A bundle approach to reduce the incidence of external ventricular and lumbar drain-related infections.

OBJECT: An important complication of external CSF drainage is bacterial meningitis or ventriculitis, resulting in increased morbidity, mortality, and health care costs. In 2003, a high rate (37%) of probable drain-related infections was identified at the authors' hospital. A multidisciplinary working group was installed to reduce this incidence to < 10% within 1.5 years. METHODS: An intervention strategy based on 5 pillars (increased awareness, focused standard operating procedures, a diagnostic and therapeutic algorithm, timely administration of prophylaxis, and improvement of the drainage system) was designed and implemented from 2004 to 2006. During this period all patients with external CSF drainage were prospectively monitored. RESULTS: Between 2004 and 2006, there were 467 patients in whom 579 drains (external ventricular and external lumbar) had been placed. The overall incidence of drain-related infections was 16.2% in 2004, 8.9% in 2005, and 11.3% in 2006. For external lumbar drains the number of infections per 100 drain days was 2.4 in 2004, 0.6 in 2005, and 0.8 in 2006. For external ventricular drains these rates were 1.7, 1.0, and 1.2, respectively. Meanwhile, the causative noncutaneous microorganisms, indicative for systemic-contamination during manipulation, decreased. By retrospective analysis, the proportion of patients with a probable drain-related infection decreased from 37% in 2003 to 9% in 2005 and 2006. CONCLUSIONS: The authors' multidisciplinary approach in which different preventive measures were combined was associated with a significant reduction in the incidence of drain-related secondary meningitis, and thus provides an important improvement of patient safety.

Hemodialysis access imaging: comparison of flow-interrupted contrast-enhanced MR angiography and digital subtraction angiography.

PURPOSE: To compare flow-interrupted contrast material-enhanced magnetic resonance (MR) angiography with conventional digital subtraction angiography (DSA) for hemodialysis access imaging. MATERIALS AND METHODS: Twenty-two accesses (14 arteriovenous grafts [AVGs], eight arteriovenous fistulas [AVFs]) in 18 consecutive patients were imaged with flow-interrupted contrast-enhanced MR angiography and subsequent conventional DSA. MR image quality was assessed as excellent, good, or nondiagnostic. Anastomotic diameters in AVGs and postanastomotic diameters in AVFs were measured in consideration of an adjacent normal segment. Reductions in the diameter of the lumen and interobserver differences were analyzed with method comparison as described by Bland and Altman and expressed as the mean difference with its 95% confidence limits (CLs) (mean +/- 2 SDs). RESULTS: Image quality obtained with flow-interrupted contrast-enhanced MR angiography was considered excellent in 73% (16 of 22) and good in 23% (5 of 22). Method comparison analysis between MR angiography and DSA indicated a mean difference of 3.2% (95% CLs: -26.7%, 33.1%) for observer 1 and 4.1% (95% CLs: -23.8%, 32.1%) for observer 2. Interobserver analysis at MR angiography indicated a mean difference of 3.2% (95% CLs: -28.8%, 35.2%), and that at DSA indicated a mean difference of 3.6% (95% CLs: -9.4%, 16.7%). CONCLUSION: Image quality and anatomic depiction with flow-interrupted contrast-enhanced MR angiography and with DSA were comparable.