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1.
Article in English | MEDLINE | ID: mdl-28408715

ABSTRACT

BACKGROUND: Postoperative infections contribute substantially to morbidity and mortality after congenital heart disease surgery and are often preventable. We sought to identify risk factors for postoperative infection and the impact on outcomes after congenital heart surgery, using data from the International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries. METHODS AND RESULTS: Pediatric cardiac surgical cases performed between 2010 and 2012 at 27 participating sites in 16 developing countries were included. Key variables were audited during site visits. Demographics, preoperative, procedural, surgical complexity, and outcome data were analyzed. Univariate and multivariable logistic regression were used to identify risk factors for infection, including bacterial sepsis and surgical site infection, and other clinical outcomes. Standardized infection ratios were computed to track progress over time. Of 14 545 cases, 793 (5.5%) had bacterial sepsis and 306 (2.1%) had surgical site infection. In-hospital mortality was significantly higher among cases with infection than among those without infection (16.7% versus 5.3%; P<0.001), as were postoperative ventilation duration (80 versus 14 hours; P<0.001) and intensive care unit stay (216 versus 68 hours; P<0.001). Younger age at surgery, higher surgical complexity, lower oxygen saturation, and major medical illness were independent risk factors for infection. The overall standardized infection ratio was 0.65 (95% confidence interval, 0.58-0.73) in 2011 and 0.59 (95% confidence interval, 0.54-0.64) in 2012, compared with that in 2010. CONCLUSIONS: Postoperative infections contribute to mortality and morbidity after congenital heart surgery. Younger, more complex patients are at particular risk. Quality improvement targeted at infection risk may reduce morbidity and mortality in the developing world.


Subject(s)
Cardiac Surgical Procedures/adverse effects , Cross Infection/epidemiology , Developing Countries , Heart Defects, Congenital/surgery , Quality Improvement , Quality Indicators, Health Care , Sepsis/epidemiology , Surgical Wound Infection/epidemiology , Adolescent , Cardiac Surgical Procedures/mortality , Child , Child, Preschool , Cross Infection/microbiology , Cross Infection/mortality , Cross Infection/therapy , Databases, Factual , Female , Heart Defects, Congenital/mortality , Hospital Mortality , Humans , Infant , Infant, Newborn , Logistic Models , Male , Medical Audit , Multivariate Analysis , Odds Ratio , Program Evaluation , Risk Factors , Sepsis/microbiology , Sepsis/mortality , Sepsis/therapy , Surgical Wound Infection/microbiology , Surgical Wound Infection/mortality , Surgical Wound Infection/therapy , Time Factors , Treatment Outcome
2.
Pediatrics ; 134(5): e1422-30, 2014 Nov.
Article in English | MEDLINE | ID: mdl-25311607

ABSTRACT

BACKGROUND: There is little information about congenital heart surgery outcomes in developing countries. The International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries uses a registry and quality improvement strategies with nongovernmental organization reinforcement to reduce mortality. Registry data were used to evaluate impact. METHODS: Twenty-eight sites in 17 developing world countries submitted congenital heart surgery data to a registry, received annual benchmarking reports, and created quality improvement teams. Webinars targeted 3 key drivers: safe perioperative practice, infection reduction, and team-based practice. Registry data were audited annually; only verified data were included in analyses. Risk-adjusted standardized mortality ratios (SMRs) and standardized infection ratios among participating sites were calculated. RESULTS: Twenty-seven sites had verified data in at least 1 year, and 1 site withdrew. Among 15,049 cases of pediatric congenital heart surgery, unadjusted mortality was 6.3% and any major infection was 7.0%. SMRs for the overall International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries were 0.71 (95% confidence interval [CI] 0.62-0.81) in 2011 and 0.76 (95% CI 0.69-0.83) in 2012, compared with 2010 baseline. SMRs among 7 sites participating in all 3 years were 0.85 (95% CI 0.71-1.00) in 2011 and 0.80 (95% CI 0.66-0.96) in 2012; among 14 sites participating in 2011 and 2012, the SMR was 0.80 (95% CI 0.70-0.91) in 2012. Standardized infection ratios were similarly reduced. CONCLUSIONS: Congenital heart surgery risk-adjusted mortality and infections were reduced in developing world programs participating in the collaborative quality improvement project and registry. Similar strategies might allow rapid reduction in global health care disparities.


