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.

Humidicare - an implementation study of a novel HME safety device designed to prevent ventilator circuit occlusion due to inadvertent dual humidification.

Mechanical ventilation bypasses the protective mechanisms of the upper respiratory tract which are designed to heat and humidify inspired air to 37 °C and 44 mg H2O/L respectively. Artificial humidification systems are therefore incorporated into ventilation circuits to condition cold and dry medical gases before they reach the lower respiratory tract and cause patient harm. Commonly either a heat and moisture exchanger (HME) or a heated humidifier (HH) are utilised for this purpose, however the inadvertent simultaneous use of both devices within the same circuit can cause critical airway occlusion within 24 h. The Humidicare HME (Medovate, Cambridge, UK) is a safety engineered temperature-dependent warning system designed to activate when inadvertently placed into a warm circuit containing a HH. This study aimed to determine the efficacy of the Humidicare HME warning system in simulated clinical conditions. The threshold temperature for activation of the device was determined in a digital incubator, and the device was tested for efficacy with a HH present or absent from the breathing circuit. The device performed reliably and activated rapidly when required across all simulations. The Humidicare HME warning system is a simple and unobtrusive device which can effectively alert the operator to the error of dual humidification.

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.

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.

Chlorhexidine to Maintain Cleanliness of Restroom Door Handles.

Restroom internal door handles have the potential to become contaminated by pathogenic bacteria, particularly because frequent breakdowns occur in hand hygiene. Cleaning these door handles periodically could reduce this cross-contamination risk. The sustained effect following cleaning with chlorhexidine could be beneficial in restroom facilities as cleaning episodes are of necessity at time intervals. The cleaning efficacies and residual effects of Sani Cloth CHG 2% wipes were investigated in a double-blinded randomized crossover controlled trial in a school setting. No significant difference occurred in initial cleaning efficacy; however, following a six-hour period of use by pupils of the restroom facilities, the internal door handles wiped with Sani-Cloth CHG 2% wipes were significantly less contaminated than those with the control wipe (14% v. 32%, p = .02). Cleaning with Sani-Cloth CHG 2% wipes demonstrated significant improvements in the continuous cleanliness of restroom door handles during use with this simple and inexpensive technique.

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.

Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review.

IMPORTANCE: Small trials suggest that postoperative outcomes may be improved by the use of cardiac output monitoring to guide administration of intravenous fluid and inotropic drugs as part of a hemodynamic therapy algorithm. OBJECTIVE: To evaluate the clinical effectiveness of a perioperative, cardiac output-guided hemodynamic therapy algorithm. DESIGN, SETTING, AND PARTICIPANTS: OPTIMISE was a pragmatic, multicenter, randomized, observer-blinded trial of 734 high-risk patients aged 50 years or older undergoing major gastrointestinal surgery at 17 acute care hospitals in the United Kingdom. An updated systematic review and meta-analysis were also conducted including randomized trials published from 1966 to February 2014. INTERVENTIONS: Patients were randomly assigned to a cardiac output-guided hemodynamic therapy algorithm for intravenous fluid and inotrope (dopexamine) infusion during and 6 hours following surgery (n=368) or to usual care (n=366). MAIN OUTCOMES AND MEASURES: The primary outcome was a composite of predefined 30-day moderate or major complications and mortality. Secondary outcomes were morbidity on day 7; infection, critical care-free days, and all-cause mortality at 30 days; all-cause mortality at 180 days; and length of hospital stay. RESULTS: Baseline patient characteristics, clinical care, and volumes of intravenous fluid were similar between groups. Care was nonadherent to the allocated treatment for less than 10% of patients in each group. The primary outcome occurred in 36.6% of intervention and 43.4% of usual care participants (relative risk [RR], 0.84 [95% CI, 0.71-1.01]; absolute risk reduction, 6.8% [95% CI, -0.3% to 13.9%]; P = .07). There was no significant difference between groups for any secondary outcomes. Five intervention patients (1.4%) experienced cardiovascular serious adverse events within 24 hours compared with none in the usual care group. Findings of the meta-analysis of 38 trials, including data from this study, suggest that the intervention is associated with fewer complications (intervention, 488/1548 [31.5%] vs control, 614/1476 [41.6%]; RR, 0.77 [95% CI, 0.71-0.83]) and a nonsignificant reduction in hospital, 28-day, or 30-day mortality (intervention, 159/3215 deaths [4.9%] vs control, 206/3160 deaths [6.5%]; RR, 0.82 [95% CI, 0.67-1.01]) and mortality at longest follow-up (intervention, 267/3215 deaths [8.3%] vs control, 327/3160 deaths [10.3%]; RR, 0.86 [95% CI, 0.74-1.00]). CONCLUSIONS AND RELEVANCE: In a randomized trial of high-risk patients undergoing major gastrointestinal surgery, use of a cardiac output-guided hemodynamic therapy algorithm compared with usual care did not reduce a composite outcome of complications and 30-day mortality. However, inclusion of these data in an updated meta-analysis indicates that the intervention was associated with a reduction in complication rates. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN04386758.

