Practices to prevent central line-associated bloodstream infection: A 2021 survey of infection preventionists in US hospitals.

OBJECTIVE: To determine prevalence of technical and behavioral interventions aimed at preventing central line-associated bloodstream infection (CLABSI) following the COVID19 pandemic. DESIGN: Cross-sectional survey. SETTING: US acute care hospitals. PARTICIPANTS: Infection preventionists at participating hospitals. METHODS: Surveys were sent to infection preventionists from a national random sample of 881 US acute care hospitals. Questions covered use of technical interventions to prevent CLABSI (eg, alcohol-containing chlorhexidine gluconate [CHG] for skin antisepsis, use of coated catheters), socio-adaptive interventions (eg, feedback of CLABSI rates, use of appropriateness criteria), and leadership support for CLABSI prevention. RESULTS: Survey response rate was 47% (415/881). Technical interventions such as maximal sterile barriers (99%) or CHG-impregnated dressings (92%) were highly prevalent, but routine use of CHG bathing was less common (68% indicated regular use in intensive care unit [ICU] vs 18% in non-ICU settings). Although 97% of respondents indicated use of systems to monitor CLABSI, feedback to providers on CLABSI events was reported by 89%. Only 53% of respondents indicated regular use of tools to determine appropriateness of central venous catheters (CVC). Three-quarters of respondents indicated their hospital assessed CVC necessity daily, but only 23% reported strategies to reduce routine blood cultures. CLABSI prevention was extremely important to hospital leadership at 82% of responding hospitals. CONCLUSIONS: Most US hospitals continue to use evidence-based methods to prevent CLABSI as recommended by leading organizations. Opportunities to focus on socio-adaptive interventions such as feedback of infection rates, use of appropriateness criteria for CVC placement, and improving the "culture of pan-culturing" remain.

Inappropriate Diagnosis of Pneumonia Among Hospitalized Adults.

Importance: Little is known about incidence of, risk factors for, and harms associated with inappropriate diagnosis of community-acquired pneumonia (CAP). Objective: To characterize inappropriate diagnosis of CAP in hospitalized patients. Design, Setting, and Participants: This prospective cohort study, including medical record review and patient telephone calls, took place across 48 Michigan hospitals. Trained abstractors retrospectively assessed hospitalized patients treated for CAP between July 1, 2017, and March 31, 2020. Patients were eligible for inclusion if they were adults admitted to general care with a discharge diagnostic code of pneumonia who received antibiotics on day 1 or 2 of hospitalization. Data were analyzed from February to December 2023. Main Outcomes and Measures: Inappropriate diagnosis of CAP was defined using a National Quality Forum-endorsed metric as CAP-directed antibiotic therapy in patients with fewer than 2 signs or symptoms of CAP or negative chest imaging. Risk factors for inappropriate diagnosis were assessed and, for those inappropriately diagnosed, 30-day composite outcomes (mortality, readmission, emergency department visit, Clostridioides difficile infection, and antibiotic-associated adverse events) were documented and stratified by full course (>3 days) vs brief (≤3 days) antibiotic treatment using generalized estimating equation models adjusting for confounders and propensity for treatment. Results: Of the 17 290 hospitalized patients treated for CAP, 2079 (12.0%) met criteria for inappropriate diagnosis (median [IQR] age, 71.8 [60.1-82.8] years; 1045 [50.3%] female), of whom 1821 (87.6%) received full antibiotic courses. Compared with patients with CAP, patients inappropriately diagnosed were older (adjusted odds ratio [AOR], 1.08; 95% CI, 1.05-1.11 per decade) and more likely to have dementia (AOR, 1.79; 95% CI, 1.55-2.08) or altered mental status on presentation (AOR, 1.75; 95% CI, 1.39-2.19). Among those inappropriately diagnosed, 30-day composite outcomes for full vs brief treatment did not differ (25.8% vs 25.6%; AOR, 0.98; 95% CI, 0.79-1.23). Full vs brief duration of antibiotic treatment among patients was associated with antibiotic-associated adverse events (31 of 1821 [2.1%] vs 1 of 258 [0.4%]; P = .03). Conclusions and Relevance: In this cohort study, inappropriate diagnosis of CAP among hospitalized adults was common, particularly among older adults, those with dementia, and those presenting with altered mental status. Full-course antibiotic treatment of those inappropriately diagnosed with CAP may be harmful.

