Development of key interventions and quality indicators for the management of an adult potential donor after brain death: a RAND modified Delphi approach.

BACKGROUND: A substantial degree of variability in practices exists amongst donor hospitals regarding the donor detection, determination of brain death, application of donor management techniques or achievement of donor management goals. A possible strategy to standardize the donation process and to optimize outcomes could lie in the implementation of a care pathway. The aim of the study was to identify and select a set of relevant key interventions and quality indicators in order to develop a specific care pathway for donation after brain death and to rigorously evaluate its impact. METHODS: A RAND modified three-round Delphi approach was used to build consensus within a single country about potential key interventions and quality indicators identified in existing guidelines, review articles, process flow diagrams and the results of the Organ Donation European Quality System (ODEQUS) project. Comments and additional key interventions and quality indicators, identified in the first round, were evaluated in the following rounds and a subsequent physical meeting. The study was conducted over a 4-month time period in 2016. RESULTS: A multidisciplinary panel of 18 Belgian experts with different relevant backgrounds completed the three Delphi rounds. Out of a total of 80 key interventions assessed throughout the Delphi process, 65 were considered to contribute to the quality of care for the management of a potential donor after brain death; 11 out of 12 quality indicators were validated for relevance and feasibility. Detection of all potential donors after brain death in the intensive care unit and documentation of cause of no donation were rated as the most important quality indicators. CONCLUSIONS: Using a RAND modified Delphi approach, consensus was reached for a set of 65 key interventions and 11 quality indicators for the management of a potential donor after brain death. This set is considered to be applicable in quality improvement programs for the care of potential donors after brain death, while taking into account each country's legislation and regulations regarding organ donation and transplantation.

Care pathways for organ donation after brain death: guidance from available literature?

AIMS: A discussion of the literature concerning the impact of care pathways in the complex and by definition multidisciplinary process of organ donation following brain death. BACKGROUND: Enhancing the quality and safety of organs for transplantation has become a central concern for governmental and professional organizations. At the local hospital level, a donor coordinator can use a range of interventions to improve the donation and procurement process. Care pathways have been proven to represent an effective intervention in several settings for optimizing processes and outcomes. DESIGN: A discussion paper. DATA SOURCES: A systematic review of the Medline, CINAHL, EMBASE and The Cochrane Library databases was conducted for articles published until June 2015, using the keywords donation after brain death and care pathways. Each paper was reviewed to investigate the effects of existing care pathways for donation after brain death. An additional search for unpublished information was conducted. DISCUSSION: Although literature supports care pathways as an effective intervention in several settings, few studies have explored its use and effectiveness for complex care processes such as donation after brain death. IMPLICATIONS FOR NURSING: Nurses should be aware of their role in the donation process. Care pathways have the potential to support them, but their effectiveness has been insufficiently explored. CONCLUSION: Further research should focus on the development and standardization of the clinical content of a care pathway for donation after brain death and the identification of quality indicators. These should be used in a prospective effectiveness assessment of the proposed pathway.

A clinical algorithm to diagnose invasive pulmonary aspergillosis in critically ill patients.

RATIONALE: The clinical relevance of Aspergillus-positive endotracheal aspirates in critically ill patients is difficult to assess. OBJECTIVES: We externally validate a clinical algorithm to discriminate Aspergillus colonization from putative invasive pulmonary aspergillosis in this patient group. METHODS: We performed a multicenter (n = 30) observational study including critically ill patients with one or more Aspergillus-positive endotracheal aspirate cultures (n = 524). The diagnostic accuracy of this algorithm was evaluated using 115 patients with histopathologic data, considered the gold standard. Subsequently, the diagnostic workout of the algorithm was compared on the total cohort (n = 524), with the categorization based on the diagnostic criteria of the European Organization for the Research and Treatment of Cancer/Mycoses Study Group. MEASUREMENTS AND MAIN RESULTS: Among 115 histopathology-controlled patients, 79 had proven aspergillosis. The algorithm judged 86 of 115 cases to have putative aspergillosis. This diagnosis was confirmed in 72 and rejected in 14 patients. The algorithm judged 29 patients to have Aspergillus colonization. This was confirmed in 22 and rejected in 7 patients. The algorithm had a specificity of 61% and a sensitivity of 92%. The positive and negative predictive values were 61 and 92%, respectively. In the total cohort (n = 524), 79 patients had proven invasive pulmonary aspergillosis (15.1%). According to the European Organization for the Research and Treatment of Cancer/Mycoses Study Group criteria, 32 patients had probable aspergillosis (6.1%) and 413 patients were not classifiable (78.8%). The algorithm judged 199 patients to have putative aspergillosis (38.0%) and 246 to have Aspergillus colonization (46.9%). CONCLUSIONS: The algorithm demonstrated favorable operating characteristics to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients.

