WireSafeTM - A pilot study of a novel safety engineered device designed to prevent guidewire retention and reduce sharps injuries during central venous catheter insertion.

Background: Guidewire retention and sharps injury during central venous catheter insertion are errors that cause patient and healthcare professional harm. The WireSafeTM is a novel procedure safety pack engineered to prevent guidewire retention and sharps injury during central venous catheter insertion. This is a pilot study aimed to determine its acceptability, usability and safety during clinical practice. Methods: An observational time and motion study was conducted comparing central venous catheter insertion and sharps disposal practice using standard versus WireSafeTM techniques. One-year following implementation, a structured survey was conducted to determine clinician opinion and experiences of using the WireSafeTM. Results: 15 procedures were observed using standard practice and 16 using the WireSafeTM technique. The WireSafeTM technique decreased the time taken from removal of the guidewire to disposal of sharps (standard 11.4 ± 5.6 min vs WireSafeTM 8.7 ± 1.4 min, p = 0.035), as well as total procedure time (standard 16 ± 7 min vs WireSafeTM 14.2 ± 2 min, p = 0.17), although this latter trend did not reach significance. Clinicians frequently practiced unsafe behaviour during sharps disposal in the standard group (53%), but when using the WireSafeTM technique, 100% exhibited safe practice by transferring sharps to the bin inside the sealed WireSafeTM box. One-year following implementation, 20 clinicians participated in the structured survey. Clinicians across three different departments used the WireSafeTM in varying clinical situations and reported that its use for central line insertion was either easier (10/20) or no different (10/20) compared to standard practice. All clinicians (20/20) felt that the WireSafeTM reduced the risk of guidewire retention and all stated that they approved of the WireSafeTM technique, and supported its use for convenience and safety benefits. Conclusion: Utilising the WireSafeTM for central line insertion facilitated earlier and safer sharps disposal, and the device was well supported by clinicians for its convenience and safety benefits.

Central Venous Catheter Guidewire Retention: Lessons From England's Never Event Database.

OBJECTIVES: Guidewire retention during central venous catheter (CVC) insertion is considered a "never event." We analyzed the National Health Service England Never Event database (2004-2015) to explore the process of guidewire retention and identify potential preventative measures. METHODS: We performed a systematic analysis of reported retained guidewire incidents by 3 independent reviewers. RESULTS: There was a rising frequency of reported retained CVC guidewires, with an average of 2 never events per month. Only 11% of retained guidewires are identified during the procedure itself, with the remainder identified during equipment clear-up (6%), after the procedure (4%), at the first check radiograph (23%), or after the first radiograph (55%). In 59 cases, the grade of the operator was reported, and among these, 88% were inserted by trainee doctors. Analysis of causative factors was only possible for 38 cases, and of these, operator's mistake (32%), operator/human error (16%), and distraction (16%) were the most common. Of 163 reported cases, preventative measures instigated were actions taken against the individual clinician (36%), departmental actions such as investigations, additional teaching or reminders (37%), and additional checklists (27%). CONCLUSIONS: Most retained guidewires are discovered after the procedure. Despite the introduction of safety measures, guidewire retention still occurs because the checks, alerts, reminders, and additional checklists all solely rely on the operator remembering not to make the mistake. System changes or design modifications to the CVC equipment are needed to prevent guidewire retention, this being at the top of the hierarchy of intervention effectiveness.

The glucose error in arterial sampling: assessing staff awareness and the effect of sampling technique.

BACKGROUND: Using a dextrose-containing solution, instead of normal saline, to maintain the patency of an arterial cannula results in the admixture of glucose in line samples. This can misguide the clinician down an inappropriate treatment pathway for hyperglycaemia. METHODS: Following a near-miss and subsequent educational and training efforts at our institution, we conducted two simulations: (1) to observe whether 20 staff would identify a 5% dextrose/0.9% saline flush solution as the cause for a patient's refractory hyperglycaemia, and (2) to compare different arterial line sampling techniques for glucose contamination. RESULTS: (1) Only 2/20 participants identified the incorrect dextrose-containing flush solution, with the remainder choosing to escalate insulin therapy to levels likely to risk fatality, and (2) glucose contamination occurred regardless of sampling technique. CONCLUSION: Despite national guidance and local educational efforts, this is still an under-recognised error. Operator-focussed preventative strategies have not been effective and an engineered solution is needed.

A bedside rescue method for retrieving retained guidewires: The 'Suck Out' technique.

