In the previously referenced systematic review, Patel et al. (2018) found that successful interventions aiming to reduce CLABSIs and CAUTIs often used checklists, auditing, and monitoring and focused on removal of devices. These checklists and monitoring procedures help reduce human error during the maintenance and removal of devices. The CDC guidelines for intravascular catheters also provide recommendations on device removal and care. These include assessment of an insertion site infection, removal of unnecessary catheters, quick replacement of catheters when aseptic technique cannot be ensured, and appropriate length of time to use certain types of catheters (e.g., up to 14 days for umbilical venous catheters). The CDC also has various recommendations on the evaluation and monitoring of device use for urinary catheters. These guidelines include the removing urinary catheters for operative patients as quickly as possible (<24 hours if possible), reducing kinking and obstruction of catheter tubes, and implementing guidelines to advise on proper catheter maintenance. Lastly, the SHEA/IDSA guidelines include several recommendations on evaluation and monitoring of ventilator use. Some of these recommendations include changing the ventilator circuit if it is visibly soiled or malfunctioning, minimizing breaks in the ventilator circuit, and assessing the readiness to extubate daily. Unintended Outcomes Some of the above interventions, such as ABL solutions, topical skin ointments, and oropharynx decontamination involve the use of antibiotics. As with any antimicrobial use, overuse and inappropriate use can lead to increased drug resistance and increased risk of MDRO colonization or infection. Regarding ventilator-associated antibiotic use, one before-and-after study discussed the effectiveness of selective digestive decontamination using polymyxin, tobramycin, and amphotericin B in the oropharynx and the gastric tube plus a mupirocin and chlorhexidine regimen in intubated patients. This study maintained that use of antibiotics in this scenario did not confer antibiotic resistance, but evidence showed that this practice increased the risk of MRSA infection and tobramycin resistance in aerobic Gram-negative bacilli such as P. aeruginosa and Enterobacteriaceae. 82 The SHEA/ IDSA guidelines recommend that facilities with high levels of antimicrobial resistance not use digestive decontamination until higher quality, long-term studies are performed to assess the risks. 81 For intravascular catheters, the CDC states that antibiotic ointments and creams should not be used on insertion sites (other than dialysis catheters) because of the risk of conferring antimicrobial resistance and fungal infections. Chlorhexidine dressings are appropriate in some cases. When considering the use of antibiotics to prevent CLABSIs, CAUTIs, or VAPs, clinicians should exercise caution and be diligent about referencing the existing guidelines, which specifically warn
against or promote antibiotics for certain uses and populations. Further research is needed on long-term effects of antibiotic use for selective digestive decontamination and long-term use of locking solutions. Education To Reduce Device-Related Infection Risk Ongoing education of patients, staff, and caregivers can also help reduce the harms associated with device use. The CDC recommends several education and implementation interventions for staff and patients to help improve outcomes associated with device use. Further, the CDC advises allowing only individuals (including family and at- home caregivers) trained in appropriate techniques for catheter insertion and maintenance to perform these tasks. Other agency recommendations include quality improvement programs to provide ongoing training for staff on all the PSPs discussed above: automated alerts to reassess the need for device use, written guidelines, auditing and feedback of staff practices, and periodic training on insertion, maintenance, and removal. The SHEA/IDSA guidelines also state that staff education can help maintain high levels of compliance with recommended practices. Staff educational activities include workshops, hands-on training, and use of multiple modalities to convey information. Making information accessible in pocket pamphlets, posters, flowsheets, and other readily available modalities is also suggested. Finally, these guidelines state that educating patients and family on ventilator-associated guidelines can help them engage with and support the medical team’s care. Key findings related to invasive devices • Using devices minimally and appropriately and practicing hygiene and infection control precautions when inserting them are basic steps that can be taken to reduce device- associated infections. • Further research is needed to determine the safest and most effective uses of antimicrobial lockingsolutions and catheter materials. • Antimicrobial resistance has not been eliminated as a concern when using antibiotics in antibiotic locking solutions, impregnated catheters, or prophylactic treatment to prevent infections. education, monitoring, and feedback for medical staff, patients, and caregivers are recommended for improving adherence to recommended PSPs. Infusion Pumps Use of infusion pumps, and increasingly smart pumps, has become standard practice in hospitals to administer critical fluids to patients. However, there is still limited research on best practices for reducing errors and improving infusion pump use through workflow and process changes as well as education and training. Infusion pumps are used to administer fluids such as nutrients or medications to patients. • Ongoing implementation
In comparison to manual administration of fluids, infusion pumps provide the advantage of controlled administration—the ability to deliver fluids in small volumes or at precisely programmed rates or intervals. Many newer infusion pumps are equipped with predetermined clinical guidelines, dose error reduction systems (DERSs), and drug libraries that provide a comprehensive list of medicines and fluids with dose, volume, and flow rate details. These “smart pumps” are designed to address the programming errors that traditional pumps are susceptible to by notifying a user when there is a risk of an adverse drug interaction or when the pump’s parameters are set outside of specified safety limits for the medication being administered. Alerts generated by smart pumps include clinical advisories, soft stops, and hard stops. Clinical advisories provide information about medications within the administering facility’s drug library, including prompts for correct administration, which are programmed into the pump by the facility or larger organization. Soft stops notify users that a selected dose is outside of the anticipated range for a specific medication. These alerts can be overridden without changing the pump’s settings. Hard stops alert users that a dose is out of the institution’s determined range and prohibit the infusion from being administered unless the pump is reprogrammed. As infusion pump technology continues to evolve, use of smart pumps in hospitals has increased. Along with this increase, many national organizations have identified implementing smart pumps as a key patient safety tool. The Institute for Safe Medication Practices (ISMP) strongly supports the use of smart pump safety features, and in 2006, the Institute of Medicine identified adoption of smart pumps as a strategy hospitals can use to help reduce the frequency and severity of medication errors. 83 Despite the growing support for the use of smart pumps as a safety strategy, however, the literature shows varying results for the effect they have on reducing medication errors. User error, inadequate use of safety technology, incorrect programming, and equipment failures can still occur, significantly impacting patient safety. Potential harms The infusion pump, along with its failures and user errors, can have significant implications for patient safety because of its ubiquitous nature and frequent use to administer critical fluids. Infusion-associated medication errors are mistakes related to ordering, transcribing, dispensing, administering, or monitoring drugs. 84 From 2005 to 2009, the U.S. Food and Drug Administration (FDA) received approximately 56,000 reports of adverse events related to the use of infusion pumps, and manufacturers conducted 87 infusion pump recalls. Fourteen of these recalls were categorized as Class I, in which there is a reasonable probability that use of the recalled device will cause serious adverse health consequences or death.
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