The role of hospital-based vascular access teams and implications for patient safety: A multi-methods study.

BACKGROUND: Peripherally inserted central catheters (PICCs) and midline catheters are often placed by nurse-led vascular access teams (VATs). While some data regarding the effectiveness of these teams exists, less is known about their structure and function. OBJECTIVES: To examine the roles, functions, and composition of VATs related to the use and management of PICC and midline catheters. METHODS: A descriptive, multi-method study that included an online survey of 62 hospitals participating in a quality improvement consortium and qualitative interviews with 74 hospital-based clinicians in 10 sites. Interviews were recorded, transcribed, and analyzed using a rapid analysis and matrix approach. The survey, which contained closed-ended, categorical questions, was analyzed using frequencies and percentages. RESULTS: More than 77% (n = 48) of hospitals had an on-site VAT. The average team size was seven nurses; their primary function was device insertion. Interview findings revealed that teams varied in characteristics and functions. Interviewees described the broad role that teams play in device insertion, care and removal, and in educating/training hospital staff. However, we found that teams' role in decision making, particularly related to appropriate device selection, was limited and, in some cases, met with physician resistance. CONCLUSIONS: To realize the full benefit of VATs, changes in hospital culture, along with an increased willingness from physicians to integrate VAT nurses in decision making, may be needed. Future interventions aimed at engaging and empowering teams appear necessary.

Peripheral intravenous catheter infection and failure: A systematic review and meta-analysis.

BACKGROUND: Peripheral intravenous catheters are the most frequently used invasive device in nursing practice, yet are commonly associated with complications. We performed a systematic review to determine the prevalence of peripheral intravenous catheter infection and all-cause failure. METHODS: The Cochrane Library, PubMed, CINAHL, and EMBASE were searched for observational studies and randomised controlled trials that reported peripheral intravenous catheter related infections or failure. The review was limited to English language and articles published from the year 2000. Pooled estimates were calculated with random-effects models. Meta-analysis of observation studies in epidemiology guidelines and the Cochrane process for randomised controlled trials were used to guide the review. Prospero registration number: CRD42022349956. FINDINGS: Our search retrieved 34,725 studies. Of these, 41 observational studies and 28 randomised controlled trials (478,586 peripheral intravenous catheters) met inclusion criteria. The pooled proportion of catheter-associated bloodstream infections was 0.028 % (95 % confidence interval (CI): 0.009-0.081; 38 studies), or 4.40 catheter-associated bloodstream infections per 100,000 catheter-days (20 studies, 95 % CI: 3.47-5.58). Local infection was reported in 0.150 % of peripheral intravenous catheters (95 % CI: 0.047-0.479, 30 studies) with an incidence rate of 65.1 per 100,000 catheter-days (16 studies; 95 % CI: 49.2-86.2). All cause peripheral intravenous catheter failure before treatment completion occurred in 36.4 % of catheters (95 % CI: 31.7-41.3, 53 studies) with an overall incidence rate of 4.42 per 100 catheter days (78,891 catheter days; 19 studies; 95 % CI: 4.27-4.57). INTERPRETATION: Peripheral intravenous catheter failure is a significant worldwide problem, affecting one in three catheters. Per peripheral intravenous catheter, infection occurrence was low, however, with over two billion catheters used globally each year, the absolute number of infections and associated burden remains high. Substantial and systemwide efforts are needed to address peripheral intravenous catheter infection and failure and the sequelae of treatment disruption, increased health costs and poor patient outcomes.

The impact of a structured assessment and decision tool (I-DECIDED®) on improving care of peripheral intravenous catheters: A multicenter, interrupted time-series study.