BACKGROUND: Central venous catheter guidewire retention is classed as a 'never event' in the United Kingdom, with the potential for significant patient harm. If the retained guidewire remains within the central venous catheter lumen, bedside techniques may facilitate guidewire retrieval. However, these techniques may be ineffective if the guidewire has already passed below skin level. We investigated a novel 'suck out' technique for bedside guidewire retrieval and compared this against traditional retrieval methods. METHODS: Simulation 1: in a benchtop model, seven different central venous catheters had their corresponding guidewire placed in the last 2 cm of the catheter tip which was immersed horizontally in fluid. A 50-mL syringe was attached to the distal lumen central venous catheter hub and suction applied for 5 s, and the distance of guidewire retraction was recorded. Simulation 2: a central venous catheter guidewire was intentionally retained within the catheter at either 5 cm above or below skin level in a pigskin model. Simple catheter withdrawal, catheter clamping withdrawal and the 'suck out' method were compared for efficacy using Fisher's exact test. RESULTS: Simulation 1: retained guidewires were retracted by 13 cm on average. Simulation 2: when guidewires were retained 5 cm above skin level, all retrieval methods were 100% effective; however, when retained 5 cm below skin level, simple catheter withdrawal was ineffective, clamping and withdrawal was only 10% effective and the 'suck out' technique was 90% effective (p < 0.001). CONCLUSION: The 'suck out' technique can effectively retract guidewires retained within central venous catheter lumens and demonstrates superiority over traditional methods of retained guidewire extraction in simulated models.

Unintentional endotracheal tube cuff deflation during routine checks: a simulation study.

BACKGROUND: Endotracheal tube cuff pressures should be maintained between 20 and 30 cm H2 O to prevent the aspiration of subglottic secretions past the cuff. Guidance recommends regular monitoring of the cuff pressure, performed using a handheld manometer/inflator. Poor technique can lead to transient deflation of the cuff, leading to the bolus aspiration of upper respiratory tract secretions, tracheal colonization and, ultimately, ventilator-associated pneumonia. AIMS AND OBJECTIVES: To determine whether intensive care staff transiently deflate the endotracheal tube cuff to below 20 cm H2 O during routine cuff pressure checks when using a handheld manometer/inflator device. DESIGN: This was an exploratory simulation study. METHODS: A sample of medical (n = 10) and nursing staff (n = 10), capable of caring for a tracheally intubated patient, participated in the study on a single day. A mannequin was intubated with a standard oral endotracheal tube with the cuff pressure set at 50 cm H2 O. Participants were required to check and correct the cuff pressure to the appropriate level with a manometer. The lowest attained and the final target pressures were recorded. RESULTS: Three doctors were unfamiliar with the manometer and did not attempt measurement. During cuff pressure readjustment, 59% (10/17) of participants transiently deflated the cuff below 20 cm H2 O and then re-inflated to attain the final pressure. Of these participants, four deflated the cuff pressure to 0 cm H2 O before re-adjusting it back into range. Most participants, 88% (15/17), corrected the final cuff pressure to between 20 and 30 cm H2 O. CONCLUSIONS: Poor technique when using the manometer led to unintentional cuff deflation during routine checks. In clinical practice, this could increase the risk of pulmonary aspiration and ventilator-associated pneumonia. Further research into alternatives for handheld manometers, such as automated continuous cuff pressure monitors, is warranted. RELEVANCE TO CLINICAL PRACTICE: Cuff deflations can easily occur during routine cuff pressure checks. Staff should be aware of the implications of cuff deflations and seek to improve training with manometers.

Accidental dual humidification in intensive care units: Repeated alerts and system changes are not enough.

PURPOSE: The inadvertent, simultaneous use of heat and moisture exchangers (HMEs) and heated humidifiers (HHs) can result in waterlogging of the filter and sudden ventilation tube occlusion, with potentially fatal consequences. Following an NHS England Safety Alert, a near miss and educational reminders in our institution, we introduced new guidelines to solely use HHs in the intensive care unit and HMEs only for patient transfers. No further incidents have occurred, however this solution is potentially fallible. Two years later, we sought to assess staff knowledge and likelihood of recognising this error should it occur. MATERIALS AND METHODS: In a simulation study, a tracheally intubated and ventilated mannequin had a breathing circuit containing both a HME and a HH. Participants were asked to assess the circuit, identify errors and undertake corrective measures. RESULTS: Only 30% (6/20) recognised and undertook corrective measures. CONCLUSIONS: Despite educational efforts and system changes, recognition of this error remained poor. System changes may reduce the likelihood of the error occurring, but when it does, recognition may not occur. Substantial reductions or elimination of this error may be achieved through a safety-engineered fail-safe within the equipment, which alerts staff to improve recognition and prevent the mistake.

