Patterns of vascular access device use and thrombosis outcomes in patients with COVID-19: a pilot multi-site study of Michigan hospitals.

Venous thromboembolism (VTE) is an important complication of coronavirus disease 2019 (COVID-19). To date, few studies have described vascular access device use and VTE risk in this cohort. To examine the use of vascular access devices and incidence of VTE in patients hospitalized with COVID-19. We performed a retrospective, multi-center cohort study of patients hospitalized with COVID-19 who received a midline catheter, peripherally inserted central catheter (PICCs), tunneled or non-tunneled central venous catheter (CVC), hemodialysis (HD) catheter or a port during hospitalization. Mixed-effects multivariable logit models adjusting for VTE risk factors in the Caprini risk score were fit to understand the incremental risk of VTE in patients with vascular access devices vs. those that did not receive devices. Management of VTE was determined by examining anticoagulant use pre- vs. post-thrombosis. Results were expressed using odds ratios (ORs) and associated 95% confidence intervals (CI). A total of 1228 hospitalized COVID-19 patients in 40 hospitals, of which 261 (21.3%) received at least one vascular access device of interest, were included. The prevalence of acute, non-tunneled CVCs was 42.2%, acute HD catheters 18.4%, midline catheters 15.6%, PICCs 15.6%, tunneled CVCs 6.8%, and implanted ports 1.4%. The prevalence of VTE was 6.0% in the study cohort, and 10.0% among patients with vascular access devices. After adjusting for known VTE risk factors, patients that had a vascular access device placed were observed to have a four-fold greater odds of VTE than those that did not (OR 4.17, 95% CI 2.33-7.46). Patients who received multiple different catheters experienced more VTE events compared with patients that received only one type (21.5% vs. 6.1%, p < .001). Among the 26 patients with VTE, only 8 (30.8%) survived to discharge and among these, only 5 were discharged on therapeutic doses of anticoagulation. Hospitalized patients with COVID-19 that receive vascular access devices experienced higher rates of VTE than those that do not. Future studies to evaluate the nexus between COVID-19, vascular device use, and thrombosis appear are warranted.

Peripherally Inserted Central Catheters in the ICU: A Retrospective Study of Adult Medical Patients in 52 Hospitals.

OBJECTIVES: To quantify variation in use and complications from peripherally inserted central catheters placed in the ICU versus peripherally inserted central catheters placed on the general ward. DESIGN: Retrospective cohort study. SETTING: Fifty-two hospital Michigan quality collaborative. PATIENTS: Twenty-seven-thousand two-hundred eighty-nine patients with peripherally inserted central catheters placed during hospitalization. MEASUREMENTS AND MAIN RESULTS: Descriptive statistics were used to summarize patient, provider, and device characteristics. Bivariate tests were used to assess differences between peripherally inserted central catheters placed in the ICU versus peripherally inserted central catheters placed on the ward. Multilevel mixed-effects generalized linear models adjusting for patient and device factors with a logit link clustered by hospital were used to examine the association between peripherally inserted central catheter complications and location of peripherally inserted central catheter placement. Variation in ICU peripherally inserted central catheter use, rates of complications, and appropriateness of use across hospitals was also examined. Eight-thousand two-hundred eighty patients (30.3%) received peripherally inserted central catheters in the ICU versus 19,009 (69.7%) on the general ward. The commonest indication for peripherally inserted central catheter use in the ICU was difficult IV access (35.1%) versus antibiotic therapy (53.3%) on wards. Compared with peripherally inserted central catheters placed in wards, peripherally inserted central catheters placed in the ICU were more often multilumen (59.5% vs 39.3; p < 0.001) and more often associated with a complication (odds ratio, 1.30; 95% CI, 1.18-1.43; p < 0.001). Substantial variation in ICU peripherally inserted central catheter use and outcomes across hospitals was observed, with median peripherally inserted central catheter dwell time ranging from 3 to 38.5 days (p < 0.001) and complications from 0% to 40.2% (p < 0.001). Importantly, 87% (n = 45) of ICUs reported median peripherally inserted central catheter dwell times less than or equal to 14 days, a duration where traditional central venous catheters, not peripherally inserted central catheters, are considered appropriate by published criteria. CONCLUSIONS: Peripherally inserted central catheter use in the ICU is highly variable, associated with complications and often not appropriate. Further study of vascular access decision-making in the ICU appears necessary.

Do clinicians know which of their patients have central venous catheters?: a multicenter observational study.