BACKGROUND: Peripheral intravenous catheters are the most widely used invasive device in hospitals but have serious risks. OBJECTIVE: To determine if a structured assessment and decision tool (I-DECIDED®) improves daily peripheral intravenous catheter assessment and care decisions. DESIGN: Prospective, interrupted time-series study. SETTINGS: Seven adult inpatient wards in three Australian hospitals. PARTICIPANTS: 825 adults with 867 peripheral intravenous catheters. METHODS: Between August 2017 and December 2018, peripheral intravenous catheter assessments and chart audits were undertaken with informed patient consent. Following a 4-month pre-intervention period (with 2-weekly measures), the I-DECIDED® tool was implemented over 3 months (no data collection) using multiple strategies (stakeholder meetings, vascular access device form, education sessions, ward champions, lanyard cards, and posters), followed by a 4-month post-intervention period (with 2-weekly measures). Primary outcomes were device utilization (number of peripheral intravenous catheters per total number of patients screened); idle/unused catheters; insertion site complications, substandard dressing quality; and primary bloodstream infections. RESULTS: Of 2055 patients screened, 1175 (57.2%) had a peripheral intravenous catheter, and 825 patients (867 catheters) consented and were included in the final analysis. Device utilization increased from 42.0% of catheters at baseline to 49.6% post-intervention (absolute risk difference [ARD] 7.5%, 95% confidence interval [CI] 4.8, 10.3; relative risk [RR] 1.18, 95% CI 1.11, 1.25; p < 0.001). The proportion of idle catheters reduced from 12.7% to 8.3% (ARD -4.4%, 95% CI -8.5, -0.3; RR 0.66, 95% CI 0.44, 0.97; p = 0.035). Peripheral intravenous catheter complications reduced from 16.1% to 10.9% (ARD -5.2%, 95% CI -9.7, -0.6; RR 0.68, 95% CI 0.48, 0.96; p = 0.026). Substandard dressings reduced from 24.6% to 19.5% (ARD -5.2%, 95% CI -10.7, 0.4; RR 0.79, 95% CI 0.61, 1.02; p = 0.067). Only one primary bloodstream infection occurred (post-intervention). CONCLUSIONS: Implementation of a comprehensive device assessment and decision tool (I-DECIDED®) reduced idle catheters and catheter complications, despite higher device utilization. Dressing quality improved but was not statistically significant. Further implementation of the tool could improve hospital safety for patients with an intravenous catheter. ANZCTR TRIAL REGISTRATION: ACTRN12617000067370. Date of registration 13 January 2017. Date of first data collection 3rd August 2017. TWEETABLE ABSTRACT: #IDECIDEDassessment reduces prevalence of idle peripheral catheters and device complications.

Midline catheters in patients with advanced chronic kidney disease.

BACKGROUND: Midline catheters (midlines) are increasingly used in patients with advanced chronic kidney disease (CKD). OBJECTIVE: This study describes current practice and acute complications associated with midlines in CKD patients. DESIGNS, SETTING, AND PARTICIPANTS: Trained abstractors at 66 hospitals from the Michigan Hospital Medicine Safety (HMS) Consortium collected data on a sample of patients who received a midline during hospitalization. Patients were classified as having advanced CKD if their estimated glomerular filtration rate was <45 mL/min/1.73 m2 . MAIN OUTCOME AND MEASURES: Midline recipients with advanced CKD were compared to those without advanced CKD by patient, provider, and device characteristics, and by the occurrence of acute complications including major (e.g., upper extremity deep vein thrombosis [UE-DVT] and catheter-related bloodstream infection [CRBSI]) or minor (e.g., catheter occlusion, catheter dislodgement, infiltration, superficial thrombophlebitis, and leaking at insertion site) events. Multivariable mixed effects logistic regression was used to evaluate the association between catheter-related complications and stage of CKD. RESULTS: Of 21,415 midline recipients, 5272 (24.6%) had advanced CKD, while 16,143 (75.4%) did not. Most midlines were single lumen (90.5%) and remained in place for a median of 6 days. A major or minor midline complication occurred in 804 (15.3%) patients with and 2239 (14.4%) patients without advanced CKD (adjusted odds ratios = 1.04; 95% confidence interval: 0.94-1.14). Among patients with advanced CKD, CRBSI occurred in 13 patients (0.2%) and UE-DVT occurred in 65 patients (1.2%). The proportion of advanced CKD among midline recipients and the frequency of midline-related complications varied across hospitals (interquartile range [IQR] = 19.2% to 29.8% [median = 25.0%] and IQR = 11.0%-18.9% [median = 15.4%], respectively).

Associations Between Hospitalist Shift Busyness, Diagnostic Confidence, and Resource Utilization: A Pilot Study.