Preventing Retained Central Venous Catheter Guidewires: A Randomized Controlled Simulation Study Using a Human Factors Approach.

BACKGROUND: Retained central venous catheter guidewires are never events. Currently, preventative techniques rely on clinicians remembering to remove the guidewire. However, solutions solely relying upon humans to prevent error inevitably fail. A novel locked procedure pack was designed to contain the equipment required for completing the procedure after the guidewire should have been removed: suture, suture holder, and antimicrobial dressings. The guidewire is used as a key to unlock the pack and to access the contents; thereby, the clinician must remove the guidewire from the patient to complete the procedure. METHODS: A randomized controlled forced-error simulation study replicated catheter insertion. We created a retained guidewire event and then determined whether clinicians would discover it, comparing standard practice against the locked pack. RESULTS: Guidewires were retrieved from 2/10 (20%) standard versus 10/10 (100%) locked pack, n = 20, P < 0.001. In the locked pack group, participants attempted to complete the procedure; however, when unable to access the contents, this prompted a search for the key (guidewire). Participants discovered the guidewire within the catheter lumen, recovered it, utilized it to unlock the pack, and finish the procedure. A structured questionnaire reported that the locked pack also improved subjective safety of central venous catheter insertion and allowed easy disposal of the sharps and guidewire (10/10). CONCLUSIONS: The locked pack is an engineered solution designed to prevent retained guidewires. Utilizing forced-error simulation testing, we have determined that the locked pack is an effective preventative device and is acceptable to clinicians for improving patient safety.

Endotracheal tubes and fluid aspiration: an in vitro evaluation of new cuff technologies.

BACKGROUND: Aspiration of subglottic secretions past the endotracheal tube (ETT) cuff is a prerequisite for developing ventilator-associated pneumonia (VAP). Subglottic secretion drainage (SSD) ETTs reduce aspiration of subglottic secretions and have demonstrated lower VAP rates. We compared the performance of seven SSD ETTs against a non-SSD ETT in preventing aspiration below inflated cuffs. METHODS: ETTs were positioned vertically in 2 cm diameter cylinders. Four ml of a standard microbial suspension was added above inflated cuffs. After 1 h, aspiration was measured and ETTs demonstrating no leakage were subjected to rotational movement and evaluation over 24 h. Collected aspirated fluid was used to inoculate agar media and incubated aerobically at 37 °C for 24 h. The aspiration rate, volume and number of microorganisms that leaked past the cuff was measured. Experiments were repeated (×10) for each type of ETT, with new ETTs used for each repeat. Best performing ETTs were then tested in five different cylinder diameters (1.6, 1.8, 2.0, 2.2 and 2.4 cm). Experiments were repeated as above using sterile water. Volume and time taken for aspiration past the cuff was measured. Experiments were repeated (×10) for each type of ETT. Results were analysed using non-parametric tests for repeated measures. RESULTS: The PneuX ETT prevented aspiration past the cuff in all experiments. All other ETTs allowed aspiration, with considerable variability in performance. The PneuX ETT was statistically superior in reducing aspiration compared to the SealGuard (p < 0.009), KimVent (p < 0.002), TaperGuard (p < 0.004), Lanz (p < 0.001), ISIS (p < 0.001), SACETT (p < 0.001) and Soft Seal (p < 0.001) ETTs. Of the 4 ETTs tested in differing cylinder sizes, the PneuX significantly reduced aspiration across the range of diameters compared to the SealGuard (p < 0.0001), TaperGuard (p < 0.0001) and KimVent (p < 0.0001) ETTs. CONCLUSIONS: ETTs showed substantial variation in fluid aspiration, relating to cuff material and design. Variability in performance was likely due to the random manner in which involutional folds form in the inflated ETT cuff. The PneuX ETT was the only ETT able to consistently prevent aspiration past the cuff in all experiments.

Preoxygenation and apneic oxygenation using Transnasal Humidified Rapid-Insufflation Ventilatory Exchange for emergency intubation.

