scholarly journals Reducing Central Line Associated Bloodstream Infections in Allogeneic Hematopoietic Stem Cell Transplant Patients

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 4942-4942
Author(s):  
Nataly Valeria Torrejon ◽  
Tiffany Onger ◽  
Ronald M. Sobecks ◽  
Megan Corrao ◽  
Debra Scott ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Infection Prevention ◽  
Conditioning Regimen ◽  
Cleveland Clinic ◽  
Bloodstream Infections ◽  
B Cell Lymphoma ◽  
Central Line ◽  
Cell Transplant ◽  
Improvement Project ◽  
Hematopoietic Stem

Abstract Background: The blood and marrow transplant (BMT) unit at Cleveland Clinic had an increased rate of central line associated bloodstream infections (CLABSIs) in 2020 for allogeneic transplant admissions from an expected average of 1 per month to 4 in August of 2020. We aimed to reduce the number of CLABSIs in allogeneic BMT patients during their transplant admission to an average of 1 per month. Patients and Methods: We formed a multidisciplinary team with nursing, advanced practice providers (APPs), infection prevention, fellows, residents, BMT staff, and Taussig quality improvement staff. We underwent training through the SolVE (Solutions for Value Enhancement) program, with biweekly meetings for training and coaching sessions to help design and support the quality improvement project. Results: We performed an initial data review of CLABSIs from January 2020 until September 2020 with a total of 13 cases identified. 53% of cases were female, 76% of patients were neutropenic, 53% of patients had mucositis, 61% of patients had diarrhea and 7% of patients had graft versus host disease. Patients had the following underlying diagnoses: myelodysplastic syndrome (4), acute myeloid leukemia (3), acute lymphoblastic leukemia (4) and diffuse large B-cell lymphoma (1). Central line data revealed that all lines were placed at Cleveland Clinic. 76% of lines were removed after identification of infection, 46% of lines had signs of infection or malfunction. Microbiologic data culture revealed that 7 cases were Pseudomonas aeruginosa, 3 Staphylococcus epidermidis, 1 vancomycin-resistant Enterococcus faecalis, 1 Streptococcus mitis and 1 Stenotrophomonas maltophilia. To build our process map we performed a Gemba walk where we observed central line use and access on the BMT unit. We conducted a root cause analysis and identified the following factors as drivers of the rise in CLABSIs: severe immunocompromised state, pre-existing infections, long duration of line present, frequent access, excessive line manipulation, and poor hand hygiene. The changes that were implemented on the unit included: retraining of all nurses on central line care, central line care being added as a topic to the annual competency review, site and tubing checks were to be performed at the time of bedside handoff at shift change, increasing Shine Audits to 40 per week from 10 on average and deep clean of nursing unit by EVS following outbreak of pseudomonas. Following the above interventions, we decided to form a CLABSI review meeting to review each CLABSI in real time and to be able to have a longitudinal comprehensive data collection of factors contributing to each case. These meetings involve nursing, infection prevention, APPs, and physicians directly involved with the patient's care. Data is stored in Redcap and includes patient factors (admission date, conditioning regimen, type of transplant, disease data), line factors (placement date, location, infection date, line removal date), microbiologic data (organism, reason for culture collection), personnel factors, maintenance/environmental factors and space for other comments. Data is presented at regular quality meetings with the section chair to develop further quality improvement projects. Initially the reduction of CLABSI rates did not reach our objective: we had 5 CLABSIs from January to February 2021. However, in the following months (March to June, 2021) we were able to reach our objective of 0-1 CLABSI's per month. Conclusion We continue to work as a team to reduce the number of infections in the BMT unit. Next steps include continuing CLABSI review meetings, discussions with ICU to better understand indications and process of blood culture collections, discussion with infectious disease for input on other strategies for CLABSI reduction and examining central line processes in other institutions. Disclosures Sobecks: CareDX: Membership on an entity's Board of Directors or advisory committees.