BACKGROUND: Complications associated with central venous catheters (CVCs) increase over time. Although early removal of unnecessary CVCs is important to prevent complications, the extent to which clinicians are aware that their patients have a CVC is unknown. OBJECTIVE: To assess how often clinicians were unaware of the presence of triple-lumen catheters or peripherally inserted central catheters (PICCs) in hospitalized patients. DESIGN: Multicenter, cross-sectional study. SETTING: 3 academic medical centers in the United States. PATIENTS: Hospitalized medical patients in intensive care unit (ICU) and non-ICU settings. MEASUREMENTS: To ascertain awareness of CVCs, whether a PICC or triple-lumen catheter was present was determined; clinicians were then queried about device presence. Differences in device awareness among clinicians were assessed by chi-square tests. RESULTS: 990 patients were evaluated, and 1881 clinician assessments were done. The overall prevalence of CVCs was 21.1% (n=209), of which 60.3% (126 of 209) were PICCs. A total of 21.2% (90 of 425) of clinicians interviewed were unaware of the presence of a CVC. Unawareness was greatest among patients with PICCs, where 25.1% (60 of 239) of clinicians were unaware of PICC presence. Teaching attendings and hospitalists were more frequently unaware of the presence of CVCs than interns and residents (25.8% and 30.5%, respectively, vs. 16.4%). Critical care physicians were more likely to be aware of CVC presence than general medicine physicians (12.6% vs. 26.2%; P=0.003). LIMITATIONS: Awareness was determined at 1 point in time and was not linked to outcomes. Patient length of stay and indication for CVC were not recorded. CONCLUSION: Clinicians are frequently unaware of the presence of PICCs and triple-lumen catheters in hospitalized patients. Further study of mechanisms that ensure that clinicians are aware of these devices so that they may assess their necessity seems warranted. PRIMARY FUNDING SOURCE: None.

Awareness of peripheral IV catheters among nurses, physicians, and trainees: A prospective cohort study.

BACKGROUND: Peripheral intravenous catheters (PIVs) are the most frequently used invasive device in hospitalized patients. These devices are not benign and are associated with complications. However, clinician awareness of them is variable and poorly understood. METHODS: We conducted a prospective, multicenter, observational point prevalence study to assess awareness of PIV presence among clinicians caring for hospitalized patients in 4 hospitals between May 2018 and February 2019 located in Michigan, USA. We first assessed patients for the presence of a PIV then interviewed their providers. Differences in awareness by provider type were assessed via χ² tests; P < .05 was considered statistically significant. Analyses were performed on Stata MP v16. RESULTS: A total of 1,385 patients and 4,003 providers were interviewed. Nurses had the greatest awareness of overall PIV presence, 98.6%, while attendings were correct 88.1% of the time. Nurses were more likely to correctly assess PIV presence and exact location than physicians (67.7% vs <30% for all others). Awareness of PIV presence did not significantly vary in patients on contact precautions or those receiving infusions. CONCLUSIONS: Given the ubiquity of PIVs and known complications, methods to increase awareness to ensure appropriate care and removal are necessary.

National Early Warning Score Deployment in a Veterans Affairs Facility: A Quality Improvement Initiative and Analysis.

Early warning scores are algorithms designed to identify clinical deterioration. Current literature is predominantly in non-Veteran populations. Studies in Veterans are lacking. This study was a prospective quality improvement project deploying and assessing the National Early Warning Score (NEWS) at Kansas City VA Medical Center. Performance of NEWS was assessed as follows: discrimination for predicting a composite outcome of intensive care unit transfer or mortality within 24 hours via area under the receiver operating curve. A total of 4781 Veterans with 142 375 NEWS values were included. The NEWS area under the receiver operating curve for the composite outcome was 0.72 (95% CI, 0.71-0.74), indicating acceptable predictive accuracy. A NEWS of ≥7 was more likely associated with the composite outcome versus <7 (13.6% vs 0.8%; P < 0.001). This is one of the first studies to demonstrate successful deployment of NEWS in a Veteran population, with resultant important implications across the Veterans Health Administration.

High Reliability Organization Principles Improve VA Workplace Burnout: The Truman THRIVE2 Model.

