Explore the vast range of titles available.

Background Urinary and (peripheral and central) intravenous catheters are widely used in hospitalized patients. However, up to 56% of the catheters do not have an appropriate indication and some serious complications with the use of these catheters can occur. The main objective of our quality improvement project is to reduce the use of catheters without an appropriate indication by 25–50%, and to evaluate the affecting factors of our de-implementation strategy. Methods In a multicenter, prospective interrupted time series analysis, several interventions to avoid inappropriate use of catheters will be conducted in seven hospitals in the Netherlands. Firstly, we will define a list of appropriate indications for urinary and (peripheral and central) intravenous catheters, which will restrict the use of catheters and urge catheter removal when the indication is no longer appropriate. Secondly, after the baseline measurements, the intervention will take place, which consists of a kick-off meeting, including a competitive feedback report of the baseline measurements, and education of healthcare workers and patients. Additional strategies based on the baseline data and local conditions are optional. The primary endpoint is the percentage of catheters with an inappropriate indication on the day of data collection before and after the de-implementation strategy. Secondary endpoints are catheter-related infections or other complications, catheter re-insertion rate, length of hospital (and ICU) stay and mortality. In addition, the cost-effectiveness of the de-implementation strategy will be calculated. Discussion This study aims to reduce the use of urinary and intravenous catheters with an inappropriate indication, and as a result reduce the catheter-related complications. If (cost-) effective it provides a tool for a nationwide approach to reduce catheter-related infections and other complications. Trial registration Dutch trial registry: NTR6015 . Registered 9 August 2016.

The prevalence of radial access for transradial catheterization remains low in the United States, occurring in only 28% of cases in the National Cardiovascular Data Registry (NCDR) CathPCI. It is unknown whether the low adoption rate has been influenced by patient characteristics or is more operator dependent. In a 10-center study, we compared clinical and demographic characteristics among 323 radial and 1,506 femoral access percutaneous coronary intervention (PCIs) performed by 65 interventionists capable of radial PCI. We created a hierarchical logistic regression model to identify operator and patient characteristics associated with radial PCI and the median rate ratio to quantify the variation across operators. A subset was interviewed to assess health literacy and preferences in shared medical decision making. Radial access was used in 17.7% of patients. Patient factors associated with lower rate of radial PCI were previous PCI (33.4% vs 41.4%, p = 0.008), history of coronary artery bypass graft (8.4% vs 23.0%, p <0.001), and chronic total occlusion PCI (10.2% vs 17.9%, p <0.001). Operator characteristics associated with lower rate of radial PCI are being older, being longer in practice, lower number of publications, and Southern practice location. The range of radial use across operators was 1% to 99% and the median rate ratio was 1.97. Patients with radial access had lower health literacy, as assessed by the Rapid Estimate of Adult Literacy in Medicine Revised (REALM) score (6.6 ± 2.6 vs 7.1 ± 2.0, p = 0.03) but did not differ in their preferences for shared decision making. In conclusion, our study demonstrates a high degree of variability of radial access for PCI among different operators, with few differences in patient characteristics, suggesting that improvement efforts should focus on operators.

Emergency medical services (EMS) preparedness is essential to reduce morbidity and mortality from mass casualty incidents (MCIs). We sought to describe types and frequencies of common procedures performed during MCIs by EMS providers at different service levels. This study was carried out using the 2012 US National EMS Public-Release Research Dataset maintained by the National Emergency Medical Services Information System. Emergency medical services activations coded as MCI at dispatch or by EMS personnel were included. The Center for Medicare and Medicaid Services service level was used for the level of service provided. A descriptive analysis characterizing the most common procedure types and frequencies by service level was carried out. Among the 19831189 EMS activations in the 2012 national data set, 53334 activations had an MCI code, of which 26110 activations were included. There were 8179 advanced life support (31.3%), 5811 basic life support (22.3%), 399 air medical transport (air transport fixed or rotary) (1.5%), and 38 specialty care transport (0.2%) activations. A total of 107 different procedure types were reported. The most common procedures by procedure count were “spine immobilization” (21.8%) followed by “venous access extremity” (14.1%) and “assessment adult” (13.4%). A similar order was found for procedure frequencies by included EMS activations (24.1%, 19.3%, and 18.3%, respectively). Top 20 procedures had different frequencies by levels of care except for “medical director control” (P = .19). Advanced EMS interventions are not frequent during MCIs in the United States. Emergency medical services systems with other types of providers or MCI response patterns might report different findings.