Subject(s)
Cardiac Surgical Procedures/mortality , Developing Countries , Heart Defects, Congenital/mortality , Heart Defects, Congenital/surgery , Surgical Wound Infection/mortality , Surgical Wound Infection/prevention & control , Adolescent , Cardiac Surgical Procedures/adverse effects , Cardiac Surgical Procedures/standards , Child , Child, Preschool , Female , Humans , Infant , Infant, Newborn , Male , Quality Improvement/standards , Registries/standards , Surgical Wound Infection/diagnosis
3.
Am J Infect Control ; 41(8): e77-9, 2013 Aug.
Article in English | MEDLINE | ID: mdl-23394859

ABSTRACT

The optimal disinfection method for needleless connectors (NCs) is unclear. We used an experimental model of microbial NC contamination to test different scrub times (swipe, 5, 15, 30 seconds) of chlorhexidine-alcohol versus alcohol and for residual disinfectant activity. Swipe with alcohol did not adequately disinfect NCs, particularly when contaminated with Staphylococcus aureus or Pseudomonas aeruginosa. With ≥5-second scrub, chlorhexidine-alcohol and alcohol performed similarly, but chlorhexidine-alcohol showed residual disinfectant activity for up to 24 hours.


Subject(s)
2-Propanol/administration & dosage , Catheters, Indwelling/microbiology , Chlorhexidine/administration & dosage , Disinfectants/administration & dosage , Disinfection/methods , Equipment Contamination/prevention & control , 2-Propanol/pharmacology , Chlorhexidine/pharmacology , Cross Infection/prevention & control , Disinfectants/pharmacology , Pseudomonas aeruginosa/drug effects , Staphylococcus aureus/drug effects
4.
Ann Thorac Surg ; 89(6): 1833-41; discussion 1841-2, 2010 Jun.
Article in English | MEDLINE | ID: mdl-20494036

ABSTRACT

BACKGROUND: We sought to identify risk factors for surgical site infections (SSI) in children undergoing cardiac surgery. METHODS: A matched case-control study was conducted in the Children's Hospital Boston Cardiovascular Program. Surgical site infections were identified for 3 years (2004 to 2006). We identified two randomly selected control patients who underwent cardiac surgery within 7 days of each index case. Univariate and multivariate conditional logistic regression analyses were used to identify risk factors for SSI. In a secondary analysis, risk factors for organ space SSI (mediastinitis) were sought. Secondary analyses were also conducted using only those variables known preoperatively. RESULTS: Seventy-two SSI and 144 controls were included. Independent risk factors for any type of SSI were age younger than 1 year (adjusted odds ratio, 2.28; 95% confidence interval, 1.18 to 4.39) and duration of cardiopulmonary bypass greater than 105 minutes (adjusted odds ratio, 1.92; 95% confidence interval, 1.02 to 3.62). Independent risk factors for organ space SSI were aortic cross-clamp time greater than 85 minutes (adjusted odds ratio, 5.61; 95% confidence interval, 1.06 to 29.67) and postoperative exposure to at least three separate red blood cell transfusions (adjusted odds ratio, 7.87; 95% confidence interval, 1.63 to 37.92). When only those potential risk factors known preoperatively were considered, age younger than 1 year independently predicted the subsequent development of any type of SSI, and preoperative hospitalization independently predicted the subsequent development of organ space SSI. CONCLUSIONS: Younger patients undergoing longer surgical procedures and those requiring more postoperative blood transfusions are at greatest risk for SSI. Additional preventive strategies, including restrictive blood transfusion policies, warrant further investigation.


Subject(s)
Cardiac Surgical Procedures/adverse effects , Surgical Wound Infection/epidemiology , Surgical Wound Infection/etiology , Case-Control Studies , Humans , Infant , Risk Factors
5.
Pediatr Crit Care Med ; 10(4): 453-9, 2009 Jul.
Article in English | MEDLINE | ID: mdl-19307818