Provider burnout is a significant health care concern. It is unclear whether high reliability organization (HRO) practices can prevent it. The Truman Veterans Affairs Medical Center (VAMC) undertook an initiative implementing HRO principles and assessed for impact on burnout metrics. This became known as the Transformative HRO Initiative Via Employee Engagement (THRIVE2) model. THRIVE2 consisted of Just Culture training, Clinical Team Training, and continuous process improvement through Lean. Truman VAMC was compared with other Veterans Health Affairs (VHA) facilities regarding burnout and employee satisfaction metrics. Truman VAMC saw significant changes in multiple HRO metrics (P < 0.001) as well as improvements in work group psychological safety and employee exhaustion (P < 0.001). High burnout rates decreased by 52% (6.2%-2.95%; P < 0.001). Truman VAMC went from 75th to the No. 1 ranked VHA facility regarding Best Places to Work. These findings have significant national policy implications given the effects of burnout.

Factors Associated with Radiation Toxicity and Survival in Patients with Presumed Early-Stage Non-Small Cell Lung Cancer Receiving Empiric Stereotactic Ablative Radiotherapy.

OBJECTIVES: Stereotactic ablative radiotherapy (SABR) has become the standard of care for inoperable early-stage non-small cell lung cancer (NSCLC). Many patients cannot safely undergo a biopsy because of poor pulmonary function and are empirically treated with radiotherapy. This study aimed to evaluate factors associated with radiation toxicity in patients receiving empiric SABR. METHODS: We performed a retrospective review of 69 patients. Patients and tumor characteristics, radiation doses, pulmonary function tests, and toxicity (acute ≤ 90 days and late > 90 days) were analyzed to find associations with overall survival on Kaplan-Meier curves and differences in patient populations with χ2 and Mann-Whitney U tests. RESULTS: Median age was 71 years. Tumors were classified as peripheral in 62 patients (89.9%). After a median follow-up of 18 months, 39 patients (56.5%) were alive with 4 local recurrences (5.7%), 10 regional failures (14.3%), and 15 distant metastases (21.4%). Nineteen of 67 (26.3%) patients had acute toxicity of which 9 had acute grade ≥ 2 toxicity. There were differences in overall survival based on operability status (P = .031) and acute toxicity (P < .001). Pretreatment oxygen dependence (P = .003), central location (P < .001), and new oxygen requirement (P = .02) were significantly associated with acute grade ≥ 2 toxicity. No association was found with performance on pulmonary function tests. CONCLUSION: Empiric SABR in presumed early-stage NSCLC appears to be safe and may increase overall survival. Acute grade ≥ 2 toxicity was significantly associated with pretreatment oxygen dependence, central location, and new oxygen requirement. No association was found with poor pulmonary function.

To PICC or not to PICC? A cross-sectional survey of vascular access practices in the ICU.

PURPOSE: Vascular access patterns in the intensive care unit (ICU) have shifted from non-tunneled central venous catheters (CVCs) towards peripherally inserted central catheters (PICCs). We evaluated perceptions of critical care practitioners regarding these devices and variation in evidence-based practice. MATERIALS: A 35-question survey on ICU vascular access was deployed in 13 Michigan hospitals. Descriptive statistics summarized responses. Differences in utilization, perceptions and evidence-based practices between PICCs and CVCs, by participant and site-level characteristics, were assessed. RESULTS: 314 of 621 eligible providers responded to the survey (response rate 51%). 15% of providers reported not routinely using ultrasound when placing CVCs. Respondents whom were trainees, from larger hospitals, and from closed ICUs were more likely to use ultrasound (p < 0.001). Additionally, 21% of respondents stated they did not specify number of CVC lumens, while 46% did not specify number of PICC lumens (p < 0.001). The likelihood of specifying PICC lumens increased when vascular access protocols were in place (p = 0.001). 2/3 of respondents (n = 173, 66%) stated more research on ICU vascular access was needed. CONCLUSION: Variation in guideline-based vascular access practices exists in the ICU. Defined local protocols may improve guideline adherence. Studies evaluating vascular access decisions and patient safety in the ICU appear necessary.

Spontaneous cranial osteomyelitis in an otherwise healthy ten-year-old male.

Frontal bone osteomyelitis is a relatively rare entity, particularly in the otherwise healthy pediatric population. Most cases trace their origins to either previous frontal sinusitis or trauma. In children, three origins for cranial osteomyelitis appear to dominate: Pott's puffy tumor, skull base osteomyelitis secondary to ear infection, or post-surgical complications. However, on extremely rare occasions, risk factors or etiology may not be ascertained. We present a case of spontaneous frontal bone osteomyelitis in a ten-year-old African-American male with no previous history of cranial surgeries, frontal sinusitis, or major trauma.

A comprehension scale for central-line associated bloodstream infection: Results of a preliminary survey and factor analysis.

