Clinical Outcome of Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage with Bundled Treatments: A Propensity Score-Matched Analysis.

BACKGROUND: Poor-grade aneurysmal subarachnoid hemorrhage (aSAH), defined as Hunt and Hess (HH) grades IV and V, is a challenging disease because of its high mortality and poor functional outcomes. The effectiveness of bundled treatments has been demonstrated in critical diseases. Therefore, poor-grade aSAH bundled treatments have been established. This study aims to evaluate whether bundled treatments can improve long-term outcomes and mortality in patients with poor-grade aSAH. METHODS: This is a comparative study using historical control from 2008 to 2022. Bundled treatments were introduced in 2017. We compared the rate of favorable outcomes (modified Rankin Scale score 0-2) at 6 months and mortality before and after the introduction of the bundled treatments. To eliminate confounding bias, the propensity score matching method was used. RESULTS: A total of 90 consecutive patients were evaluated. Forty-three patients received bundled treatments, and 47 patients received conventional care. The proportion of patients with HH grade V was higher in the bundle treatment group (41.9% vs. 27.7%). Conversely, the proportion of patients with fixed pupils on the initial examination was higher in the conventional group (30.2% vs. 38.3%). After 1:1 propensity score matching, 31 pairs were allocated to each group. The proportion of patients with 6-month favorable functional outcomes was significantly higher in the bundled treatments group (46.4% vs. 20.7%, p = 0.04). The 6-month mortality rate was 14.3% in the bundled treatments group and 27.3% in the conventional group (p = 0.01). Bundled treatments (odd ratio 14.6 [95% confidence interval 2.1-100.0], p < 0.01) and the presence of an initial pupil reflex (odd ratio 12.0 [95% confidence interval 1.4-104.6], p = 0.02) were significantly associated with a 6-month favorable functional outcome. CONCLUSIONS: The bundled treatments improve 6-month functional outcome and mortality in patients with poor-grade aSAH.

Effect of intensive training and education of health care workers on the maintenance bundle of venous access devices in critically ill patients at a tertiary care academic hospital.

BACKGROUND: The maintenance bundle of care for all venous access devices (peripheral intravenous catheters, PIVC; central venous catheters, CVCs; hemodialysis ports) is important to prevent secondary sepsis in critically ill patients. This quality improvement project analyzed the effect of intensive training and education of health care workers (HCWs) on maintenance bundles for venous access devices. METHODS: The study period comprising of preintervention phase (3-months) included 25 random visits to the intensive care unit for point observations regarding maintenance of all venous access devices in-situ in all intensive care unit patients on the day of the visit. The observations were categorized as appropriate or inappropriate practices based on American Society of Anesthesiologists (ASA) guidelines for CVC 2020, INICC guidelines for PIVC 2017, and Australian Commission on Safety and Quality in Health Care (ACQHCS) for PIVC and hemodialysis ports, December 2019. While the intervention phase (1-month) comprised intensive training and education of HCWs, postintervention phase 3 (3-months) included similar visits and point observations as during the preintervention phase. RESULTS: The maintenance of PIVC improved significantly in terms of the condition of site (from 82.7% appropriate observations to 97.8%, P < .05); condition of connectors (45.7%-56.8%, P < .05), and any attached unused IV sets (90.5%-98.56%, P < .05). For CVC, there was significant improvement in condition of insertion site (66%-94%, P < .01); condition of connectors (0%-44.37%, P < .01); fixation (91%-99.3%, P < .05); any attached unused IV sets (38.9%-97.3%, P < .01) and knowledge of HCW (96.52%-100%, P = .05). For hemodialysis ports, no significant improvement was observed. CONCLUSIONS: Intensive training and education of HCWs led to significant improvement in the maintenance bundle of care for PIVC and CVC.

Reducing urinary tract infection in female pelvic surgery: A retrospective cohort study.