Mitigating the risk of transfusion-transmitted bacterial infections in hematology oncology patients.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e19047-e19047
Author(s):  
Harold Alvarez ◽  
Marion Lanteri ◽  
Guenther Koehne
Keyword(s):  
Bacterial Infections ◽  
Bacterial Culture ◽  
Emerging Infectious Diseases ◽  
Bloodstream Infections ◽  
Central Line ◽  
Cell Transplant ◽  
Hematopoietic Stem ◽  
Life Saving ◽  
The Uk ◽  
Transfusion Reactions

e19047 Background: Hospital acquired infections create major logistical, financial, and patient safety concerns within the healthcare system. Bacterial contamination (BC) of platelet components (PCs) can lead to transfusion-transmitted bacterial infections (TTBI), central line-associated bloodstream infections, and sepsis, with long-term complications and/or death. In the US, hematopoietic stem cell transplant (HSCT) recipients require transfusion support until engraftment and together with hematology/oncology (hemonc.) patients receive the highest number of PCs/patient. FDA’s Guidance recommends approaches to reduce BC risk including the use of enhanced bacterial culture screening (EBSC) or pathogen reduction (PR) of platelets. Methods: The Miami Cancer Institute (MCI) implemented PR-PCs for all allogeneic HSCT patients. Irradiation, CMV testing, and bacterial screening have been discontinued for PR-PCs. Transfusion outcomes are being monitored using active hemovigilance (HV) reporting. Results: Considering the fatality risk associated with BC of PCs (1:200,000 – 1:1,000,000) despite the use of optimal skin cleansing, initial sample diversion, and primary bacterial culture, 1/2,880 PCs are still contaminated (Bloch et al.); further steps towards BC mitigation are needed. As the UK and US reported a residual BC risk of 5.4-9.4/million PCs after implementation of EBSC, PR may represent an alternative approach with other cumulative benefits. Indeed, national HV data from France, Switzerland and Belgium reported no sepsis transfusion reactions since PR implementation (Benjamin et al.). In addition, the risk of TA-GVHD and other TTI including emerging infectious diseases (EID) may be decreased after the inactivation of pathogens and leukocytes (Lanteri et al.). At MCI, the percentage of transfused PR-PCs has been increasing steadily from 7.9% in July 2019 to 22.2% in January 2021. Over a 19 month-period, a total of 9,296 PC were transfused including 1,677 PR-PCs. While non-PR-PCs were all irradiated and bacterially screened, PR-PC were neither irradiated nor bacterially screened. No cases of TA-GVHD or TTI were reported. A total of 27 mild, non-life-threatening platelet transfusion reactions were reported including 22 (81.5%) after non-PR PCs transfusion and 5 (18.5%) after PR-PC transfusion. In addition, the early release of transfusion-ready fresh PR-PCs 24-48 hours after collection has proven invaluable in providing clinicians and patients with blood continuity during the COVID-19 pandemic. Conclusions: Though certain measures have improved blood safety, the risk of TTI associated with PC transfusion remains a concern for vulnerable hemonc. patients. Using PR-PC is especially important to consider when patients undergo extensive life-saving therapies such as bone marrow transplants.

scholarly journals The Efficacy of Passive Valve Antimicrobial Swab Caps Against Existing Clabsi Prevention Bundle in an Adult Hematology Inpatient Population: A Quality Improvement Initiative

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 13-14
Author(s):  
Joseph F. Ferry ◽  
Neil Bailey ◽  
Vanessa Dunleavy ◽  
Joanna Fesler ◽  
Judson Hall ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Vascular Access ◽  
Patient Population ◽  
Research Funding ◽  
B Cell Lymphoma ◽  
Central Line ◽  
Improvement Project ◽  
Common Diagnosis ◽  
The Cost ◽  
The Impact