Nurses' knowledge of evidence-based guidelines for the prevention of surgical site infection.

BACKGROUND: Prevention of surgical site infection (SSI) is an important responsibility for nurses. Knowledge of the related evidence-based recommendations is necessary to provide high-quality nursing care. AIM: Development of an evaluation tool and subsequent evaluation of intensive care unit (ICU) nurses' knowledge of the SSI prevention guideline to identify their specific educational needs, as part of a needs analysis preceding the development of an e-learning module on infection prevention. METHODS: We developed a multiple-choice knowledge test concerning evidence-based SSI prevention. After expert assessment of its face and content validity, the test was used in a survey among 809 ICU nurses. Demographics included were gender, ICU experience, number of ICU beds, and whether respondents had obtained a specialized ICU qualification. Based on the test results, an item analysis was performed. RESULTS: Face and content validity were achieved for 9 out of 10 items of the questionnaire. From the survey, we collected 650 questionnaires (response rate 80.3%). The item analysis revealed overall good results with values for item difficulty ranging from 0.1 to 0.5 for eight questions, while one question had a value of 0.02; discriminative values ranging from 0.27 to 0.53 and values for the quality of the response alternatives between 0.1 and 0.7. Overall, these results demonstrate the questionnaire's reliability. The nurses' mean score on the knowledge test was 29%. Males were shown to have better scores. CONCLUSIONS: Opportunities exist to improve ICU nurses' knowledge about SSI prevention recommendations. Current guidelines should support their ongoing training and education.

Centers for Disease Control and Prevention guidelines for preventing central venous catheter-related infection: results of a knowledge test among 3405 European intensive care nurses.

OBJECTIVE: To determine European intensive care unit (ICU) nurses' knowledge of guidelines for preventing central venous catheter-related infection from the Centers for Disease Control and Prevention. DESIGN: Multicountry survey (October 2006-March 2007). SETTING: Twenty-two European countries. PARTICIPANTS: ICU nurses. MEASUREMENTS AND MAIN RESULTS: Using a validated multiple-choice test, knowledge of ten recommendations for central venous catheter-related infection prevention was evaluated (one point per question) and assessed in relation to participants' gender, ICU experience, number of ICU beds, and acquisition of a specialized ICU qualification. We collected 3405 questionnaires (70.9% response rate); mean test score was 44.4%. Fifty-six percent knew that central venous catheters should be replaced on indication only, and 74% knew this also concerns replacement over a guidewire. Replacing pressure transducers and tubing every 4 days, and using coated devices in patients requiring a central venous catheter >5 days in settings with high infection rates only were recognized as recommended by 53% and 31%, respectively. Central venous catheters dressings in general are known to be changed on indication and at least once weekly by 43%, and 26% recognized that both polyurethane and gauze dressings are recommended. Only 14% checked 2% aqueous chlorhexidine as the recommended disinfection solution; 30% knew antibiotic ointments are not recommended because they trigger resistance. Replacing administration sets within 24 hrs after administering lipid emulsions was recognized as recommended by 90%, but only 26% knew sets should be replaced every 96 hrs when administering neither lipid emulsions nor blood products. Professional seniority and number of ICU beds showed to be independently associated with better test scores. CONCLUSIONS: Opportunities exist to optimize knowledge of central venous catheter-related infection prevention among European ICU nurses. We recommend including central venous catheter-related infection prevention guidelines in educational curricula and continuing refresher education programs.