Objective: Our objective was to safely reduce the number of peripherally inserted central catheters (PICCs) inserted in infants with umbilical venous catheter using quality improvement methods. Study Design: In a tertiary neonatal intensive care unit, a questionnaire designed to prompt critical thinking around the decision to place a PICC, along with an updated standardized feeding guideline was introduced. PICC insertion in 86 infants with umbilical venous catheter (pre intervention) with birth weight 1000–1500 g were compared with 115 infants (post intervention) using Fisher’s exact test. Results: PICC lines inserted after the intervention decreased by 37.5% (67/86; 77.9% vs 56/115; 48.7%; P <0.001). The proportion of central line-associated blood stream infection were 2.49 vs 2.82/1000 umbilical venous catheter days; P =0.91 in the two epochs, respectively. Conclusion: Quality improvement methodology was successful in significantly reducing the number of PICCs inserted without an increase in central line-associated blood stream infection.

Time to delivery of medications, fluids, and blood products can be vital for survival. Because of ease and speed, pediatric advanced life support (PALS) training advises IO access if intravenous (IV) access is unsuccessful after 2 attempts [2]. To compare emergent vascular access techniques, a convenience sample of 41 EM residents, faculty, and physician assistants from our academic institution volunteered to place a simulated femoral central line, ultrasound-guided IV, and proximal tibia IO.

In critical care settings, arterial catheters (ACs) are very useful in monitoring the blood pressure and are often used for repetitive blood sampling. No studies have been performed that compare the approach and complication rates of ACs in a medical intensive care unit (MICU) to those in a surgical intensive care unit (SICU). Over a 24-month period, 3255 patients were admitted to the MICU and 1677 to the SICU of Howard University Hospital. Of the total patients admitted, 2119 patients had an AC placed at the time of admission and were included in this study. Patient age, site of catheter insertion, interval to catheter change, number of changes, and overall complications associated with arterial catheterization were determined for both ICUs. In the MICU, 1554 patients (48%) were subjected to an AC as compared to 565 (33%) in the SICU. The femoral artery was cannulated in 45 per cent of the patients in the MICU and in 11.5 per cent in the SICU. The radial artery was used in 52 per cent of MICU patients and in 78 per cent of SICU patients. The brachial artery was cannulated in 0.5 per cent of MICU patients and 3 per cent of SICU patients. AC was changed in 9.5 per cent of MICU patients and 13 per cent of SICU patients. The choice of the femoral artery as a new line was more common in the MICU than in the SICU. The most common complication was vascular insufficiency (3.4% in MICU and 4.6% in SICU), followed by bleeding (1.8% in MICU and 2.6% in SICU) and infection (0.4% in MICU and 0.7% in SICU). Patients who had femoral arterial lines in MICU were older than those in SICU (mean age, 66 vs 43 years). Rate of infection was similar in both ICUs and between radial and femoral arterial sites (43% in MICU and 50% in SICU). We conclude that the preferred site for artificial cannulation in MICU is femoral and in SICU is radial artery. The infection rate was similar in both units, regardless of the different site or approach used. Vascular insufficiency followed by bleeding was the most common vascular complication after line changes using a guide wire. Arterial spasm and pulselessness were more commonly found after new-site insertion. The site of AC placement and the timing/number of catheter/site changes made no significant difference in terms of complications, which is a new finding compared to other previous reports. The rates of infection between radial and femoral artery were similar.