Chlorhexidine to maintain cleanliness of laryngoscope handles: an audit and laboratory study.

CONTEXT: Laryngoscope handles are a potential vector for infection transmission and require adequate decontamination. OBJECTIVE: To establish an effective cleaning regimen for laryngoscope handles. DESIGN: Three laboratory studies and an audit cycle. SETTING: The Queen Elizabeth Hospital, King's Lynn, UK. MATERIALS: Twenty Heine laryngoscope handles. INTERVENTIONS: Twenty laryngoscope handles were contaminated with microbial broth and then disinfected with chemical wipes, either using Sani-Cloth CHG 2% (chlorhexidine 2%/alcohol 70%) or Tuffie 5 wipes. This was repeated with an interval of 24 h between cleaning and contamination. A further experiment repeatedly re-contaminated the handles at varying time intervals after cleaning. The audit established the current level of contamination of laryngoscope handles within the hospital, and this was repeated following a change in cleaning protocol. MAIN OUTCOME MEASURES: Bacterial growth on agar plates was counted as the number of colony forming units. RESULTS: Both Sani-Cloth CHG 2% and Tuffie 5 wipes were effective against microorganisms, including methicillin-resistant Staphylococcus aureus, immediately following wiping (P = 0.002). However, the chlorhexidine wipes also had a residual effect such that after wiping, the handle remained sterile following further contamination and this effect persisted for 24 h. Audit following the introduction of this practice showed significant improvements in the incidence and extent of contamination compared with the previous disinfection practice (P<0.002). CONCLUSION: Decontamination with Sani-Cloth CHG 2% wipes confers additional advantages over routine autoclaving or handle disposal, due to a residual effect. Autoclaving handles may be desirable on a scheduled basis and if Clostridium difficile is encountered.

The incidence of ventilator-associated pneumonia using the PneuX System with or without elective endotracheal tube exchange: A pilot study.

BACKGROUND: The PneuX System is a novel endotracheal tube and tracheal seal monitor, which has been designed to minimise the aspiration of oropharyngeal secretions. We aimed to determine the incidence of ventilator-associated pneumonia (VAP) in patients who were intubated with the PneuX System and to establish whether intermittent subglottic secretion drainage could be performed reliably and safely using the PneuX System. FINDINGS: In this retrospective observational study, data was collected from 53 sequential patients. Nine (17%) patients were initially intubated with the PneuX System and 44 (83%) patients underwent elective exchange to the PneuX System. There were no episodes of VAP while the PneuX System was in situ. On an intention to treat basis, the incidence VAP was 1.8%. There were no complications from, or failure of, subglottic secretion drainage during the study. CONCLUSIONS: Our study demonstrates that a low incidence of VAP is possible using the PneuX System. Our study also demonstrates that elective exchange and intermittent subglottic secretion drainage can be performed reliably and safely using the PneuX System.

The pressure exerted on the tracheal wall by two endotracheal tube cuffs: A prospective observational bench-top, clinical and radiological study.