Epidemiology and outcome of nosocomial bloodstream infection in elderly critically ill patients: a comparison between middle-aged, old, and very old patients.

BACKGROUND: We investigated the epidemiology of nosocomial bloodstream infection in elderly intensive care unit (ICU) patients. METHODS: In a single-center, historical cohort study (1992-2006), we compared middle-aged (45-64 years; n = 524), old(65-74 years; n = 326), and very old ICU patients (> 75 years; n = 134) who developed a nosocomial bloodstream infection during their ICU stay. RESULTS: Although the total number of ICU admissions (patients aged > or = 45 years) decreased by approximately 10%, the number of very old patients increased by 33% between the periods 1992-1996 and 2002-2006. The prevalence of bloodstream infection (per 1,000 ICU admissions) increased significantly over time among old (p = 0.001) and very old patients (p = 0.002), but not among middle-aged patients (p = 0.232). Yet, this trend could not be confirmed with the incidence data expressed per 1,000 patient days (p > 0.05). Among patients with bloodstream infection, the proportion of very old patients increased significantly with time from 7.2% (1992-1996) to 13.5% (1997-2001) and 17.4% (2002-2006) (p <0.001). The incidence of bloodstream infection (per 1000 patient days) decreased with age: 8.4 per thousand in middle-aged, 5.5 per thousand in old, and 4.6 per thousand in very old patients (p < 0.001). Mortality rates increased with age: 42.9%, 49.1%, and 56.0% for middle-aged, old, and very old patients, respectively (p = 0.015). Regression analysis revealed that the adjusted relationship with mortality was borderline significant for old age (hazard ratio, 1.2; 95% confidence interval, 1.0 -1.5) and significant for very old age (hazard ratio,1.8; 95% confidence interval, 1.4 -2.4). CONCLUSION: Over the past 15 years, an increasing number of elderly patients were admitted to our ICU. The incidence of nosocomial bloodstream infection is lower among very old ICU patients when compared to middle-aged and old patients. Yet, the adverse impact of this infection is higher in very old patients.

Adherence to guidelines for the management of donors after brain death.

PURPOSE: Guideline adherence for the management of a donor after brain death (DBD) is largely unknown. This study aimed to perform an importance-performance analysis of prioritized key interventions (KIs) by linking guideline adherence rates to expert consensus ratings for the management of a DBD. MATERIALS AND METHODS: This observational, cross-sectional multicenter study was performed in 21 Belgian ICUs. A retrospective review of patient records of adult utilized DBDs between 2013 and 2016 used 67 KIs to describe adherence to guidelines. RESULTS: A total of 296 patients were included. Thirty-five of 67 KIs had a high level of adherence congruent to a high expert panel rating of importance. Nineteen of 67 KIs had a low level of adherence in spite of a high level of importance according to expert consensus. However, inadequate documentation proved an important issue, hampering true guideline adherence assessment. Adherence ranged between 3 and 100% for single KI items and on average, patients received 72% of the integrated expert panel recommended care set. CONCLUSIONS: Guideline adherence to an expert panel predefined care set in DBD donor management proved moderate leaving substantial room for improvement. An importance-performance analysis can be used to improve implementation and documentation of guidelines.

Biomarkers in patients admitted to the emergency department after exposure to acrylonitrile in a major railway incident involving bulk chemical material.