OBJECTIVE: To compare prebundle versus postbundle implementation urinary tract infection (UTI) rates among inpatients within 6 weeks of clean-contaminated pelvic reconstructive surgery. METHODS: The authors conducted a retrospective cohort study from September 2019 to December 2021 at a tertiary hospital. The bundle strategy included the following: universal preoperative UTI check with treatment if positive, replacing prolonged postoperative voiding trials on the ward with earlier discharge and indwelling catheter removal by a nurse continence advisor the next day, and daily cranberry extract for 6 weeks postoperatively. UTI was defined as positive urine culture (≥100 000 colony-forming unit per mL) in a symptomatic patient. Data analysis involved hypothesis testing and logistic regression. RESULTS: The authors reviewed 132 postbundle inpatient charts and retained 93 for analyses. The results were compared with 204 prebundle inpatient charts. The rate of postoperative UTI decreased from 17.6% in the prebundle group to 6.5% after bundle implementation (P = 0.01). The adjusted odds ratio for postbundle versus prebundle likelihood of UTI was 0.35 (95% confidence interval, 0.13-0.98; P = 0.045). Significantly more postbundle patients compared with prebundle patients were discharged home on the first day postoperatively (76.3% vs. 37.7%, P < 0.001). CONCLUSIONS: A clinical bundle can significantly decrease both UTI rates and hospital stay after pelvic reconstructive surgery.

Care bundle for the prevention of peripheral venous catheter blood stream infections at a secondary care university hospital: Implementation and results.

BACKGROUND: Venous catheterization for diagnostic and therapeutic purposes is part of routine hospital practice, as approximately 70% of hospitalized patients have a peripheral venous catheter (PVC). This practice, however, can lead to both local complications, (e.g., chemical, mechanical and infectious phlebitis) and systemic complications (e.g., PVC-related bloodstream infections [PVC-BSIs]). Surveillance data and activities are central to preventing nosocomial infections, phlebitis and improving patient care and safety. The aim of this study was to evaluate the impact of a care bundle on reducing PVC-BSI rates and phlebitis at a secondary care hospital in Mallorca, Spain. METHODS: Three-phase intervention study targeting hospitalized patients with a PVC. The VINCat criteria were used to define PVC-BSIs and calculate incidence. In phase I (August-December 2015), we retrospectively analyzed baseline PVC-BSI rates at our hospital. In phase II (2016-2017), we conducted safety rounds and developed a care bundle with the goal of reducing PVC-BSI rates. In phase III (2018), we expanded the PVC-BSI bundle to prevent phlebitis and analyzed its impact. RESULTS: The incidence of PVC-BSIs decreased from 0.48 episodes per 1000 patient-days in 2015 to 0.17 episodes per 1000 patient-days in 2018. The 2017 safety rounds also detected a reduction in phlebitis (from 4.6% of 2.6%). Overall, 680 healthcare professionals were trained in catheter care and five safety rounds were conducted to assess bedside care. CONCLUSION: Implementation of a care bundle significantly reduced PVC-BSI rates and phlebitis at our hospital. Continuous surveillance programs are needed to adapt measures to improve patient care and guarantee safety.

Implementation of an evidence-based bundle to reduce surgical site infection after caesarean section - Review of the interventions.

BACKGROUND: Surgical site infection (SSI) is the most common complication post caesarean section (CS) with a significant impact on women and health services. A bundle approach incorporating previously studied individual interventions has shown increased reductions in SSI. AIM: To assess compliance with a SSI intervention bundle and to examine readmission rates for SSI. METHODS: A retrospective audit of women who underwent CS at a regional hospital in Queensland, Australia pre-intervention (February 2015-January 2017) and post-intervention (February 2018-December 2020). RESULTS: There was good compliance with vaginal cleansing (27.7% vs 84.8%), chlorhexidine skin preparation (90.4% vs 98.4%), BMI-based antibiotic dose adjustment (48.8% vs 74.3%), and Alexis retractor use (9.9% vs 66%), pre and post-implementation periods respectively. There was a reduction in documented hair shaving (2.1% vs 0.5%). There was a trend towards less admission for SSI, a trend that could have been even better had there not been an increasing number of women with high BMI over the years. Fewer cases needed return to theatre post-implementation. Endometritis rates were unchanged. CONCLUSIONS: Good compliance can be achieved with good collaboration. There was a reduction in admission rates for SSI. Larger prospective studies are needed to further examine these findings.