Background : Central line associated blood stream infections (CLABSI) have been the costliest of all healthcare associated infections. The average CLABSI cost is approximately $46,000 (Haddadin & Regunath, 2019). Most cases may be preventable with utilization of aseptic techniques, surveillance, and management through local protocols. The majority of CLABSI occur more than five days after central vascular access (CVA); therefore, there has been a growing focus on central line handling and maintenance techniques. CLABSI prevention data has been largely focused on the intensive care unit (ICU) patient population where an average of about half of patients have CVA. There have been few studies exploring the rates of CLABSI in the adult hematology population, a population with unique risk factors due to their immunosuppressing treatments and prolonged immunocompromised states. There has been emerging data that suggests the use of new technology in addition to existing central line maintenance recommendations by the Center for Disease Control may further reduce the rate of CLABSI occurrences in high-risk patient populations. Aim: To determine the efficacy of passive valve antimicrobial swab caps on the reduction of CLABSI in an inpatient hematology patient population when compared to current existing local practices. Outcomes of reported incidents of CLABSI have been evaluated against pre-interventional data for this setting. Methods : Retrospective analysis of medical records from January 2016 - September 2019 identified the existing rate of CLABSI occurrence among inpatient hematology patients at a single institution. We utilized the intervention of antimicrobial swab caps for 10 months and tracked the rate of CLABSI during this time. The nursing staff were educated on the quality improvement project, the use of the new equipment, and expectations that existing standard practices per local policy for CLABSI prevention bundles would be adhered to prior to the start of the intervention. To evaluate the impact of the antimicrobial swab caps on the rate of CLABSI we compared the number of infections pre- and post-intervention. Randomized audits, including chart reviews for compliance with existing standard CLABSI bundle practices were performed during the initial 3 months of the intervention. Results : Prior to the introduction of the passive valve antimicrobial swab cap to the existing CLABSI prevention protocol, CLABSI rates on the hematology unit exceeded the standardized infection ratio 75th percentile on 9 of the previous 15 calendar quarters. The intervention was observed for 6,674 central line days. The CLABSI rate during the intervention was 0.4495 per 1,000 central line days. The CLABSIs identified were due to nosocomial opportunistic infection in setting of immunosuppressed status (66%) and gastrointestinal translocation (33%). The common diagnosis in setting of CLABSI was refractory/relapse diffuse large B-cell lymphoma (66%) and active acute myeloid leukemia (33%). The two patients who were diagnosed with CLABSI were neutropenic with an absolute neutrophil count of 0 at time of CLABSI diagnosis. The organisms identified at time of CLABSI diagnosis were Clostridium ramosom, Enterococcus faecium, Staphylococcus epidermisis, and Candida parapsilosis. When considering the cost of a CLABSI to be about $46,000 per event and the annual cost for the inpatient hematology unit's use of the caps of approximately $19,710, the implementation of the antimicrobial swab cap reduced the cost associated with CLASBI in the hematology unit by approximately $26,290 annually. Conclusions : The introduction of the passive valve antimicrobial swab caps appears to demonstrate potential for reduced costs due to CLABSI when implemented into current CLABSI prevention bundles. This resulted in a 25% reduction in rates of CLABSI in the adult hematology patient population when compared to the previous year. The prevention of CLABSI in hematology patients with central vascular access remains challenging, however, standardized protocols for CLABSI prevention and use of antimicrobial swab caps may help further reduce the rate of CLABSI in hematology patients. Disclosures: No relevant conflicts of interest to declare. Disclosures Glennie: Pharmacyclics: Speakers Bureau; Janssen: Speakers Bureau. Bensinger:BMS: Consultancy, Honoraria, Research Funding, Speakers Bureau; Sanofi: Consultancy, Honoraria, Research Funding, Speakers Bureau; Janssen: Consultancy, Honoraria, Research Funding, Speakers Bureau; Amgen: Consultancy, Honoraria, Research Funding, Speakers Bureau; GSK: Consultancy, Honoraria, Research Funding, Speakers Bureau; Regeneron: Consultancy, Honoraria, Research Funding, Speakers Bureau. Patel:Celgene/BMS: Consultancy, Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy, Speakers Bureau; AstraZeneca: Consultancy, Research Funding, Speakers Bureau; BeiGene: Consultancy; Adaptive Biotechnologies: Consultancy; Genentech: Consultancy, Speakers Bureau; Kite: Consultancy; Pharmacyclics: Consultancy, Speakers Bureau.

scholarly journals Targeted Assessment for Prevention: A Statewide Collaborative

2020 ◽  
Vol 41 (S1) ◽  
pp. s401-s401
Author(s):  
Cindy Hou ◽  
Shannon Davila ◽  
Mary Miller ◽  
Ashlee Hiester ◽  
Katherine Hosmer ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Infection Prevention ◽  
Local Level ◽  
Central Line ◽  
Interdisciplinary Teams ◽  
System Level ◽  
Healthcare Associated Infection ◽  
Hospital System ◽  
Healthcare Facilities ◽  
Clostridioides Difficile

Background: Infection preventionists (IPs) are the backbone of the quality and safety matrix of their organizations. Tools to help locate potential gaps can provide unique viewpoints from frontline staff. The CDC provides a Targeted Assessment for Prevention (TAP) strategy that identifies vulnerabilities in the prevention of healthcare-associated infection (HAIs). Methods: A statewide quality improvement organization, partnering with the CDC TAP team, administered TAP facility assessments for catheter-associated urinary tract infection (CAUTI), central-line–associated bloodstream infection (CLABSI), and Clostridioides difficile infection (CDI) to a collaborative of 15 acute-care and 2 long-term acute hospitals. More than 800 respondents filled out surveys based on their individualized perceptions of infection prevention practices. Results: The survey results yielded the following lagging indicators: lack of awareness of nursing and physician champions, need for competency-based training of clinical equipment, and feedback on device utilization. At the hospital system level, one improvement team focused on CDI, uncovered leading and lagging areas in general infrastructure, antibiotic stewardship, early detection and appropriate testing, contact precautions, and environmental cleaning. To culminate the TAP collaborative, the cohort of organizations, supported by interdisciplinary teams, participated in a full-day TAP workshop in which they reviewed detailed analyses of their HAI data and assessment results, shared best practices for infection prevention and planned for specific improvement projects using the plan-do-study-act model. Conclusions: Results of a statewide analysis of HAI prevention data and opportunities at a local level were reviewed. The TAP strategy can be used to target opportunities for improvement, to assess gaps in practice, and to develop and implement interventions for improving outcomes. Healthcare facilities and quality improvement organizations can drive infection prevention actions.Funding: NoneDisclosures: None