ABSTRACT

OBJECTIVE: To identify risk factors for central line-associated bloodstream infection (BSI) in patients receiving care in a pediatric cardiac intensive care unit. DESIGN: Matched case-control study. SETTING: CICU at Children's Hospital Boston. PATIENTS: Central line-associated BSI cases were identified between April 2004 and December 2006. We identified two randomly selected control patients who had a central vascular catheter and were admitted within 7 days of each index case. MEASUREMENTS AND MAIN RESULTS: Univariate and multivariate conditional logistic regression analyses were used to identify risk factors for central line-associated BSI. In a secondary analysis, risk factors for central line-associated BSI in those cases who underwent cardiac surgery were sought. During the study period, 67 central line-associated BSIs occurred in 61 patients. Independent risk factors for central line-associated BSI were nonelective admission for medical management (odds ratio [OR] = 6.51 [1.58-26.78]), the presence of noncardiac comorbidities (OR = 4.95 [1.49-16.49]), initial absolute neutrophil count <5000 cells/uL (OR = 6.17 [1.39-27.48]), blood product exposure > or =3 units (OR = 5.56 [1.35-22.87]), central line days > or =7 (OR = 6.06 [1.65-21.83]), and use of hydrocortisone (OR = 28.94 [2.55-330.37]). In those patients who underwent cardiac surgery (n = 37 cases and 108 controls), independent risk factors for central line-associated BSI were admission weight < or =5 kg (OR = 3.13 [1.01-9.68]), Pediatric Risk of Mortality III score > or =15 (OR = 3.44 [1.19-9.92]), blood product exposure > or =3 units (OR = 3.38 [1.28-11.76]), and mechanical ventilation for > or =7 days (OR = 4.06 [1.33-12.40]). CONCLUSIONS: Unscheduled medical admissions, presence of noncardiac comorbidities, extended device utilization, and specific medical therapies are independent risk factors for central line-associated BSI in patients receiving care in a pediatric cardiac intensive care unit.


Subject(s)
Bacteremia/epidemiology , Catheter-Related Infections/epidemiology , Catheterization, Central Venous/adverse effects , Cross Infection/epidemiology , Heart Diseases/surgery , Bacteremia/microbiology , Cardiac Surgical Procedures , Case-Control Studies , Catheter-Related Infections/microbiology , Comorbidity , Cross Infection/microbiology , Female , Heart Defects, Congenital/surgery , Humans , Infant , Infant, Newborn , Intensive Care Units, Pediatric , Male , Risk Factors , Time Factors
6.
Pediatrics ; 121(5): 915-23, 2008 May.
Article in English | MEDLINE | ID: mdl-18450894

ABSTRACT

OBJECTIVE: Our goal was to determine whether an intervention involving staff education, increased awareness, and practice changes would decrease central line-associated bloodstream infection rates in a pediatric cardiac ICU. METHODS: A retrospective, interventional study using an interrupted time-series design was conducted to compare central line-associated bloodstream infection rates during 3 time periods for all patients admitted to our pediatric cardiac ICU between April 1, 2004, and December 31, 2006. During the preintervention period (April 2004 to December 2004), a committee was convened to track and prevent nosocomial infections. Pretesting demonstrated knowledge deficits regarding nosocomial infection prevention, and educational tools were developed. During the partial intervention period (January 2005 to March 2006), a comprehensive central line-associated bloodstream infection prevention initiative was implemented, including establishment of a unit-based infection control nurse position, education for physicians and nurses, real-time feedback on central line-associated bloodstream infection data, implementation of central venous line insertion, access, and maintenance bundles, and introduction of daily goal sheets on rounds that emphasized timely central venous line removal. Central line-associated bloodstream infection rates in the preintervention, partial intervention, and full intervention (April 2006 to December 2006) periods were compared. RESULTS: The estimated mean preintervention central line-associated bloodstream infection rate was 7.8 infections per 1000 catheter-days, which decreased to 4.7 infections per 1000 catheter-days in the partial intervention period and 2.3 infections per 1000 catheter-days in the full intervention period. The preintervention central line-associated bloodstream infection rate was significantly higher than the median rate of 3.5 infections per 1000 catheter-days for multidisciplinary PICUs reporting to the National Healthcare Safety Network. During the full intervention period, our central line-associated bloodstream infection rate was lower than this pediatric benchmark, although statistical significance was not achieved. CONCLUSIONS: A multidisciplinary, evidence-based initiative resulted in a significant reduction in central line-associated bloodstream infections in our pediatric cardiac ICU.


Subject(s)
Bacteremia/prevention & control , Catheterization, Central Venous/adverse effects , Coronary Care Units , Cross Infection/prevention & control , Infection Control/methods , Bacteremia/etiology , Catheters, Indwelling/adverse effects , Child , Child, Preschool , Cross Infection/etiology , Humans , Infant , Intensive Care Units, Pediatric
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