Lessons Learned From a Gap Analysis of Obstetric Hemorrhage Protocols across a Health System.

INTRODUCTION: The United States has experienced a rising incidence of maternal deaths, including those attributable to obstetric hemorrhage (OBH). In response, the National Partnership for Maternal Safety developed a standardized OBH Consensus Bundle with the goal of universal adoption. In 2016 a large western Pennsylvania health system adopted the OBH Consensus Bundle across its 8 obstetrical units, with the goal to improve maternal outcomes. METHODS: Gap analysis was used to identify differences between existing OBH protocols and the OBH Consensus Bundle from January to June 2016. Identified gaps as well as existing practices of success were used to systematically develop and implement a standardized system-wide OBH improvement initiative. Hospitals were then categorized by annual birth volume as high (> 2000), medium (500-2000), and low (< 500) with analysis performed across these groups to identify potential trends. RESULTS: All hospitals had individual successes as well as gaps that were used to direct the system-wide OBH improvement initiative. In some cases, individual plans were tailored to meet hospital resources. When hospitals were compared by annual birth volume, variation existed in their preparedness for, and management of OBH, with the single low-volume hospital having the most gaps. DISCUSSION: This gap analysis identified areas for improvement among all hospitals in a health system regardless of annual birth volume. This systematic approach of evaluation of current protocols and identification of improvement targets with implementation strategies may improve maternity outcomes. Additionally, these lessons described may provide a useful framework for other hospitals and health systems as they implement their own safety bundles.

Adesão ao bundle para prevenção de pneumonia associada à ventilação mecânica em terapia intensiva / Adherence to the bundle for prevention of pneumonia associated with mechanical ventilation in intensive care / Adhesión del paquete de atención para prevenir la neumonía asociada al ventilador en la unidad de cuidados intensivos

Introdução: Pacientes internados em ambientes de terapia intensiva podem vir a apresentar pneumonia associada à ventilação mecânica e com expressivas taxas de morbimortalidade. Pacotes de cuidados ou bundles atualmente estão sendo utilizados como estratégia terapêutica no tratamento. Objetivo: Verificar adesão ao bundle de pneumonia associada à ventilação mecânica em terapia intensiva. Método: Transversal com delineamento descritivo, abordagem quantitativa, do tipo analítico e correlação entre variáveis, realizado em duas unidades de terapia intensiva adulto de um hospital de ensino, por meio de checklist elaborado pelo serviço de controle de infecção hospitalar. A amostragem foi não probabilística em sequência, no período de abril a novembro de 2019. Resultados: A maior faixa etária foi de 61 a 80 anos. Os pacientes que ficaram internados até 10 dias, em terapia intensiva, foram 50% e 31% ficaram entre 11 a 20 dias. O tempo de ventilação mecânica foi de até 10 dias em 66%. De 400 pacientes, 54% morreram e 46% receberam alta para a unidade de internação. Nos meses de março e abril, a porcentagem de não conformidades na variável "Cabeceira Elevada" e "Higiene Oral" foi maior em relação aos demais meses, e o período da noite foi o que teve maior adesão ao checklist. A variável "Oportunidades de Verificação do Cuff" foi uma não conformidade que se manteve alta durante todo o período estudado. A "Interrupção de Sedação diária" apresentou baixas não conformidades e depois caiu para zero. Conclusão: Não houve adesão total ao bundle de pneumonia associada à ventilação mecânica, sendo que o período que mais estava em conformidade foi o noturno, entretanto, em todos os turnos houve não conformidades, indicando a necessidade de intervenção do gestor de enfermagem e serviço de educação permanente para melhorar a adesão dos profissionais envolvidos.(AU)