BACKGROUND: A railway incident with victims of exposure to the cyanogenic substance acrylonitrile (ACN). AIMS: We retrospectively (i)built an inventory of the clinical characteristics of individuals admitted to surrounding emergency departments (ED's) and (ii)studied the correlation between N-2-cyanoethylvaline (CEV), a biomarker used in a population study for evaluating exposure to ACN, with lactate and thiocyanate (SCN), biomarkers determined during emergency care. RESULTS: 438 patients from 11 ED's were included and presented with known symptoms of ACN poisoning but also with concern about the risks. A comparison of CEV with lactate or SCN was possible in 108 and 73 patients respectively. CEV was very high in a critically ill patient with a high lactate. There was no correlation with CEV in the patients with normal or slightly elevated lactate concentrations. A correlation of CEV with SCN was only observed in smokers. LIMITATIONS: First there is a lack of data in some clinical files concerning the time and duration of exposure and the smoking-status. A second limitation is that blood samples for biomarkers were not taken systematically in all patients, which may have induced bias. A third limitation is that blood sampling was possibly done outside the correct time window related to the delayed toxicity of ACN. Finally the number of severely-intoxicated patients was low and ACN exposure may not have taken place e.g. in individuals consulting with psychological symptoms. These aspects may have contributed to the below detection limits' analyses of biomarkers. CONCLUSIONS: CEV was markedly elevated in a severely-intoxicated patient with high lactate, a sensitive marker for CN intoxication. We found no correlation of CEV with normal or slightly elevated lactate concentrations but clinicians should consider the possibility of subsequent rises due to the delay in ACN toxicity. CEV correlated with SCN in smokers, which may be explained by ACN in tobacco smoke and deserves further exploration. Further studies are necessary to evaluate the correlation between biomarkers in acute chemical exposures to ACN and these should be carried out prospectively using a preplanned template.

A randomized, blinded, multicenter trial of lipid-associated amphotericin B alone versus in combination with an antibody-based inhibitor of heat shock protein 90 in patients with invasive candidiasis.

BACKGROUND: Mycograb (NeuTec Pharma) is a human recombinant monoclonal antibody against heat shock protein 90 that, in laboratory studies, was revealed to have synergy with amphotericin B against a broad spectrum of Candida species. METHODS: A double-blind, randomized study was conducted to determine whether lipid-associated amphotericin B plus Mycograb was superior to amphotericin B plus placebo in patients with culture-confirmed invasive candidiasis. Patients received a lipid-associated formulation of amphotericin B plus a 5-day course of Mycograb or placebo, having been stratified on the basis of Candida species (Candida albicans vs. non-albicans species of Candida). Inclusion criteria included clinical evidence of active infection at trial entry plus growth of Candida species on culture of a specimen from a clinically significant site within 3 days after initiation of study treatment. The primary efficacy variable was overall response to treatment (clinical and mycological resolution) by day 10. RESULTS: Of the 139 patients enrolled from Europe and the United States, 117 were included in the modified intention-to-treat population. A complete overall response by day 10 was obtained for 29 (48%) of 61 patients in the amphotericin B group, compared with 47 (84%) of 56 patients in the Mycograb combination therapy group (odds ratio [OR], 5.8; 95% confidence interval [CI], 2.41-13.79; P<.001). The following efficacy criteria were also met: clinical response (52% vs. 86%; OR, 5.4; 95% CI, 2.21-13.39; P<.001), mycological response (54% vs. 89%; OR, 7.1; 95% CI, 2.64-18.94; P<.001), Candida-attributable mortality (18% vs. 4%; OR, 0.2; 95% CI, 0.04-0.80; P = .025), and rate of culture-confirmed clearance of the infection (hazard ratio, 2.3; 95% CI, 1.4-3.8; P = .001). Mycograb was well tolerated. CONCLUSIONS: Mycograb plus lipid-associated amphotericin B produced significant clinical and culture-confirmed improvement in outcome for patients with invasive candidiasis.

Outcome in bacteremia associated with nosocomial pneumonia and the impact of pathogen prediction by tracheal surveillance cultures.