OBJECTIVES: Hospitalized patients are at risk for diagnostic errors. Hospitalists caring for these patients are often multitasking when overseeing patient care. We aimed to measure hospitalist workload and understand its influences on diagnostic performance in a real-world clinical setting. METHODS: We conducted a single-center, prospective, pilot observational study of hospitalists admitting new patients to the hospital. Hospitalists completed an abridged Mindful Attention Awareness Tool and a survey about diagnostic confidence at shift completion. Data on differential diagnoses and resource utilization (e.g., laboratory, imaging tests ordered, and consultations) were collected from the medical record. The number of admissions and paging volume per shift were used as separate proxies for shift busyness. Data were analyzed using linear mixed effects models (continuous outcomes) or mixed effects logistic regression (dichotomous outcomes). RESULTS: Of the 53 hospitalists approached, 47 (89%) agreed to participate; complete data were available for 37 unique hospitalists who admitted 160 unique patients. Increases in admissions (odds ratio, 1.99; 95% confidence interval [CI], 1.04 to 3.82; P = 0.04) and pages (odds ratio, 1.11; 95% CI, 1.02 to 1.21; P = 0.01) were associated with increased odds of hospitalists finding it "difficult to focus on what is happening in the present." Increased pages was associated with a decrease in the number of listed differential diagnoses (coefficient, -0.02; 95% CI, -0.04 to -0.003; P = 0.02). CONCLUSIONS: Evaluation of hospitalist busyness and its associations with factors that may influence diagnosis in a real-world environment was feasible and demonstrated important implications on physician focus and differential diagnosis.

Biomarkers Associated with Thrombosis in Patients with Peripherally Inserted Central Catheter: A Systematic Review and Meta-Analysis.

BACKGROUND: The measurement and identification of plasma biomarkers can support the estimation of risk and diagnosis of deep vein thrombosis (DVT) associated with the use of a peripherally inserted central catheter (PICC). OBJECTIVES: This systematic review and meta-analysis aimed to identify the association between the levels of potential biomarkers that reflect the activation of the blood system, long-term vascular complications, inflammatory system, and the occurrence of PICC-related DVT. METHODS: Seven electronic databases (Embase, Web of Science, Medline, Scopus, Cinahl, Cochrane Central Register of Controlled Trials, and ERIC) were searched to identify literature published until December 2022. Studies were required to report: (I) adult and pediatric patients, outpatient or admitted to clinical, surgical, or ICU with PICC; (II) patients with PICC-related DVT and patients without PICC-related DVT as a comparator; and (III) at least one biomarker available. The Newcastle-Ottawa Scale was used to evaluate the quality of the studies. Study precision was evaluated by using a funnel plot for platelets level. We provided a narrative synthesis and meta-analysis of the findings on the biomarkers' outcomes of the studies. We pooled the results using random effects meta-analysis. The meta-analysis was conducted using Review Manager software v5.4. This systematic review is registered in PROSPERO (CRD42018108871). RESULTS: Of the 3564 studies identified (after duplication removal), 28 were included. PICC-related DVT was associated with higher D-dimers (0.37 µg/mL, 95% CI 0.02, 0.72; p = 0.04, I2 = 92%; p for heterogeneity < 0.00001) and with higher platelets (8.76 × 109/L, 95% CI 1.62, 15.91; p = 0.02, I2 = 41%; p for heterogeneity = 0.06). CONCLUSIONS: High levels of D-dimer and platelet were associated with DVT in patients with PICC. However, biomarkers such as APTT, fibrinogen, FDP, glucose, hemoglobin, glycated hemoglobin, INR, prothrombin time, prothrombin fragment 1.2, the thrombin-antithrombin complex, and WBC were not related to the development of DVT associated with PICC.

The Association of Vasopressor Administration through a Midline Catheter with Catheter-related Complications.