BACKGROUND: Central line-associated bloodstream infections (CLABSI) are associated with significant morbidity and mortality. This condition is therefore the focus of quality initiatives, which primarily use audit and feedback to improve performance. However, feedback of quality data inconsistently affects clinician behavior. A hypothesis for this inconsistency is that a lack of comprehension of CLABSI data by decision makers prevents behavior change. In order to rigorously test this hypothesis, a comprehension scale is necessary. Therefore, we sought to develop a scale to assess comprehension of CLABSI quality metric data. METHODS: The initial instrument was constructed via an exploratory approach, including literature review and iterative item development. The developed instrument was administered to a sample of clinicians, and each item was scored dichotomously as correct or incorrect. Psychometric evaluation via exploratory factor analyses (using tetrachoric correlations) and Cronbach's alpha were used to assess dimensionality and internal consistency. RESULTS: 97 clinicians responded and were included. Factor analyses yielded a scale with one factor containing four items with an eigenvalue of 2.55 and a Cronbach's alpha of 0.82. The final solution was interpreted as an overall CLABSI "comprehension" scale given its unidimensionality and assessment of each piece of data within the CLABSI feedback report. The cohort had a mean performance on the scale of 49% correct (median = 50%). CONCLUSIONS: We present the first psychometric evaluation of a preliminary scale that assesses clinician comprehension of CLABSI quality metric data. This scale has internal consistency, assesses clinically relevant concepts related to CLABSI comprehension, and is brief, which will assist in response rates. This scale has potential policy relevance as it could aid efforts to make quality metrics more effective in driving practice change.

Do Experts Understand Performance Measures? A Mixed-Methods Study of Infection Preventionists.

OBJECTIVE Central line-associated bloodstream infection (CLABSI) is associated with significant morbidity and mortality. Despite a nationwide decline in CLABSI rates, individual hospital success in preventing CLABSI is variable. Difficulty in interpreting and applying complex CLABSI metrics may explain this problem. Therefore, we assessed expert interpretation of CLABSI quality data. DESIGN: Cross-sectional survey PARTICIPANTS. Members of the Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN) METHODS. We administered a 10-item test of CLABSI data comprehension. The primary outcome was percent correct of attempted questions pertaining to the CLABSI data. We also assessed expert perceptions of CLABSI reporting. RESULTS The response rate was 51% (n=67).Among experts, the average proportion of correct responses was 73% (95% confidence interval [CI], 69%-77%). Expert performance on unadjusted data was significantly better than risk-adjusted data (86% [95% CI, 81%-90%] vs 65% [95% CI, 60%-70%]; P<.001). Using a scale of 1 to 100 (0, never reliable; 100, always reliable), experts rated the reliability of CLABSI data as 61. Perceived reliability showed a significant inverse relationship with performance (r=-0.28; P=.03), and as interpretation of data improved, perceptions regarding reliability of those data decreased. Experts identified concerns regarding understanding and applying CLABSI definitions as barriers to care. CONCLUSIONS Significant variability in the interpretation of CLABSI data exists among experts. This finding is likely related to data complexity, particularly with respect to risk-adjusted data. Improvements appear necessary in data sharing and public policy efforts to account for this complexity. Infect Control Hosp Epidemiol 2018;39:71-76.

Sample size implications of mortality definitions in sepsis: a retrospective cohort study.

BACKGROUND: Many randomized controlled trials (RCTs) employ mortality at a given time as a primary outcome. There are at least three common ways to measure 90-day mortality: first, all-location mortality, that is, all-cause mortality within 90 days of randomization at any location. Second, ARDSnet mortality is death in a healthcare facility of greater intensity than the patient was in prior to the hospitalization during which they were randomized. Finally, in-hospital mortality is death prior to discharge from the primary hospitalization of randomization. Data comparing the impact of these different measurements on sample size are lacking. We evaluated the extent to which event rates vary by mortality definition. METHODS: This was a retrospective cohort study of 30,691 patients hospitalized at Veterans Affairs (VA) hospitals for sepsis during 2009. 12,727 (41.5%) received care in an ICU setting. For each patient, we measured event rates for three different 90-day mortality outcomes: all-location mortality, ARDSnet mortality, and in-hospital mortality. We also calculated sample sizes necessary to power an example RCT given those event rates. RESULTS: At 90 days, all-location mortality was 26.4% (95% CI 25.9-26.9%), ARDSnet mortality was 19.2% (95% CI 18.8-19.7%), and in-hospital mortality was 13.4% (95% CI 13.0-13.8%) (p < 0.01 all comparisons). These respective event rates result in different required sample sizes to achieve a 20% relative reduction in mortality with 80% power and a 5% false positive rate. Such a trial of VA sepsis patients would require 2080 patients for all-location mortality, 3080 for ARDSnet mortality, and 4796 for in-hospital mortality. Among sepsis patients mechanically ventilated in an ICU, 2438 experienced all-location mortality (46.2% [95% CI 44.8-47.5%]), 2181 experienced ARDSnet mortality (41.3% [95% CI 40.0-42.6%]), and 1894 experienced in-hospital mortality (36.0% [95% CI 34.7-37.3%]). CONCLUSIONS: Event rates vary substantially in sepsis patients based on the chosen 90-day mortality definition. This could have important implications for RCT design trade-offs.