OBJECTIVE: To assess whether pathogen prediction in bacteremia associated with nosocomial pneumonia (NP) by tracheal surveillance cultures improves adequacy of early antibiotic therapy and impacts mortality. DESIGN AND SETTING: A retrospective observational study of a prospectively gathered cohort. This cohort included all adult patients admitted to the ICU of a tertiary care hospital from 1992 through 2001 and who developed bacteremia associated with NP. MEASUREMENTS AND MAIN RESULTS: 128 episodes of bacteremia associated with NP were identified. In 110 episodes a tracheal surveillance culture 48-96h prior to bacteremia was available: this culture predicted the pathogen in 67 episodes (61%). Overall rates of appropriate empiric antibiotic therapy within 24 and 48h were 62 and 87%, respectively. Pathogen prediction was associated with a significantly higher rate of appropriate antibiotic therapy within 24h (71 vs 45%; p=0.01), but not within 48h (91 vs 82%; p=0.15). Crude in-hospital mortality was 50%. Pathogen prediction was associated with increased survival in univariate (OR 0.43; CI 0.19-0.93; p=0.04) and multivariate analysis (OR 0.32; CI 0.12-0.82; p=0.02). Multivariate analysis further identified age (OR 1.04; CI 1.01-1.07; p=0.02), increasing APACHEII score (OR 1.08; CI 1.02-1.15; p=0.01), and methicillin-resistant Staphylococcus aureus (OR 5.90; CI 1.36-25.36; p=0.01) and Pseudomonas aeruginosa (OR 3.30; CI 1.04-10.4; p=0.04) as independent risk factors for mortality. CONCLUSION: Pathogen prediction in bacteremia associated with NP by tracheal surveillance cultures is associated with a higher rate of adequate empiric antibiotic therapy within 24[Symbol: see text]h and with increased survival.

Outcome in severely ill patients with hematological malignancies who received intravenous chemotherapy in the intensive care unit.

OBJECTIVE: To assess the outcome in severely ill patients with hematological malignancies who receive intravenous chemotherapy in an intensive care unit (ICU) for a life-threatening malignancy-related complication. DESIGN: Retrospective observational study of prospectively collected data. PATIENTS: All 37 critically ill patients with hematological malignancies who received intravenous chemotherapy in the ICU between January 1997 and March 2005 (mean age 46+/-19 years; mean APACHE II 23+/-7). MEASUREMENTS AND RESULTS: Thirty-seven (69%) patients received chemotherapy because of extensive disease with organ involvement (54%), extensive disease without organ involvement (19%), severe disseminated intravascular coagulation (11%), and other reasons (16%). In 41% there was concomitant infection when chemotherapy was initiated, in 86% a high-grade malignancy, and 30% relapsing disease. Twenty-three (62%) patients received mechanical ventilation at the moment of or soon after initiation of chemotherapy for a median duration of 5 days (1-67), and 24% underwent renal replacement therapy during ICU stay. Only ventilation was associated with in-hospital mortality (odds ratio 9.3). ICU, in-hospital, and 6-month mortality rates in nonventilated vs. ventilated patients were 7% and 48%, 14% and 61%, and 54% and 74%, respectively. CONCLUSIONS: Starting chemotherapy in the ICU for a life-threatening malignancy related complication can be lifesaving even when infection or organ failure is present.

Aspergillosis in the ICU - The new 21st century problem?

Invasive pulmonary aspergillosis (IPA) is a serious opportunistic infection mainly affecting seriously immunocompromised patients. The major risk factor is prolonged granulocytopenia. Most literature on the epidemiology and clinical impact of Aspergillus spp. infections concern patients with hematological malignancies, cancer, stem cell transplantation and solid organ transplant patients. However, evidence from recent literature indicates that Aspergillus spp. may cause invasive disease in other categories of patients without apparent immunodeficiency, including patients in intensive care units (ICUs). Clinical diagnosis of IPA in non-immunocompromised patients is difficult. Standardized diagnostic definitions, developed by the European Organization for the Research and Treatment of Cancer/Mycosis Study Group for research purposes in patients with cancer and in recipients of haematopoietic stem cell transplants, are not feasible for patient categories with an intermediate to low probability for acquiring IPA. In routine clinical practice, most Aspergillus isolates from non-sterile body sites do not represent disease. Invasive diagnostic procedures are often not feasible in patients with severe respiratory insufficiency and critical illness. The presence of systemic risk factors, or underlying predisposing lung disease or general debilitation, may enhance the clinical relevance of a positive culture. The finding of an Aspergillus spp. positive respiratory specimen in an ICU patient should not be discarded; pre-emptive antifungal treatment should be considered, while attempting to substantiate the diagnosis.