scholarly journals Reduction of Central-Line–Associated Bloodstream Infections in a Spinal Cord Injury Unit

2020 ◽  
Vol 41 (S1) ◽  
pp. s370-s370
Author(s):  
Stephanie L. Baer ◽  
Amy Halcyon Larsh ◽  
Annalise Prunier ◽  
Victoria Thurmond ◽  
Donna Goins ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Patient Population ◽  
Bloodstream Infections ◽  
Central Line ◽  
Fiscal Year ◽  
Improvement Project ◽  
Central Lines ◽  
Cord Injury ◽  
Bundle Compliance

Background: Central-line–associated bloodstream infections (CLABSIs) are a complication of indwelling central venous catheters, which increase morbidity, mortality, and cost to patients. Objective: Due to increased rates in a spinal cord injury unit (SCIU), a performance improvement project was started to reduce CLABSI in the patient population. Methods: To reduce the incidence of CLABSI, a prevention bundle was adopted, and a peer-surveillance tool was developed to monitor compliance with the bundle. Staff were trained to monitor their peers and submit weekly surveillance. Audits were conducted by the clinical nurse leader with accuracy feedback. Bundle peer-surveillance was implemented in February of 2018 with data being fed back to leadership, peer monitors, and stakeholders. Gaps in compliance were addressed with peer-to-peer education, changes in documentation requirements, and meetings to improve communication and reduce line days. In addition, the use of an antiseptic-impregnated disc for vascular accesses was implemented for dressing changes. Further quality improvement cycles during the first 2 quarters of fiscal year 2019 included service-wide education reinforcement, identification in variance of practice, and reporting to staff and stakeholders. Results: CLABSI bundle compliance increased from 67% to 98% between February and October 2018. The weekly audit reporting accuracy improved from 33% to 100% during the same period. Bundle compliance was sustained through the fourth quarter of 2019 at 98%, and audit accuracy was 99%. The initial CLABSI rates the quarter prior to the intervention were 6.10 infections per 1,000 line days for 1 of the 3 SCIUs and 2.68 infections per 1,000 line days for the service overall. After the action plan was initiated, no CLABSIs occurred for the next 3 quarters in all SCIUs despite unchanged use of central lines (5,726 line days in 2018). The improvement was sustained, and the line days decreased slightly for 2019, with a fiscal year rate of 0.61 per 1,000 line days (ie, 3 CLABSIs in 4,927 central-line days). Conclusions: The incidence of CLABSI in the SCIU was reduced by an intensive surveillance intervention to perform accurate peer monitoring of bundle compliance with weekly feedback, communication, and education strategies, improvement of the documentation, and the use of antiseptic-impregnated discs for dressings. Despite the complexity of the patient population requiring long-term central lines, the CLABSI rate was greatly impacted by evidence-based interventions coupled with reinforcement of adherence to the bundle.Funding: NoneDisclosures: None

scholarly journals Effect of Removing Contact Precautions for Multidrug-Resistant Organisms on Hospital Infections in a Pediatric Health System

2020 ◽  
Vol 41 (S1) ◽  
pp. s199-s200
Author(s):  
Matthew Linam ◽  
Dorian Hoskins ◽  
Preeti Jaggi ◽  
Mark Gonzalez ◽  
Renee Watson ◽  
...  
Keyword(s):  
Hand Hygiene ◽  
Antibiotic Stewardship ◽  
Infection Prevention ◽  
Tertiary Care ◽  
Bloodstream Infections ◽  
Central Line ◽  
Contact Precautions ◽  
Stewardship Program ◽  
Tract Infections ◽  
The Impact