Rationale: Little is known about the safety of infusing vasopressors through a midline catheter. Objectives: To evaluate safety outcomes after vasopressor administration through a midline. Methods: We conducted a cohort study of adults admitted to 39 hospitals in Michigan (December 2017-March 2022) who received vasopressors while either a midline or peripherally inserted central catheter (PICC) was in place. Patients receiving vasopressors through a midline were compared with those receiving vasopressors through a PICC and, separately, to those with midlines in place but who received vasopressors through a different catheter. We used descriptive statistics to characterize and compare cohort characteristics. Multivariable mixed effects logistic regression models were fit to determine the association between vasopressor administration through a midline with outcomes, primarily catheter-related complications (bloodstream infection, superficial thrombophlebitis, exit site infection, or catheter occlusion). Results: Our cohort included 287 patients with midlines through which vasopressors were administered, 1,660 with PICCs through which vasopressors were administered, and 884 patients with midlines who received vasopressors through a separate catheter. Age (median [interquartile range]: 68.7 [58.6-75.7], 66.6 [57.1-75.0], and 67.6 [58.7-75.8] yr) and gender (percentage female: 50.5%, 47.3%, and 43.8%) were similar in all groups. The frequency of catheter-related complications was lower in patients with midlines used for vasopressors than PICCs used for vasopressors (5.2% vs. 13.4%; P < 0.001) but similar to midlines with vasopressor administration through a different device (5.2% vs. 6.3%; P = 0.49). After adjustment, administration of vasopressors through a midline was not associated with catheter-related complications compared with PICCs with vasopressors (adjusted odds ratios [aOR], 0.65 [95% confidence interval, 0.31-1.33]; P = 0.23) or midlines with vasopressors elsewhere (aOR, 0.85 [0.46-1.58]; P = 0.59). Midlines used for vasopressors were associated with greater risk of systemic thromboembolism (vs. PICCs with vasopressors: aOR, 2.69 [1.31-5.49]; P = 0.008; vs. midlines with vasopressors elsewhere: aOR, 2.42 [1.29-4.54]; P = 0.008) but not thromboses restricted to the ipsilateral upper extremity (vs. PICCs with vasopressors: aOR, 2.35 [0.83-6.63]; P = 0.10; model did not converge for vs. midlines with vasopressors elsewhere). Conclusions: We found no significant association of vasopressor administration through a midline with catheter-related complications. However, we identified increased odds of systemic (but not ipsilateral upper extremity) venous thromboembolism warranting further evaluation.

Promoting appropriate midline catheter and PICC placement through implementation of an EHR-based clinical decision support tool: An interrupted time-series analysis.

BACKGROUND: Inappropriate use of peripherally inserted central catheters (PICCs), including multilumen PICCs, may increase the risk of patient complications. OBJECTIVE: Implement computerized decision support to: (a) increase the use of midline catheters over PICCs when appropriate and (b) decrease PICC lumens when a PICC is necessary. DESIGNS: Quasi-experimental, interrupted time series. SETTING: Single tertiary academic medical center. PATIENTS: Hospitalized adults who received a midline or PICC during clinical care. INTERVENTION: Decision support on appropriate vascular access device choice via a set of electronic orders embedded within the electronic health record. MEASUREMENTS: Proportion of midline catheter and single-lumen PICCs placed between January 2, 2017 and November 19, 2017 (preintervention) versus November 20, 2017 to December 1, 2019 (postintervention). RESULTS: A total of 8758 midline and PICCs were inserted during the study period. A statistically significant increase in the insertion of midline catheters was observed during the intervention (p = .006). In parallel, single-lumen PICC insertion as a proportion of all PICCs also increased after the intervention (p = .035). Results were consistent across multiple disciplines, including internal medicine, surgery, and intensive care. After considering the hospital census, total PICC and midline utilization rates and rates of complications did not change over time. However, an increase in catheter exchanges from less to more invasive devices occurred. CONCLUSIONS: In this single-center study, the implementation of electronic decision support to inform appropriate catheter use led to a more appropriate midline catheter and single-lumen PICC insertion. Dissemination of this single, effective intervention to examine efficacy in other hospital settings would be welcomed.

Comparing Complication Rates of Midline Catheter vs Peripherally Inserted Central Catheter. A Systematic Review and Meta-analysis.

Background: Peripherally inserted central catheters (PICCs) and midlines are commonly used devices for reliable vascular access. Infection and thrombosis are the main adverse effects of these catheters. We aimed to evaluate the relative risk of complications from midlines and PICCs. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies. The primary outcomes were catheter-related bloodstream infection (CRBSI) and thrombosis. Secondary outcomes evaluated included mortality, failure to complete therapy, catheter occlusion, phlebitis, and catheter fracture. The certainty of evidence was assessed using the GRADE approach. Results: Of 8368 citations identified, 20 studies met the eligibility criteria, including 1 RCT and 19 observational studies. Midline use was associated with fewer patients with CRBSI compared with PICCs (odds ratio [OR], 0.24; 95% CI, 0.15-0.38). This association was not observed when we evaluated risk per catheter. No significant association was found between catheters when evaluating risk of localized thrombosis and pulmonary embolism. A subgroup analysis based on location of thrombosis showed higher rates of superficial venous thrombosis in patients using midlines (OR, 2.30; 95% CI, 1.48-3.57). We did not identify any significant difference between midlines and PICCs for the secondary outcomes. Conclusions: Our findings suggest that patients who use midlines might experience fewer CRBSIs than those who use PICCs. However, the use of midline catheters was associated with greater risk of superficial vein thrombosis. These findings can help guide future cost-benefit analyses and direct comparative RCTs to further characterize the efficacy and risks of PICCs vs midline catheters.