Impact of computerized physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial.

INTRODUCTION: Medication errors in the intensive care unit (ICU) are frequent and lead to attributable patient morbidity and mortality, increased length of ICU stay and substantial extra costs. We investigated if the introduction of a computerized ICU system (Centricity Critical Care Clinisoft, GE Healthcare) reduced the incidence and severity of medication prescription errors (MPEs). METHODS: A prospective trial was conducted in a paper-based unit (PB-U) versus a computerized unit (C-U) in a 22-bed ICU of a tertiary university hospital. Every medication order and medication prescription error was validated by a clinical pharmacist. The registration of different classes of MPE was done according to the National Coordinating Council for Medication Error Reporting and Prevention guidelines. An independent panel evaluated the severity of MPEs. We identified three groups: minor MPEs (no potential to cause harm); intercepted MPEs (potential to cause harm but intercepted on time); and serious MPEs (non-intercepted potential adverse drug events (ADE) or ADEs, being MPEs with potential to cause, or actually causing, patient harm). RESULTS: The C-U and the PB-U each contained 80 patient-days, and a total of 2,510 medication prescriptions were evaluated. The clinical pharmacist identified 375 MPEs. The incidence of MPEs was significantly lower in the C-U compared with the PB-U (44/1286 (3.4%) versus 331/1224 (27.0%); P < 0.001). There were significantly less minor MPEs in the C-U than in the PB-U (9 versus 225; P < 0.001). Intercepted MPEs were also lower in the C-U (12 versus 46; P < 0.001), as well as the non-intercepted potential ADEs (21 versus 48; P < 0.001). There was also a reduction of ADEs (2 in the C-U versus 12 in the PB-U; P < 0.01). No fatal errors occurred. The most frequent drug classes involved were cardiovascular medication and antibiotics in both groups. Patients with renal failure experienced less dosing errors in the C-U versus the PB-U (12 versus 35 serious MPEs; P < 0.001). CONCLUSION: The ICU computerization, including the medication order entry, resulted in a significant decrease in the occurrence and severity of medication errors in the ICU.

Clinical relevance of Aspergillus isolation from respiratory tract samples in critically ill patients.

INTRODUCTION: The diagnosis of invasive pulmonary aspergillosis, according to the criteria as defined by the European Organisation for the Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG), is difficult to establish in critically ill patients. The aim of this study is to address the clinical significance of isolation of Aspergillus spp. from lower respiratory tract samples in critically ill patients on the basis of medical and radiological files using an adapted diagnostic algorithm to discriminate proven and probable invasive pulmonary aspergillosis from Aspergillus colonisation. METHODS: Using a historical cohort (January 1997 to December 2003), all critically ill patients with respiratory tract samples positive for Aspergillus were studied. In comparison to the EORTC/MSG criteria, a different appreciation was given to radiological features and microbiological data, including semiquantitative cultures and direct microscopic examination of broncho-alveolar lavage samples. RESULTS: Over a 7 year period, 172 patients were identified with a positive culture. Of these, 83 patients were classified as invasive aspergillosis. In 50 of these patients (60%), no high risk predisposing conditions (neutropenia, hematologic cancer and stem cell or bone marrow transplantation) were found. Typical radiological imaging (halo and air-crescent sign) occurred in only 5% of patients. In 26 patients, histological examination either by ante-mortem lung biopsy (n = 10) or necropsy (n = 16) was performed, allowing a rough estimation of the predictive value of the diagnostic algorithm. In all patients with histology, all cases of clinical probable pulmonary aspergillosis were confirmed (n = 17). Conversely, all cases classified as colonisation had negative histology (n = 9). CONCLUSION: A respiratory tract sample positive for Aspergillus spp. in the critically ill should always prompt further diagnostic assessment, even in the absence of the typical hematological and immunological host risk factors. In a minority of patients, the value of the clinical diagnostic algorithm was confirmed by histological findings, supporting its predictive value. The proposed diagnostic algorithm needs prospective validation.

