Infection Control & Hospital Epidemiology
31 to 401,532 patients.15,17,20,22,24,26–28 Other studies reported only the patient days16,25 or number of studied hospitals.21 Another 3 studies did not specify the sample size.18,19,23 The duration of data collection was variable from 1 month to 60 months, and some studies collected >1 set of preintervention or/and postinterven- tion data. For our analysis, we used only the first preintervention and the final postintervention data.
Description of interventions
The types of interventions reported varied across studies. We classified all interventions into 2 categories. First, we considered interventions that sought to avoid unnecessary CVC placement (ie, patients without CVCs do not develop CLABSIs). Accord- ingly, 7 studies (50.0%) examined the effect of interventions to avoid unnecessary CVC placement. Among them, 1 study (7.1%) implemented institutional restrictions on CVCs, which used the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) to improve PICC use.20 Another 6 studies (42.9%) used ultrasound-guided peripheral intravenous catheters (USGPIVs) as an alternative to CVCs.17–19,22–24 Especially for patients with difficult vascular access, USGPIVs may reduce the need for CVCs. Second, we considered interventions to prompt the removal of unnecessary CVCs. Although guidelines strongly recommend prompt removal of CVCs,many CVCs are left in place when they are no longer needed. Chopra et al29 reported that 21.2% of clinicians were unaware of the presence of a CVC, and only a few hospitals had a written policy to evaluate CVC necessity or appropriateness.30 The most common strategy is to maintain physician or nurse awareness
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of the CVC’s existence, which occurs with reminder-system interventions. The remaining 7 studies (50.0%) all implemented reminder interventions.15,16,21,25–28 Reminder formats included verbal reminders, written or printed reminders, and online reminders.
Quality of included studies
The quality analysis of the included studies is presented in the Supplementary Materials online. The only RCT included had a medium risk of bias due to random sequence generation and blinding of outcome assessment, but it did not include allocation concealment or blinding of participants.28 Among the 9 QESs, 8 reported clear cause and effect,15–17,19–21,25,27 5 included similar participants in comparisons,15,17,19–21 and all 9 reported participants that received similar treatments. However, only 1 study had a control group,20 and 4 studies hadmultiplemeasurements of outcomes both before and after the intervention.18–21 The remaining 4 cohort studies all reported a low risk of bias in the selection of participants, comparability of cohorts, and outcome measures.22–24,26 Overall, the quality of studies included was moderate to high.
Primary outcomes
CVC use. All included studies reported the outcomes of CVC use despite diverse measurements and reporting methods (Table 2). Overall, 7 studies reported the number of CVCs used,18–20,22–25 with different reporting methods. Moreover, 2 studies reported the number of CVCs used per 1,000 patient days. Compared with nonintervention groups, CVC use in the intervention groups sig- nificantly decreased by 46.6% and 33.6%, respectively (P<.01).20,25
Table 2. Details of Central Venous Catheter (CVC) Use Outcomes Reported in Studies Results Outcome: CVC Use No. of CVCs /1,000 patient days
No. of newly placed CVCs/day Patients with CVCs, %
First Author, Year
Swaminathan 201720 Grady 201525 Galen 201823 Morata 201718 Reeves 201719 AU 201222
Patients with inappropriate CVCs, no. (%)
Mccarthy 201324 Reeves 201719
Total CVC days, mean (SD) CVC days avoided
Mean duration of CVC days, median (IQR) Mean duration of CVC days, mean (SD) Total catheter days/total patient days, %
Reduction rate, (pre–post)/pre × 100%. aP<.05, statistically significant.
Swaminathan 201720 Ilan 201226 Arora 201415 Weeks 201421 Deutsc 201317 Seguin 201027
Rattanaumpawan 201628 Chandramohan 201816
Pre (Con) 9.51
130.8 0.67
Not reported Not reported Not reported 0.81
26/60 (43.3)
472/517 (91.3) 41/81 (50.6) 3,986 (199.3) 516(403)
Post (Exp) 6.31
69.8 0.47
Not reported Not reported Not reported 0.16
17/64 (26.6)
291/446 (65.3) 29/110 (26.4) 4,305 (215.2) 481(420)
283 central-line days avoided 5(3–9)
2.7 ± 14.6 46
4 (3–7)
1.9 ± 8.8 39
Reduction Rate (%) 33.6a 46.6a 29.9 46.7 24.0 85.0 80.2
38.7a 28.5a 47.8a − 8.0a 6.8a
20.0a 29.6a 15.2
Note. CVC, central venous catheter; SD, standard deviation; IQR, interquartile range; Pre (Con), preintervention or control group; Post (Exp), postintervention or experimental group;
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