Objectives To evaluate the efficacy and safety of purse-string sutures (PSS) compared with manual compression for access hemostasis in children with atrial septal defects (ASDs) after large-caliber venous delivery sheaths removal. Methods We conducted a retrospective clinical data review of 271 children with ASDs who underwent transcatheter device closure through large-caliber venous delivery sheaths (≥ 8 Fr) at our institution from January 2018 to January 2023. The PSS group ( n  = 144) was compared to the control group ( n  = 127), which underwent manual compression for femoral venous hemostasis after sheath removal, focusing on hemostatic time, limb braking time, bed rest time, hospital stay, and vascular access complications. Two days post-catheterization, the sutures were taken out and a vascular ultrasound found the evidence of thrombosis, embolism, or venous narrowing. Results Compared to the control group, the PSS group had significantly shorter average hemostatic time (4.63 ± 1.95 min vs. 19.69 ± 5.64 min), limb braking time (6.83 ± 2.25 h vs. 13.45 ± 2.87 h), and bed rest time (8.69 ± 1.43 h vs. 22.93 ± 2.24 h) (all, p  < 0.001). There were no statistically significant differences in hospital stay and complications between the two groups. Conclusions The PSS is a simple, effective, and safe procedure that may play a valuable role in achieving rapid hemostasis after the removal of the large-caliber venous delivery sheaths in children. It allows earlier mobilization, reduces bed rest time, and alleviates discomfort compared to manual compression.

Background Many patients are admitted to hospital with non-visible or palpable veins, often resulting in multiple painful attempts at cannulation, anxiety and catheter failure. We developed a difficult intravenous pathway at our institution to reduce the burden of difficult access for patients by increasing first attempt success with ultrasound guidance. The emphasis was to provide a solution for hospitalised patients after business hours by training the after-hours clinical support team in ultrasound guided cannulation. Methods Inception cohort study of patients referred to the after-hours clinical support team including outcomes such as number of attempts at cannulation before and after referral, insertion site, type of device inserted and recorded pain score for attempts prior to referral and for attempts by the after-hours clinical support team. Results Between January and December 2016, 379 patients were referred to the after-hours clinical support team for placement of a peripheral intravenous catheter under ultrasound guidance. The median number of unsuccessful attempts before referral was 2 (IQR 2, 4), this ranged between 1 attempt to 10 attempts compared to only 1 attempt (IQR 1, 1, p  < 0.001) with no more than 2 attempts in total by the after-hours clinical support team. The first time success rate by the after-hours clinical support team was 93% ( n  = 348). The median pain score for attempts with ultrasound use was 2/10 (IQR 1–3) compared to 7/10 (IQR 5–9) for previous attempts without ultrasound ( p  < 0.001). Conclusion The use of ultrasound guidance for peripheral intravenous catheter insertion by the after-hours clinical support team for patients with difficult venous access has been successful at our institution with 9 out of every 10 catheters inserted at first attempt with significantly lower recorded pain scores.

Many successful implementation studies fail to be sustained and spread after the publication. We aimed to spread a successful deimplementation strategy that reduced inappropriate peripheral venous catheter and urinary catheter use and evaluated the spread, adoption and effects of this strategy in clinical practice.We adapted the original successful study into a more accessible project, creating a toolkit called Better without catheter. We recruited 39 hospitals (more than half of all Dutch hospitals) across the Netherlands, which participated in regular online meetings. After 21 months, we sent an online survey to the project leaders of the participating hospitals to assess progress, barriers and facilitators to adopting the project.Widespread promotion and targeted emails were key factors in spreading Better without catheter. There was considerable variation in the hospitals’ progress; five had not yet started, six had completed the project and the others were at various stages in between. Major barriers included lack of time and resources, organisational facilities and the composition of local project teams. Key facilitators were organisational support and the involvement of physicians and nurse leaders. Project leaders valued the toolkit, the flexibility to tailor the project and the online meetings.Overall, the spread and adoption of this deimplementation strategy showed encouraging results, with 39 hospitals joining the network within 2 years. Although reach and engagement were high, the hospitals’ progress in the project was frequently hindered by organisational and management factors. Four elements supported the uptake: widespread promotion, the translation of the original study into an accessible improvement project with practical tools, the flexibility to tailor the approach locally and participation in a peer network.