The Value of E-Learning for the Prevention of Healthcare-Associated Infections.

BACKGROUND Healthcare workers (HCWs) lack familiarity with evidence-based guidelines for the prevention of healthcare-associated infections (HAIs). There is good evidence that effective educational interventions help to facilitate guideline implementation, so we investigated whether e-learning could enhance HCW knowledge of HAI prevention guidelines. METHODS We developed an electronic course (e-course) and tested its usability and content validity. An international sample of voluntary learners submitted to a pretest (T0) that determined their baseline knowledge of guidelines, and they subsequently studied the e-course. Immediately after studying the course, posttest 1 (T1) assessed the immediate learning effect. After 3 months, during which participants had no access to the course, a second posttest (T2) evaluated the residual learning effect. RESULTS A total of 3,587 HCWs representing 79 nationalities enrolled: 2,590 HCWs (72%) completed T0; 1,410 HCWs (39%) completed T1; and 1,011 HCWs (28%) completed T2. The median study time was 193 minutes (interquartile range [IQR], 96-306 minutes) The median scores were 52% (IQR, 44%-62%) for T0, 80% (IQR, 68%-88%) for T1, and 74% (IQR, 64%-84%) for T2. The immediate learning effect (T0 vs T1) was +24% (IQR, 12%-34%; P300 minutes yielded the greatest residual effect (24%). CONCLUSIONS Moderate time invested in e-learning yielded significant immediate and residual learning effects. Decision makers could consider promoting e-learning as a supporting tool in HAI prevention. Infect Control Hosp Epidemiol 2016;37:1052-1059.

Recommendations for further improvement of the deceased organ donation process in Belgium.

Belgium has achieved high deceased organ donation rates but according to the medical record data in the Donor Action database, deceased potential donors are still missed along the pathway. Between 2010 and 2014, 12.9 ± 3.3% of the potential donors after brain death (DBD) and 24.6 ± 1.8% of the potential donors after circulatory (DCD) death were not identified. Conversion rates of 41.7 ± 2.1% for DBD and 7.9 ± 0.9% for DCD indicate room for further improvement. We identify and discuss different issues in the monitoring of donation activities, practices and outcomes; donor pool; legislation on deceased organ donation; registration; financial reimbursement; educational and training programs; donor detection and practice clinical guidance. The overall aim of this position paper, elaborated by a Belgian expert panel, is to provide recommendations for further improvement of the deceased organ donation process up to organ procurement in Belgium.

Clinical and economic outcomes in critically ill patients with nosocomial catheter-related bloodstream infections.

BACKGROUND: Central venous catheters are universally used during the treatment of critically ill patients. Their use, however, is associated with a substantial infection risk, potentially leading to increased mortality and costs. We evaluate clinical and economic outcomes associated with nosocomial central venous catheter-related bloodstream infection (CR-BSI) in intensive care unit (ICU) patients. METHODS: A retrospective (1992-2002), pairwise-matched (ratio of case patients to control subjects, 1:2 or 1:1), risk-adjusted cohort study was performed at a 54-bed general ICU at a university hospital. ICU patients with microbiologically documented CR-BSI (n = 176) were matched with control subjects (n = 315) on the basis of disease severity, diagnostic category, and length of ICU stay (equivalent or longer) before the onset of CR-BSI in the index case patient. Clinical outcome was principally evaluated by in-hospital mortality. Economic outcome was evaluated on the basis of duration of mechanical ventilation, length of ICU and hospital stays, and total hospital costs, as derived from the patient's hospital invoices. RESULTS: The attributable mortality rate for CR-BSI was estimated to be 1.8% (95% confidence interval, -6.4% to 10.0%); in-hospital mortality rates for patients with CR-BSI and matched control subjects were 27.8% and 26.0%, respectively. CR-BSI was associated with significant excesses in duration of mechanical ventilation, duration of ICU and hospital stays, and a significant increase in total hospital cost. Linear regression analysis with adjustment for duration of hospitalization and clinical covariates, revealed that CR-BSI is independently associated with higher costs. CONCLUSIONS: In ICU patients, CR-BSI does not result in increased mortality. It is, however, associated with a significant economic burden, emphasizing the importance of continuous efforts in prevention.