BACKGROUND: The Lotrach endotracheal tube has a unique low-volume, low-pressure (LVLP) cuff, which has been designed to prevent pressure injury to the tracheal wall. We aimed to estimate the pressure exerted on the tracheal wall by the LVLP cuff and a conventional cuff in a bench-top, clinical and radiological study. METHOD: In the bench-top study, a model trachea was intubated with the LVLP cuff and the conventional cuff. The cuff pressure was controlled using a constant pressure device. We assessed the pressure exerted on the tracheal wall by measuring the ability of the cuffs to support a column of water using a standard protocol. In the clinical study, we tested the ability of both cuffs to prevent air leak during a staged recruitment manoeuvre. In the radiological study, we recorded the degree of anatomical distortion of the trachea from both cuffs in the antero-posterior (AP) and transverse tracheal diameters. We performed statistical analysis using non-inferiority tests. RESULTS: In the bench-top study, the LVLP cuff achieved a plateau at a mean height of 25.2 cmH2O (SD 0.34). In contrast, the conventional cuff failed to maintain any water above the cuff and a plateau could not be measured. In the clinical study, the mean pressure at which air leak occurred was 30.0 +/- 0.8 cmH2O (SD 3.8) using the LVLP cuff and 32.4 +/- 0.7 cmH2O (SD 3.0) using the conventional cuff. In the radiological study, the mean degree of anatomical distortion of the trachea in AP and transverse tracheal diameter was 2.9 +/- 2.2 mm (SD 2.1) and 1.8 +/- 1.4 mm (SD 1.4) using the LVLP cuff and 4.4 +/- 1.3 mm (SD 1.4) and 2.6 +/- 1.5 mm (SD 1.6) using the conventional cuff. CONCLUSIONS: The bench-top and clinical studies both demonstrated that the LVLP cuff exerted approximately 30 cmH2O of pressure on the tracheal wall. These results are supported by our radiological study. We conclude that the LVLP cuff exerts an acceptable amount of pressure on the tracheal wall when it is operated at the recommended intracuff pressure.

The impact of offering a relatives' clinic on the satisfaction of the next-of-kin of critical care patients-a prospective time-interrupted trial.

BACKGROUND: Families have been shown to be dissatisfied with the frequency of doctor communication in the Critical Care setting. Discussions with families are often conducted in an ad-hoc fashion. We hypothesised that the offer of a formal daily weekday clinic for the relatives of Critical Care patients would increase the relatives' satisfaction. METHODS: All patients admitted to a 12-bedded Critical Care Unit over a 6-month period in a 480-bed hospital in the East of England were included in the study. The design was a time-interrupted prospective trial assessing the impact of an offered relatives' clinic on the satisfaction of the next-of-kin. Satisfaction was assessed 4 weeks following discharge from the Critical Care Unit by mail survey using the validated Critical Care Family Satisfaction Survey (1-5 scoring scale). RESULTS: Three hundred twenty-one patients met inclusion criteria. Survey return rate was 46%. The control and intervention groups were similar in size and demographics. Mean satisfaction of the control group was 4.50, and that of the intervention group was 4.55 (p=0.35). CONCLUSION: Offering a relatives' clinic does not significantly improve the satisfaction of the next-of-kin in this setting. Other means of improving satisfaction have been highlighted as a result of the study.

A low-volume, low-pressure tracheal tube cuff reduces pulmonary aspiration.

OBJECTIVE: Leakage of fluid from the subglottic space to the lungs occurs along the longitudinal folds within the wall of an inflated high-volume, low-pressure (HVLP) cuff. The low-volume, low-pressure (LVLP) cuff does not have these folds yet allows for convenient and reliable control of tracheal wall pressure. Pulmonary aspiration during anesthesia has been linked with postoperative pneumonia and during critical illness causes ventilator-associated pneumonia. DESIGN: Prospective, blinded, randomized controlled trial; prospective observational study; and benchtop models. SETTING: Department of Anaesthesia and Critical Care, Queen Elizabeth Hospital. PATIENTS: Anesthetized patients (n=38) and critically ill patients with either an LVLP or HVLP cuffed tracheostomy tube following swallow assessments (n=67). INTERVENTIONS: The LVLP cuff was compared with HVLP cuffs for leakage of dye placed in the subglottic space to the tracheobronchial tree in a rigid tracheal model and a benchtop pig trachea model (before and after a standardized cuff movement). MEASUREMENTS AND MAIN RESULTS: In the rigid tracheal model, the incidence of leakage was 0% in the LVLP group and 100% in the HVLP group (p<.01). Dye leakage in the pig tracheal model with HVLP cuffs was 44% before tube movement, increasing to 79% afterward. The LVLP cuff did not leak in the pig tracheal model. Dye leakage in anesthetized patients was 0% before movement and 5% after in the LVLP group and in the HVLP group 22% increasing to 67% after movement (p<.001). Forty-nine percent of swallow assessments were scored as failed in the critical care patients with HVLP tracheostomy tube cuffs, and there were no episodes of aspiration following swallow assessment in the LVLP group (p<.05). CONCLUSIONS: The LVLP cuffed tracheal and tracheostomy tubes reduced pulmonary aspiration in the benchtop models and in anesthetized and critically ill patients. The single failure of the LVLP cuff in the anesthesia group was probably associated with accidental endobronchial intubation following tube movement.