Parent Preferences for Neonatal Intensive Care Unit Physician Attire: A Cross-Sectional Study.

OBJECTIVE: Physician attire may influence the parent-provider relationship. Previous studies in adult and outpatient pediatrics showed that formal attire with a white coat was preferred. We aimed to describe parent preferences for physician attire in the neonatal intensive care unit (NICU). STUDY DESIGN: We surveyed 101 parents in a level IV NICU. The survey included photographs of a physician in seven different attires. Attire was scored in five domains and parents selected the most preferred attire in different contexts. All attires were compared with formal attire with white coat. Descriptive statistics, Fisher's exact tests, and one-way analysis of variance were used to compare parent responses. RESULTS: Scrubs without white coat (40.8 [7.0]) and formal attire without white coat (39.7 [8.0]) had the highest mean (standard deviation) composite preference scores. However, no significant differences between formal attire with white coat (37.1 [9.0]) versus any other attire were observed. When asked to choose a single most preferred attire, scrubs with a coat (32%) and formal with a coat (32%) were chosen most often, but preferences varied by clinical context and parent age. For example, parents preferred surgical scrubs for physicians performing procedures. Parents indicated that physician attire is important to them but does not influence their satisfaction with care. CONCLUSION: Although parents generally favored formal attire and scrubs, the variations based on the context of care and lack of significant preference of one attire suggests that a single dress code policy for physicians in a NICU is unlikely to improve the patient-provider relationship. KEY POINTS: · Adult patients prefer doctors to wear formal attire.. · Physician attire preferences influenced by age, setting, and context of care.. · Little is known about physician attire preferences of the parents of neonates.. · Unlike adult patients, NICU parents did not prefer formal attire with a white coat..

Experiences of children with central venous access devices: a mixed-methods study.

BACKGROUND: Our study aims to explore the experience of having a central venous access device (CVAD) from the perspective of the child and family and how movements within and outside of hospital environments influence this experience. METHODS: A mixed-methods study was conducted across Children's Health Queensland (Australia), including inpatient and home-care settings. Children less than 18 years with CVADs were eligible and followed for 3 months or CVAD removal. A subgroup of primary caregivers participated in semi-structured interviews. Quantitative and qualitative measures of child and family CVAD experiences were explored. RESULTS: In total, 163 patients with 200 CVADs were recruited and followed for 6993 catheter days (3329 [48%] inpatients; 3147 [45%] outpatients; 517 [7%] home). Seventeen participants were interviewed. Experiences of having a CVAD were complex but predominantly positive primarily related to personalized CVAD care, healthcare quality, and general wellbeing. Their experience was shaped by their movements through hospital and home environments, including care variation and distress with procedures. Device selection and insertion location further influenced experience, including safety, impairments in activities of daily living, school, and recreation. CONCLUSIONS: CVAD experiences were influenced by nonmodifiable (e.g., diagnosis) and modifiable factors (e.g., education; care variation). Clinical approaches and policies that account for family and child considerations should be explored. IMPACT: Variation in decision making and management for pediatric CVADs is accepted by many clinicians, but the influence this variation has on the health experience of children and their families is less well explored. This is the first study to draw from a broad range of children requiring CVADs to determine their experience within and outside of healthcare facilities. Interdisciplinary clinicians and researchers need to work collaboratively with children and their families to provide resources and support services to ensure they have positive experiences with CVADs, no matter where they are managed, or who they are managed by.

Impact of socio-behavioral measures implemented during the SARS-CoV-2 pandemic on the outcomes of febrile neutropenia episodes in pediatric cancer patients: a single center quasi-experimental pre-post study.