Colonization status and appropriate antibiotic therapy for nosocomial bacteremia caused by antibiotic-resistant gram-negative bacteria in an intensive care unit.

OBJECTIVE: Timely initiation of antibiotic therapy is crucial for severe infection. Appropriate antibiotic therapy is often delayed for nosocomial infections caused by antibiotic-resistant bacteria. The relationship between knowledge of colonization caused by antibiotic-resistant gram-negative bacteria (ABR-GNB) and rate of appropriate initial antibiotic therapy for subsequent bacteremia was evaluated. DESIGN: Retrospective cohort study. SETTING: Fifty-four-bed intensive care unit (ICU) of a university hospital. In this unit, colonization surveillance is performed through routine site-specific surveillance cultures (urine, mouth, trachea, and anus). Additional cultures are performed when presumed clinically relevant. PATIENTS: ICU patients with nosocomial bacteremia caused by ABR-GNB. RESULTS: Infectious and microbiological characteristics and rates of appropriate antibiotic therapy were compared between patients with and without colonization prior to bacteremia. Prior colonization was defined as the presence (detected > or = 2 days before the onset of bacteremia) of the same ABR-GNB in colonization and subsequent blood cultures. During the study period, 157 episodes of bacteremia caused by ABR-GNB were suitable for evaluation. One hundred seventeen episodes of bacteremia (74.5%) were preceded by colonization. Appropriate empiric antibiotic therapy (started within 24 hours) was administered for 74.4% of these episodes versus 55.0% of the episodes that occurred without prior colonization. Appropriate therapy was administered within 48 hours for all episodes preceded by colonization versus 90.0% of episodes without prior colonization. CONCLUSION: Knowledge of colonization status prior to infection is associated with higher rates of appropriate therapy for patients with bacteremia caused by ABR-GNB.

Influence of matching for exposure time on estimates of attributable mortality caused by nosocomial bacteremia in critically ill patients.

OBJECTIVE: To evaluate the influence of matching on exposure time on estimates of attributable mortality of nosocomial bacteremia as assessed by matched cohort studies. DESIGN: Two retrospective, pairwise-matched (1:2) cohort studies. SETTING: A 54-bed intensive care unit (ICU) in a university hospital. PATIENTS: Patients with nosocomial Escherichia coli bacteremia (n = 68) and control-patients without nosocomial bacteremia (n = 136 for each matched cohort study). INTERVENTION: In both matched cohort studies, the same set of bacteremic patients was matched with control-patients using the APACHE II system. In the first study, control-patients were required to have an ICU stay at least as long as the respective bacteremic patient prior to onset of bacteremia (matching on exposure time). In the second study, control-patients were required to have an ICU stay shorter than the stay prior to the development of bacteremia in the respective bacteremic patient (no matching on exposure time). RESULTS: For bacteremic patients, the mean ICU stay before onset of the bacteremia was 9 days (median, 6 days). In the first matched cohort study, hospital mortality was not different between bacteremic patients and control-patients (44.1% vs 43.4%; P = .999). In the second study, mortality of bacteremic patients and control-patients was also not different (44.1% vs 47.8%; P = .657). Mortality rates between control groups were not different (43.4% vs 47.8%; P = .543). CONCLUSION: Matching or not matching on exposure time did not alter the estimate of attributable mortality for ICU patients with E. coli bacteremia.