Do Clinicians Understand Quality Metric Data? An Evaluation in a Twitter-Derived Sample.

OBJECTIVE: Despite significant efforts and cost, quality metrics do not consistently influence practice. While research has focused on improving data through statistical risk-adjustment, whether clinicians understand these data is unknown. Therefore, we assessed clinician comprehension of central line-associated blood stream infection (CLABSI) quality metric data. DESIGN: Cross-sectional survey with an 11-item test of CLABSI data comprehension. Each question assessed 1 of 3 concepts concerning CLABSI understanding: basic numeracy, risk-adjustment numeracy, and risk-adjustment interpretation. Hypothetical data were used and presented in a validated format. PARTICIPANTS: Clinicians were recruited from 6 nations via Twitter to take an online survey. Clinician eligibility was confirmed by assessing responses to a question regarding CLABSI. MAIN MEASURES: The primary outcome was percent correct of attempted questions pertaining to the presented CLABSI data. RESULTS: Ninety-seven clinicians answered at least 1 item, providing 939 responses; 72 answered all 11 items. The mean percentage of correct answers was 61% (95% confidence interval [CI], 57%-65%). Overall, doctor performance was better than performance by nurses and other respondents (68% [95% CI, 63%-73%] vs. 57% [95% CI, 52%-62%], P = 0.003). In basic numeracy, mean percent correct was 82% (95% CI, 77%-87%). For risk-adjustment numeracy, the mean percent correct was 70% (95% CI, 64%-76%). Risk-adjustment interpretation had the lowest average percent correct, 43% (95% CI, 37%-49%). All pairwise differences between concepts were statistically significant at P <0.05. CONCLUSIONS: CLABSI quality metric comprehension appears low and varies substantially among clinicians. These findings may contribute to the limited impact of quality metric reporting programs, and further research is needed. Journal of Hospital Medicine 2017;12:18-22.

Identifying Barriers to Delivering the Awakening and Breathing Coordination, Delirium, and Early Exercise/Mobility Bundle to Minimize Adverse Outcomes for Mechanically Ventilated Patients: A Systematic Review.

BACKGROUND: Improved outcomes are associated with the Awakening and Breathing Coordination, Delirium, and Early exercise/mobility bundle (ABCDE); however, implementation issues are common. As yet, no study has integrated the barriers to ABCDE to provide an overview of reasons for less successful efforts. The purpose of this review was to identify and catalog the barriers to ABCDE delivery based on a widely used implementation framework, and to provide a resource to guide clinicians in overcoming barriers to implementation. METHODS: We searched MEDLINE via PubMed, CINAHL, and Scopus for original research articles from January 1, 2007, to August 31, 2016, that identified barriers to ABCDE implementation for adult patients in the ICU. Two reviewers independently reviewed studies, extracted barriers, and conducted thematic content analysis of the barriers, guided by the Consolidated Framework for Implementation Research. Discrepancies were discussed, and consensus was achieved. RESULTS: Our electronic search yielded 1,908 articles. After applying our inclusion/exclusion criteria, we included 49 studies. We conducted thematic content analysis of the 107 barriers and identified four classes of ABCDE barriers: (1) patient-related (ie, patient instability and safety concerns); (2) clinician-related (ie, lack of knowledge, staff safety concerns); (3) protocol-related (ie, unclear protocol criteria, cumbersome protocols to use); and, not previously identified in past reviews, (4) ICU contextual barriers (ie, interprofessional team care coordination). CONCLUSIONS: We provide the first, to our knowledge, systematic differential diagnosis of barriers to ABCDE delivery, moving beyond the conventional focus on patient-level factors. Our analysis offers a differential diagnosis checklist for clinicians planning ABCDE implementation to improve patient care and outcomes.