Stewardship Intervention to Optimize Central Venous Catheter Utilization in Critically Ill Children

Abstract

Introduction: We aimed to describe utilization and indication(s) for long-term central venous catheters (CVCs) in a pediatric intensive care unit (PICU) and identify potential strategies to decrease CVC utilization. Methods: We conducted a single-center prospective quality improvement initiative at a 30-bed PICU in a large, freestanding, academic children’s hospital. We created an electronic report to identify patients with an indwelling CVC for 7 days and older (defined as long term). We discussed the ongoing need for each long-term CVC with PICU clinicians at weekly interdisciplinary structured “CVC stewardship rounds.” We then made recommendations around expedited removal of CVCs. We conducted multiple Plan-Do-Study-Act cycles to categorize CVC indications, identify modifiable factors, and educate PICU clinicians. We hypothesized that CVC stewardship rounds would decrease long-term CVC utilization in our PICU. Results: From October 2016 to September 2017, 607 long-term CVCs were eligible for the stewardship intervention. Compared to the preintervention period, we recorded a significant increase in peripherally inserted central catheters and a decrease in nontunneled CVCs ( P < 0.001). Most patients had single- or double-lumen CVCs in both the preintervention and intervention periods (86% and 91%, respectively). The utilization of overall long-term CVC devices, and those with modifiable indications, decreased during the intervention period. Conclusions: A single-center QI intervention focused on PICU CVC stewardship was associated with a decrease in CVC utilization.

Key process and outcome indicators on quality and safety of care for critically ill pediatric patients according to international standard organization protocols: a four-year follow-up study

“…The main reasons for admission were: respiratory failure (21.2%), postoperative care (20.9%), neurologic failure (12.7%), trauma (11.1%), Status Epilepticus (10.8%), sepsis (7.4%), cardiac arrest-Return of Spontaneous Circulation (ROSC) (6.3%), metabolic diseases (3.4%), other diseases (3.7%) and cardiac diseases (2.4%). The median PRISM III-24 score was 9 (6)(7)(8)(9)(10)(11)(12)(13). More than half (51.9%) suffered from complex chronic conditions.…”

“…The last decade an effort has started worldwide to keep their rate as low as possible, and their control is considered not only a safety and a quality indicator, but a reimbursement one as well [57]. DUR is inseparably related to CVC infection rates and reduction in CVC use is among the first bundles of care to be taken under their control [9,58]. DUR in our occasion was 0.89, very high compared to international ICU values of around 0.70 [59] and PICU values which are even lower, about 0.50 [60,61], and are another confirming factor regarding high illness severity in our population.…”

“…The concept is to define the process you want to optimize by (1) measuring how it currently performs, (2) analyzing how it can be optimized, (3) deciding how to improve it, (4) implementing the new process and creating a plan to measure it, and (5) reviewing it again in future in a continually improvement effort. Small steps are followed initially to reach significant future results [7][8][9].…”