Background: Discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) have failed to show an increase in associated transmission or infections in adult healthcare settings. Pediatric experience is limited. Objective: We evaluated the impact of discontinuing contact precautions for MRSA, VRE, and extended-spectrum β-lactamase–producing gram-negative bacilli (ESBLs) on device-associated healthcare-associated infections (HAIs). Methods: In October 2018, contact precautions were discontinued for children with MRSA, VRE, and ESBLs in a large, tertiary-care pediatric healthcare system comprising 2 hospitals and 620 beds. Coincident interventions that potentially reduced HAIs included blood culture diagnostic stewardship (June 2018), a hand hygiene education initiative (July 2018), a handshake antibiotic stewardship program (December 2018) and multidisciplinary infection prevention rounding in the intensive care units (November 2018). Compliance with hand hygiene and HAI prevention bundles were monitored. Device-associated HAIs were identified using standard definitions. Annotated run charts were used to track the impact of interventions on changes in device-associated HAIs over time. Results: Average hand hygiene compliance was 91%. Compliance with HAI prevention bundles was 81% for ventilator-associated pneumonias, 90% for catheter-associated urinary tract infections, and 97% for central-line–associated bloodstream infections. Overall, device-associated HAIs decreased from 6.04 per 10,000 patient days to 3.25 per 10,000 patient days after October 2018 (Fig. 1). Prior to October 2018, MRSA, VRE and ESBLs accounted for 10% of device-associated HAIs. This rate decreased to 5% after October 2018. The decrease in HAIs was likely related to interventions such as infection prevention rounds and handshake stewardship. Conclusions: Discontinuation of contact precautions for children with MRSA, VRE, and ESBLs were not associated with increased device-associated HAIs, and such discontinuation is likely safe in the setting of robust infection prevention and antibiotic stewardship programs.Funding: NoneDisclosures: None

scholarly journals 577. Incidence and Outcomes of Positive Outpatient Surveillance Blood Cultures in Hematopoietic Stem Cell Transplant (HSCT) Patients with Graft Versus Host Disease (GvHD) On High Dose ≥ 0.5 mg/kg/day (HD) and Low Dose < 0.5mg/kg/day (LD) Steroid Therapy

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S353-S354
Author(s):  
Sarah Perreault ◽  
Molly Schiffer ◽  
Jennifer Zhao ◽  
Dayna McManus ◽  
Francine Foss ◽  
...  
Keyword(s):  
Steroid Therapy ◽  
Central Line ◽  
Blood Cultures ◽  
High Dose ◽  
Cell Transplant ◽  
Coagulase Negative Staphylococci ◽  
Hematopoietic Stem ◽  
Surveillance Cultures ◽  
Number Of Patients ◽  
Clinically Significant

Abstract Background Treatment of GvHD with steroids increases the risk of infection in HSCT patients due to additive immunosuppression and may delay the diagnosis of infection due to lack of symptoms. Outpatient surveillance blood cultures in HSCT with GvHD being treated with HD steroids has demonstrated a blood culture positivity rate of 3.5%. Currently, the utility of surveillance cultures in patients receiving LD steroid therapy is unknown. Our practice includes weekly outpatient surveillance cultures for all GvHD patients treated with steroids regardless of the dose. The primary endpoint of this study was to assess the incidence of positive surveillance blood cultures in GvHD patients receiving HD or LD steroids. Secondary endpoints included number of patients treated, hospitalization, 30 day mortality due to infection, and organisms isolated. Methods This was a single-center, retrospective review of GvHD patients at Yale New Haven Hospital between January 2013 and May 2019. Patients were excluded if: lack of signs or symptoms of GvHD, treatment with steroids for any indication other than GvHD, and active GvHD without central line. Cultures from patients receiving antibiotics for concurrent infection were also excluded. Results A total of 71 patients met criteria with 901 blood cultures. On HD, eight patients (14%) had 12 positive cultures (4%), and on LD, 16 patients (25%) had 22 positive cultures (4%) (p=0.15). Treatment occurred in six patients (75%) with four (24%) requiring hospitalization on HD, and 12 patients (75%) with 10 (83%) requiring hospitalization on LD (p=0.45). The median duration of steroid therapy was 93 and 236 days with a median dose of steroids of 1mg/kg/day and 0.15mg/kg/day, respectively. The number of positive cultures/1000 steroid days was 1.2 on HD and 0.5 on LD (RR 2.2). 30 day mortality was only noted in one patient (8%) on LD. The most common organism in both groups was Coagulase-negative staphylococci with all six cultures on HD classified as contaminants and 6/10 cultures requiring treatment on LD. Conclusion Although the relative risk of positive surveillance blood cultures in HD patients compared to LD was twofold higher, there were clinically significant infections identified in the LD group. Disclosures All Authors: No reported disclosures

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