PURPOSE: Hypoxia is one of the leading causes of anesthesia-related injury. In response to the limitations of conventional preoxygenation, Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) has been used as a method of providing both preoxygenation and apneic oxygenation during intubation. MATERIALS AND METHODS: In this prospective, observational study, THRIVE was introduced in a critical care unit (CCU), operating room (OR), and emergency department (ED) during emergency intubation of patients at high risk of hypoxia. Linear regression analysis tested for correlation between apnea time or body mass index and hemoglobin saturation (Spo2). RESULTS: Across 71 sequential patients, the interquartile range for apnea time and decrease in Spo2 were 60 to 125 seconds and 0% to 3%, respectively. Significant desaturation occurred in 5 (7%) patients. There was no evidence of correlation between apnea time or body mass index and Spo2 (R2=0.04 and 0.08 for CCU/ED and OR and 0.01 and 0.04 CCU/ED and OR, respectively). There were no complications reported from using THRIVE. CONCLUSIONS: This study demonstrated that preoxygenation and apneic oxygenation using THRIVE were associated with a low incidence of desaturation during emergency intubation of patients at high risk of hypoxia in the CCU, OR, and ED. THRIVE has the potential to minimize the risk of hypoxia in these patient groups.

Using an alarm to improve drug trolley safety.

Leaving drug trolleys unlocked and unattended during drug rounds creates opportunities for drug theft and tampering. A new device was developed by our trust to detect when an open drug trolley is left unattended; it then sounds an alarm to remind staff to return to the trolley. This article describes use of the alarm on general hospital wards in one trust in the east of England. When the alarm was installed into drug trolleys on ahospital ward, it reduced the number of times unlocked trolleys were left unattended. The drug trolley alarm successfully changed the behaviour of staff on drug rounds and, in so doing, improved patient safety.

The simultaneous use of a heat and moisture exchanger and a heated humidifier causes critical airway occlusion in less than 24 hours.

PURPOSE: Heat and moisture exchangers (HMEs) and heated humidifiers (HHs) may be used together inadvertently. Such an incident occurred at our institution resulting in airway occlusion. MATERIAL AND METHODS: A bench-top study was conducted to compare the incidence of airway occlusion when using (1) no airway humidification, (2) HME alone, (3) HH alone, and (4) both HME and HH in combination as part of a standard breathing circuit. RESULTS: The simultaneous use of a HME and a HH was associated with a reduction in tidal volume (no airway humidification, P ≤ .05; HME alone, P ≤ .01; and HH alone, P ≤ .01) and an increased incidence of airway occlusion (no airway humidification, 0/7; HME alone, 0/7; HH alone, 0/7; and HME and HH in combination, 7/7; P < .0001). CONCLUSIONS: The use of a HME and a HH in combination is likely to result in airway occlusion. Precautions should be taken to ensure that both systems are not used together in clinical practice.

The coated antiseptic tip (CAT) syringe.

Catheter-related blood stream infections (CR-BSI) account for 30% of healthcare acquired infection (HAI). Colonization of connector hubs and contaminated syringes are thought to increase the risk of CR-BSI. The Coated Antiseptic Tip (CAT) syringe was developed to decontaminate connector hubs, thereby reducing the risk of CR-BSI. Needleless valves (n = 20) and three-way connectors (n = 20) were contaminated with common critical care pathogens. At hourly intervals, CAT syringes were inserted into the connector hubs and normal saline was injected through the connector. This was repeated with control (non-coated) syringes. The internal surface of the connector hubs were swabbed at t = 0, t = 1 h and t = 4 h, inoculated onto blood agar plates and analysed by a blinded microbiologist. Growth was counted as the number of colony forming units. Baseline swabbing demonstrated 100% bacterial hub colonization in both connectors. The CAT syringe showed a significant reduction in CFU growth at 0 and 1 h compared with control syringes (p < 0.05). At 4 h, the CAT syringe completely eliminated bacterial growth in both of the connector hubs. The CAT syringe can effectively disinfect both three-way and needleless connectors.

Keyboard cleanliness: a controlled study of the residual effect of chlorhexidine gluconate.

A controlled trial of once daily cleaning of computer keyboards in an intensive care unit was performed comparing 2% chlorhexidine gluconate-70% isopropyl alcohol (CHG) and a chlorine dioxide-based product used as a standard in our hospital. A study before and after the introduction of once daily keyboard cleaning with CHG in the wider hospital was also completed. Cleaning with CHG showed a sustained and significant reduction in bacterial colony forming units compared with the chlorine dioxide-based product, demonstrating its unique advantage of maintaining continuous keyboard cleanliness over time.