During COVID-19, public health measures including masks and social distancing decreased viral upper respiratory infections (URI). Upper respiratory infections are the most common infectious etiology for low-risk pediatric febrile neutropenia (FN). This single-center, quasi-experimental, pre-post study was designed to understand the impact of public health measures on FN admissions and outcomes in the general pediatric oncology population during the COVID (March 2020-February 2021) vs. pre-COVID era (January 2018-February 2020) and their respective respiratory seasons (November-February). Episodes were risk-stratified using a tool recommended by the Children's Oncology Group. Descriptive and bivariate statistics were used to compare admission characteristics and outcomes. Comparing respiratory seasons, the Covid-era season had 60% fewer URI diagnoses (5/12), while high-risk episodes (63.6% [28/44] vs. 44.2% [23/52]) and intensive care admissions (18.2% [8/44] vs. 3.8% [2/52]) increased. Between eras, URIs were lower in the COVID-era (10.8% [16/148] vs. 19.9% [67/336]; p = 0.01), but admission characteristics and severe outcomes were not different. The impact of public health measures was most prominent during the respiratory season. Despite decreased incidence of URIs, the overall admission characteristics and severe outcomes were minimally impacted due to the brevity of respiratory seasons, but larger studies are warranted.

Racial and ethnic variation in COVID-19 care, treatment, and outcomes: A retrospective cohort study from the MiCOVID-19 registry.

BACKGROUND: Racial and ethnic disparities in COVID-19 outcomes exist, but whether in-hospital care explains this difference is not known. We sought to determine racial and ethnic differences in demographics, comorbidities, in-hospital treatments, and in-hospital outcomes of patients hospitalized with COVID-19. METHODS AND FINDINGS: This was a cohort study using MiCOVID-19, a multi-center, retrospective, collaborative quality improvement registry, which included data on patients hospitalized with COVID-19 across 38 hospitals in the State of Michigan. 2,639 adult patients with COVID-19 hospitalized at a site participating in the MiCOVID-19 Registry were randomly selected. Outcomes included in-hospital mortality, age at death, intensive care unit admission, and need for invasive mechanical ventilation by race and ethnicity. Baseline comorbidities differed by race and ethnicity. In addition, Black patients had higher lactate dehydrogenase, erythrocyte sedimentation rate, C-reactive protein, creatine phosphokinase, and ferritin levels. Black patients were less likely to receive dexamethasone and remdesivir compared with White patients (4.2% vs 14.3% and 2.2% vs. 11.8%, p < 0.001 for each). Black (18.7%) and White (19.6%) patients experienced greater mortality compared with Asian (13.0%) and Latino (5.9%) patients (p < 0.01). The mean age at death was significantly lower by 8 years for Black patients (69.4 ± 13.3 years) compared with White (77.9 ± 12.6), Asian (77.6 ± 6.6), and Latino patients (77.4 ± 15.5) (p < 0.001). CONCLUSIONS: COVID-19 mortality appears to be driven by both pre-hospitalization clinical and social factors and potentially in-hospital care. Policies aimed at population health and equitable application of evidence-based medical therapy are needed to alleviate the burden of COVID-19.

Barriers and facilitators for implementing peripherally inserted central catheter (PICC) appropriateness guidelines: A longitudinal survey study from 34 Michigan hospitals.

Peripherally inserted central catheters (PICCs) are prevalent devices for medium-to-long-term intravenous therapy but are often associated with morbid and potentially lethal complications. This multi-center study sought to identify barriers and facilitators of implementing evidence-based appropriateness criteria to improve PICC safety and patient outcomes in a pay-for-performance model. Participating hospitals received an online toolkit with five recommendations: establishing a vascular access committee; implementing a clinical decision tool for PICC appropriateness; avoiding short-term PICC use (≤5 days); increasing use of single-lumen PICCs; and avoiding PICC placement in patients with chronic kidney disease. Longitudinal online surveys conducted biannually October 2014-November 2018 tracked implementation efforts. A total of 306 unique surveys from 34 hospitals were completed. The proportion of hospitals with a dedicated committee overseeing PICC appropriateness increased from 53% to 97%. Overall, 94% of hospitals implemented an initiative to reduce short-term and multi-lumen PICC use, and 91% integrated kidney function into PICC placement decisions. Barriers to implementation included: achieving agreement from diverse disciplines, competing hospital priorities, and delays in modifying electronic systems to enable appropriate PICC ordering. Provision of quarterly benchmarking reports, a decision algorithm, access to an online toolkit, and presence of local champion support were cited as crucial in improving practice. Structured quality improvement efforts including a multidisciplinary vascular access committee, clear targets, local champions, and support from an online education toolkit have led to sustained PICC appropriateness and improved patient safety.