1446
Galen et al23 described the number of newly placed CVCs per day and found a 29.9% decrease, but the difference was not significant (P=.08). The other 4 studies simply reported the reduction in the rate of patients with CVCs, ranging from 24.0% to 85.0%.18,19,22,24 The rate of inappropriate CVC placement was reported in
days,15–17,21,26,27 and they all described a decrease of CVC days at the intervention site compared to the nonintervention site, except one. Aora et al15 found a statistically significant increase in the number of CVC days, which may have been related to more CVCs being captured through the implementation of a reminder intervention. Deutsch et al17 reported a total of 283 central-line days avoided during the study period by using USGPIVs. Weeks et al21 showed significant decreases in total line days and 4% fewer central-line catheter days. The other 2 studies reported that a reminder intervention significantly reduced the mean duration of CVC days per patient (P<.01).27,28 Chandramohan et al16 mentioned that the CVC utilization ratio, calculated by dividing the number of total catheter days by the number of patient days, nonsignificantly decreased from 46% to 39%.
3 studies, including 2 QESs19,20 and 1 cohort study,26 but the definitions of inappropriate CVCs were quite different among the 3 studies. Reeves et al19 referred to PICCs inserted only because of an inability to obtain PIV access; Swaminathan et al20 defined it in accordance with MAGIC; and Ilan et al26 referred to no apparent indication for CVC placement. In all 3 studies, however, a significant decrease in the percentage of patients with inappropriate CVCs after an intervention was reported (P<.05). Moreover, 6 studies reported the CVC use in terms of CVC
Secondary outcomes
Only 2 studies mentioned compliance with the intervention. Rattanaumpawan et al28 reported that nurse compliance was 83%, whereas responsible physician compliance was only 74%. Grady et al25 reported an overall auditing adherence rate of 70%. Only 1 study provided data on catheter-related noninfectious complications.20 They observed a significant decrease of 6.4% in the proportion of patients with catheter occlusion after inter- vention and no significant change in the proportion of patients with venous thrombus embolism. The single cluster RCT reported hospital-related outcomes.28
USGPIV to replace CVCs. Deutsch et al17 reported an estimated cost savings of $13,614 were avoied during the study period. Morata et al18 observed a cost savings of ~$1,545,600.
Discussion
CLABSI rate Overall, 7 studies reported the incidence of CLABSIs; they all described a trend toward a reduction in CLABSI ranging from 24.4% to 100.0% (Table 3). Another 4 studies reported the CLABSI rate as a percentage of patients who developed CLABSIs.15,20,27,28 Only Rattanaumpawan et al28 and Seguin et al27 found a statistically significant reduction (P<.05).Moreover,5 studiesreportedCLABSI episodes per 1,000 CVC days,15,16,21,26,27 the preferred reporting method requested by the CDC/NHSN, and 3 studies reached a statistically significant reduction in the CLABSI rate (P<.05).21,26,27
In this review, we identified a decrease in CVC use after inter- ventions, despite nonuniform reporting methods. The reduction in CVC use varied from 6.8% to 85%. Such a wide range in the reduction rate is likely related to several factors: diverse study designs, different settings, variable analysis units, and differing definitions. Half of the included studies indicated that the CLABSI rate decreased by 24.4%–100.0% after the intervention. Also, CVCs were inserted in ~30% of hospitalized patients,31 and CVC use has inherent risks, most notably CLABSI. However, many CVCs are now inserted inappropriately or are not promptly removed, resulting in CVCs being unnecessarily retained in patients.32 Our literature review revealed that the prevalence of unnecessary CVC use ranges between 4.6% to 32.7%.33,34 Pre- vious studies have described a strong link between unnecessary CVC use and adverse device-related local and systemic compli- cations.32 These reports are consistent with our findings that interventions for the prevention of unnecessary CVC use are effective in decreasing CLABSIs.
Table 3. Details of Central-Line–Associated Bloodstream Infection (CLABSI) Rate Outcomes Reported in Studies Results
Outcome: CLABSI Rate Patients who developed CLABSIs, no. (%) First Author, Year
Rattanaumpawan, 201628 Seguin, 201027
CLABSI episodes/1,000 CVC days
Swaminathan, 201720 Arora, 201415 Arora, 201415 Weeks, 201421 Seguin, 201027 Ilan, 201226
Chandramohan, 201816
pre × 100%. aP<.05, statistically significant.
Pre (Con)
13/441 (29.5) 12/676 (1.8)
126/3,083 (4.1) 14/1,776 (0.8) 3.5
1.96 2.8 0.5
1.45
Post (Exp) 9/433 (20.3) 2/595 (0.3) 14/446 (3.1) 7/1,526 (0.5) 1.6
1.15 0.7 0
0.39
Reduction Rate (%) 31.2a 83.3a 24.4 37.5 54.3
41.3a 75.0a
100.0a 73.1
Note. CLABSIs, central-line–associated bloodstream infections; pre (Con), preintervention or control group; post (Exp), postintervention or experimental group; reduction rate=(pre–post)/
In this study, the reminder group had a significantly shorter LOS, but hospital mortality was comparable between the 2 groups. Two studies analyzed the cost-effectiveness of implementing
Zhaoyu Xiong and Haiyan Chen
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