Introduction: Patients hospitalized in intensive care environments may present pneumonia associated with mechanical ventilation and with expressive morbidity and mortality rates. Care packages or bundles are currently being used as a therapeutic strategy in treatment. Objective: To verify adherence to pneumonia blister associated with mechanical ventilation in intensive care. Method: Cross-sectional with descriptive design, quantitative approach, analytical type and correlation between variables, performed in two adult intensive care units of a teaching hospital, by means of checklist elaborated by the hospital infection control service. The sampling was non-probabilistic in sequence, from April to November 2019. Results: The largest age group was 61 to 80 years. The patients who remained hospitalized for up to 10 days in intensive care were 50% and 31% were between 11 and 20 days. Mechanical ventilation time was up to 10 days in 66%. Of 400 patients, 54% died and 46% were discharged to the hospital. In the months of March and April, the percentage of non-conformities in the variable "High Head" and "Oral Hygiene" was higher in relation to the other months, and the period of the night was the one that had greater adherence to checklist. The variable "Cuff Verification Opportunities" was a non-conformity that remained high throughout the study period. The "Daily Interruption of Sedation" showed low non-conformities and then dropped to zero. Conclusion: There was no total adhesion to pneumonia bundle associated with mechanical ventilation, and the period that was most in accordance was the night, however, in all shifts there were nonconformities, indicating the need for intervention of the nursing manager and permanent education service to improve the adherence of the professionals involved.(AU)

Introducción: Los pacientes hospitalizados en cuidados intensivos pueden experimentar neumonía asociada con la ventilación mecânica, con tasas significativas de morbilidad y mortalidad. Los paquetes o paquetes de ayuda se utilizan actualmente como estrategia terapéutica en el tratamiento. Objetivo: Verificar la adherencia al paquete de neumonía asociada a la ventilación mecánica en cuidados intensivos. Método: Transversal con diseño descriptivo, abordaje cuantitativo, tipo analítico y correlación entre variables, realizado en dos unidades de cuidados intensivos de adultos de un hospital docente, mediante un checklist elaborado por el servicio de control de infecciones del hospital. El muestreo fue secuencial no probabilístico, de abril a noviembre.(AU)

Near-zero ventilator-associated pneumonia rates after implementation of a multimodal preventive strategy in a Mexican hospital.

A multimodal preventive strategy consisting of a ventilator-associated pneumonia (VAP) preventive bundle plus 3 additional sequential interventions (noninvasive ventilation, reeducation of health care workers, and early weaning) was associated with a marked reduction in VAP rates in a Latin American hospital, including 6 consecutive months without VAP cases. A positive association between the percentage of intubated patients and VAP rates was observed.

Compliance with evidence-based guidelines for the prevention of central line-associated bloodstream infections in a Belgian home care setting: An observational study.

This study assessed the compliance of Belgian home care nurses with good practice recommendations to prevent central line-associated bloodstream infections. The compliance to 3 care bundles was 0% (0 out of 7), 13.3% (2 out of 15), and 22.2% (2 out of 9), respectively. This finding is important given the increasing number of home care patients with an intravascular catheter and underscores the need for quality improvement strategies to prevent central line-associated bloodstream infections in home care.

[Efecto de un Plan de Mejora de Calidad y Seguridad Clínica en la incidencia de infección de sitio quirúrgico en apendicectomía. Estudio cuasi-experimental]. / Effect of a Plan for Quality Improvement and Clinical Safety in the incidence of surgical site infections in appendectomy. A quasi-experimental study.

