However, this additional fluid load must be carefully considered based on the needs of each patient.

Highlights

• Type of research: single center, prospective comparative cohort study.

• Key findings: results of snuffbox AVF compared with wrist fistula showed there was no statistical difference between efficacy rates of AVF in these 2 groups. Female gender and diabetes had negative effect on AVF patency.

• Take-home message: anatomical snuffbox is the most distal part of the extremity that the AVF can be constructed, and if it fails, there is an opportunity to create a fistula on the same wrist.

Abstract

Introduction: Snuffbox arteriovenous fistula (AVF) is one of the most common vascular accesses for hemodialysis. Despite all the advantages, it is not usually considered the first choice of treatment. This could be primarily due to difficulty in its technical procedure and a higher probability of failure than other sites such as cubital. Therefore, the present study aimed at comparing the efficacy and patency rate between the snuffbox and the wrist AVF. Methods: Seventy-eight patients with end-stage renal disease were enrolled in this study. They were randomly assigned into the snuffbox and the wrist groups. Each participant had an appropriate vein at the time of examination and was eligible for distal AVF creation. The procedure was conducted under local anesthesia, and arteriovenous anastomosis was done in an end-to-side configuration. AVF maturation was defined by initiation of successful dialysis through the AVF 8–10 weeks postoperatively.

Results: The results showed that 61% of snuffbox AVFs and 65% of wrist AVFs became matured and were used for further dialysis. Diabetes and female sex had negative impacts on AVF patency. In addition, no significant relationship was found between the patency rate and demographic as well as clinical variables such as age, hypertension, and duration of the previous dialysis.

Conclusions: No significant differences were found in the maturation and patency rate between the wrist and the snuffbox AVFs. Therefore, the snuffbox fistula is recommended in the first step, as there would be a possibility for re-creation on the ipsilateral wrist once the AVF fails.

Highlights

• Central venous catheter may become contaminated from patient’s body fluids.

• A clinical practice guideline assists in standardizing contamination management.

• Case report to highlight importance of adhering to clinical practice guideline.

Abstract

Healthcare organizations have prioritized patient safety and quality improvement efforts to reduce central line-associated bloodstream infections (CLABSIs). Implementation of central venous catheter (CVC) insertion and maintenance bundles have significantly reduced infection rates. Nevertheless, CLABSIs continue to be a significant cause of mortality and morbidity in hospitals, and further efforts are necessary to improve CVC care practices. A hospital-wide committee at a tertiary care pediatric hospital identified gaps in our CVC maintenance practices resulting from CVC contamination events from a patient’s body fluids. A lack of published literature on the topic resulted in the need to create an institutional clinical practice guideline (CPG) to develop guidance to mitigate potential CLASBIs from CVC contamination. Utilization of the CVC CPG in all inpatient units and other reduction strategies resulted in a steady decline in our CLABSI rates, particularly in those related to CVC contamination events. Case reports illustrate the effectiveness of the CPG.