Reducing unnecessary culturing: a systems approach to evaluating urine culture ordering and collection practices among nurses in two acute care settings.

Background: Inappropriate ordering and acquisition of urine cultures leads to unnecessary treatment of asymptomatic bacteriuria (ASB). Treatment of ASB contributes to antimicrobial resistance particularly among hospital-acquired organisms. Our objective was to investigate urine culture ordering and collection practices among nurses to identify key system-level and human factor barriers and facilitators that affect optimal ordering and collection practices. Methods: We conducted two focus groups, one with ED nurses and the other with ICU nurses. Questions were developed using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. We used iterative categorization (directed content analysis followed by summative content analysis) to code and analyze the data both deductively (using SEIPS domains) and inductively (emerging themes). Results: Factors affecting optimal urine ordering and collection included barriers at the person, process, and task levels. For ED nurses, barriers included patient factors, physician communication, reflex culture protocols, the electronic health record, urinary symptoms, and ED throughput. For ICU nurses, barriers included physician notification of urinalysis results, personal protective equipment, collection technique, patient body habitus, and Foley catheter issues. Conclusions: We identified multiple potential process barriers to nurse adherence with evidence-based recommendations for ordering and collecting urine cultures in the ICU and ED. A systems approach to identifying barriers and facilitators can be useful to design interventions for improving urine ordering and collection practices.

Attributable mortality of central line associated bloodstream infection: systematic review and meta-analysis.

PURPOSE: To identify the attributable mortality of central line associated blood stream infections (CLABSI) through meta-analysis. METHODS: Meta-analysis of case control and cohort studies, matched and unmatched, that reported on mortality of patients with and without CLABSI was performed. MEDLINE, CENTRAL, CINAHL were searched. Non-interventional studies of all languages that reported mortality in patients with CLABSI were included. Data were extracted on patient population, study setting, design, diagnostic criteria for CLABSI, and mortality. Results from studies comparing mortality due to CLABSI were pooled using a random effects model with assessment of heterogeneity. Heterogeneity of studies was assessed with an I (2) statistic and a funnel plot was generated to assess for publication bias. RESULTS: Eighteen studies were included with 1,976 CLABSI cases. Of the included studies, 17 took place in intensive care unit settings, most involved a mixed population of medical and surgical patients, and ten were matched using an illness severity index. Our findings show an odds ratio of in hospital death associated with CLABSI as 2.75 (CI 1.86-4.07) and 1.51 (CI 1.08-2.09) in the subgroup of the ten matched studies. Those studies where greater than 30 % of CLABSI were attributed to coagulase-negative Staphylococcus had an odds ratio of death of 1.64 (95 % CI 1.02-2.65) compared with 4.71 (95 % CI 1.54-14.39). CONCLUSIONS: CLABSI is associated with a significantly increased risk of death supporting the use of extensive efforts to reduce these infections.

Goal directed brain tissue oxygen monitoring versus conventional management in traumatic brain injury: an analysis of in hospital recovery.

BACKGROUND: Brain tissue oxygen monitoring (pBtO2) has been advocated in the treatment of patients with severe traumatic brain injuries (TBI); however, controversy exists regarding the improvements that pBtO2 monitoring provides. The objective of our study was to evaluate our experience and effect on mortality with goal directed pBtO2 monitoring for severe TBI compared to traditional ICP/CPP monitoring. METHODS: All patients admitted with severe TBI (GCS < 8) to our Level 1 trauma center from June 2007 through June 2009 were retrospectively analyzed. All patients had ICP monitoring and pBtO2 monitors were placed based on the current practices of the attending neurosurgeon producing two temporally matched cohorts of patients with and without pBtO2 monitors. Exclusion criteria were age <18 years and survival <24 h. Goal-directed therapy was utilized in all patients to maintain ICP <20 mmHg and CPP >60 mmHg. Patients with pBtO2 monitors were managed to maintain a level >20 mmHg. RESULTS: 74 patients were treated for severe TBI over the 2-year study period with 37 patients in each group. Both groups were similar in age, sex, and admission Glascow Coma Score(GCS).The pBtO2-monitored group did, however, have significantly lower injury severity score [26 (25-30) vs. 30 (26-36), p = 0.03] and AIS Chest [0 (0-0) vs. 2 (0-3), p = 0.02]. There was no survival difference found (64.9 vs. 54.1 %, p = 0.34). No difference with respect to discharge GCS or discharge Functional Independence Measure score was identified. CONCLUSIONS: Compared with ICP/CPP-directed therapy alone, the addition of pBtO2 monitoring did not provide a survival or functional status improvement at discharge. The true clinical benefit of pBtO2 monitoring will require further study.

Incidence of pulmonary fat embolism at autopsy: an undiagnosed epidemic.

BACKGROUND: To determine the incidence, time course, and severity of pulmonary fat embolism (PFE) and cerebral fat embolism (CFE) in trauma and nontrauma patients at the time of autopsy. METHODS: Prospectively, consecutive patients presenting for autopsy were evaluated for evidence pulmonary and brain fat embolism. The lung sections were obtained from the upper and lower lobe of the patients' lungs on the right and left and brain tissue. This tissue was prepared with osmium tetroxide for histologic evaluation. The number of fat droplets per high power field was counted for all sections. The autopsy reports and medical records were used to determine cause of death, time to death, injuries, if cardiopulmonary resuscitation (CPR) was attempted, sex, height, weight, and age. RESULTS: Fifty decedents were evaluated for PFE and CFE. The average age was 45.8 years ± 17.4 years, average body mass index was 30.1 kg/cm² ± 7.0 kg/cm², and 68% of the patients were men. The cause of death was determined to be trauma in 68% (34/50) of decedents, with 88% (30/34) blunt and 12% (4/34) penetrating. CPR was performed on 30% (15/50), and PFE was present in 76% (38/50) of all patients. Subjects with PFE had no difference with respect to sex, trauma, mechanism of injury, CPR, external contusions, fractures, head, spine, chest, abdominal, pelvic, and extremity injuries. However, subjects without PFE had significantly increased weight (109 ± 29 kg vs. 86 ± 18 kg; p = 0.023) but no difference in height or body mass index. PFE was present in 82% (28/34) of trauma patents and 63% (10/16) nontrauma patients. Eighty-eight percent of nontrauma patients and 86% of trauma patients who received CPR had PFE. Trauma patients with PFE showed no significant difference in any group. Eighty-eight percent of trauma patients died within 1 hour of injury, and 80% (24/30) of them had PFE at the time of autopsy. CFE was present only in one patient with a severe head and cervical spine injury. CONCLUSION: PFE is common in trauma patients. CPR is associated with a high incidence of PFE regardless of cause of death. PFE occurs acutely within the "golden hour" and should be considered in traumatically injured patients. Further studies are needed to evaluate the pathogenesis of PFE.