OBJETIVO: Las infecciones de sitio quirúrgico se pueden evitar y los programas de control basados en paquetes de medidas preventivas son eficaces para reducir su incidencia. El objetivo de este estudio fue evaluar el efecto de un Plan de Mejora de Calidad y Seguridad Clínica del paciente intervenido de apendicectomía en la incidencia de infección del sitio quirúrgico. MÉTODO: Se realizó un estudio cuasi-experimental con análisis antes y después de la introducción de un Plan de Calidad y Seguridad Clínica. Se incluyeron pacientes intervenidos de apendicectomía. Se estudió la incidencia de infección del sitio quirúrgico durante los 30 días posteriores a la cirugía (periodo máximo de incubación de infección quirúrgica). Se evaluó el efecto de la intervención con la odds ratio (OR) ajustada con un modelo de regresión logística. RESULTADOS: Se incluyeron 606 pacientes, 267 en el periodo 2009-2010 (antes del plan) y 339 durante 2012-2013 (después del plan). La incidencia de infección del sitio quirúrgico descendió después del plan del 6 al 5.6% (OR: 0.72; intervalo de confianza del 95%: 0.33-1.56; p = 0.839). Hubo mayor cumplimiento de la profilaxis antibiótica, de la preparación prequirúrgica y de la adherencia a la higiene de manos tras la introducción de las medidas. CONCLUSIONES: Aunque la reducción de la incidencia de infección del sitio quirúrgico no presentó diferencias estadísticamente significativas tras las medidas adoptadas, se ha conseguido mejorar la administración de la profilaxis antibiótica, la adherencia a la higiene de manos y la preparación prequirúrgica. OBJECTIVE: Surgical site infections can be prevented. Control programs based on care bundle have proven to be effective in reducing its incidence. The objective of this study was to assess the effectiveness of a Plan for Quality Improvement and Clinical Safety in preventing the incidence of surgical site infection in patients undergoing appendectomy. METHOD: A quasi-experimental study was designed for analysis before and after the introduction of a Plan for Quality and Clinical Safety. Patients undergoing appendectomy were included. The incidence of surgical site infection was studied within 30 days from the time of surgery (maximum incubation period of surgical site infection). The effectiveness of the intervention was evaluated using the odds ratio (OR) adjusted with a logistic regression model. RESULTS: A total of 606 patients were included, of which 267 were operated in the period 2009-2010 (before the plan) and 339 in 2012-2013 (after the plan). The incidence of surgical site ­infection decreased after the plan from 6 to 5.6% (OR: 0.72; 95% confidence interval: 0.33-1.56; p = 0.839). There was greater compliance of antibiotic prophylaxis, preoperative preparation and adherence to hand hygiene after the introduction of the measures. CONCLUSIONS: Although the reduction in the incidence of surgical site infection after the measures adopted did not show statistical significant differences, important progress has been made in the compliance of antibiotic prophylaxis, adherence to hand hygiene and in the preoperative preparation.

Systematic review of a patient care bundle in reducing staphylococcal infections in cardiac and orthopaedic surgery.

Surgical site infections (SSIs) are serious adverse events hindering surgical patients' recovery. In Australia and New Zealand, SSIs are a huge burden to patients and healthcare systems. A bundled approach, including pre-theatre nasal and/or skin decolonization has been used to reduce the risk of staphylococcal infection. The aim of this review is to assess the effectiveness of the bundle in preventing SSIs for cardiac and orthopaedic surgeries. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Published literature was searched in PubMed, Embase and Cochrane Library of Systematic reviews. Identified articles were selected and extracted based on a priori defined Population-Intervention-Comparator-Outcome and eligibility criteria. Data of randomized controlled trials (RCTs) and comparative observational studies were synthesized by meta-analyses. Quality appraisal tools were used to assess the evidence quality. The review included six RCTs and 19 observational studies. The bundled treatment regimens varied substantially across all studies. RCTs showed a trend of Staphylococcus aureus SSIs reduction due to the bundle (relative risk = 0.59, 95% confidence interval (CI) = 0.33, 1.06) with moderate heterogeneity. Observational studies showed statistically significant reduction in all-cause and S. aureus SSIs, with 51% (95% CI = 0.41, 0.59) and 47% (95% CI = 0.35, 0.65), respectively. No publication biases were detected. SSIs in major cardiac and orthopaedic surgeries can be effectively reduced by approximately 50% with a pre-theatre patient care bundle approach.