Acutely ill hematology/oncology patients with central-line associated bloodstream infections and the impact of timing of catheter removal on outcomes.

BACKGROUND: Hematology/oncology patients are at risk for central line-associated bloodstream infections (CLABSI). The purpose was to determine if infection-related mortality, persistent bacteremia, and recurrent bacteremia were decreased with early central venous catheter (CVC) removal. METHODS: A case-matched, retrospective cohort study was conducted comparing patients with early catheter removal (≤12 hours) to late catheter removal (>12 hours) in hematology/oncology patients with CLABSI from June 1, 2015 to May 31, 2018. Patients were case-matched based on intensive care unit admission and presence of shock to control for severity of illness. RESULTS/DISCUSSION: Of 148 patients meeting study inclusion, 128 (86.5%), had their CVC removed during hospitalization (median 11.8 hours). The majority had a hematologic malignancy (90.5%). Following case-matching, 48 patients remained in each group. The primary outcome of infection-related mortality, persistent bacteremia, or recurrent bacteremia occurred more frequently in the late catheter removal group compared to the early catheter removal group although this was not statistically significant (18.8% vs 8.3%, P = .136). CONCLUSIONS: A lower incidence of infection-related mortality, persistent bacteremia, and recurrent bacteremia was found in patients early catheter removal; however the sample size was not adequate to detect statistical differences. Investigators should continue to evaluate if early catheter removal confers a benefit in a larger patient population.

Reducing Unnecessary Laboratory Utilization in the Medical ICU: A Fellow-Driven Quality Improvement Initiative.

OBJECTIVES: Overutilization of laboratory services is now recognized as harmful to patients and wasteful. In fact, the American Board of Internal Medicine's Choosing Wisely campaign recommends against ordering routine testing that does not answer a clinical question. Per peer benchmarking, our institution as a whole occupied an extreme outlier position at the 100th percentile for laboratory utilization. We sought to address this problem starting in our medical ICUs with a quality improvement project. DESIGN: Quality improvement project using the design, measure, analyze, improve, and control process. The primary endpoint was a sustained reduction in laboratory utilization. Counterbalance metrics were also followed, and these included mortality, renal replacement therapy initiation rates, stat laboratory orders, and central catheter-associated blood stream infections. SETTING: The medical ICU at the Ohio State University Medical Center. PATIENTS: All patients admitted to the medical ICU from March 2019 to March 2020. INTERVENTIONS: Root causes were identified and addressed with the implementation of a wide range of interventions involving a multidisciplinary team led by trainee physicians. MEASUREMENTS AND MAIN RESULTS: There was a sustained 20% reduction in the number of tests performed per patient day, with no change in the counterbalance metrics. CONCLUSIONS: Trainees can affect positive change in the culture and processes at their institutions to safely reduce laboratory utilization.

Home sleep apnea testing: comparison of manual and automated scoring across international sleep centers.

PURPOSE: To determine the agreement between the manual scoring of home sleep apnea tests (HSATs) by international sleep technologists and automated scoring systems. METHODS: Fifteen HSATs, previously recorded using a type 3 monitor, were saved in European Data Format. The studies were scored by nine experienced technologists from the sleep centers of the Sleep Apnea Global Interdisciplinary Consortium (SAGIC) using the locally available software. Each study was scored separately by human scorers using the nasal pressure (NP), flow derived from the NP signal (transformed NP), or respiratory inductive plethysmography (RIP) flow. The same procedure was followed using two automated scoring systems: Remlogic (RLG) and Noxturnal (NOX). RESULTS: The intra-class correlation coefficients (ICCs) of the apnea-hypopnea index (AHI) scoring using the NP, transformed NP, and RIP flow were 0.96 [95% CI 0.93-0.99], 0.98 [0.96-0.99], and 0.97 [0.95-0.99], respectively. Using the NP signal, the mean differences in AHI between the average of the manual scoring and the automated systems were - 0.9 ± 3.1/h (AHIRLG vs AHIMANUAL) and - 1.3 ± 2.6/h (AHINOX vs AHIMANUAL). Using the transformed NP, the mean differences in AHI were - 1.9 ± 3.3/h (AHIRLG vs AHIMANUAL) and 1.6 ± 3.0/h (AHINOX vs AHIMANUAL). Using the RIP flow, the mean differences in AHI were - 2.7 ± 4.5/h (AHIRLG vs AHIMANUAL) and 2.3 ± 3.4/h (AHINOX vs AHIMANUAL). CONCLUSIONS: There is very strong agreement in the scoring of the AHI for HSATs between the automated systems and experienced international technologists. Automated scoring of HSATs using commercially available software may be useful to standardize scoring in future endeavors involving international sleep centers.