Monday 15 August 2016

Central Line

I came across an interesting long-form article in Vox. Written by Sarah Kliff and published in last July, it is subtitled There’s an infection hospitals can nearly always prevent. Why don’t they? I paused before getting to the meat to ask myself what it might be: C.diff? Kaposi's sarcocoma? Staph aureus? But the infection isn't about an infective species but an infective practice. Or rather, poor practice - with the administration of drugs by central line - that results in avoidable infection and all too often, death. As it happens, the bacteria involved is often Staphylococcus aureus or S. epidermidis, so I was partly right.

Wot's a central line, then? It is a central venous catheter CVC: a tube with a sharp end that is inserted into a large vein with quite direct access to the heart - usually femoral, jugular or sub-clavian vein. Once this is inserted, the nursing staff can connect ampoules of medication for delivery direct to the circulatory system and they can do it multiple times. Intra-muscular or sub-cutaneous injection is more appropriate for once-off administration and takes time to disperse or deliver to where it is needed. Trouble occurs where / when outside meets inside. A nurse who doesn't wash her hands, or washes her hands, gloves up and then touches the bed-stead; a dressing applied crooked, or not at all . . . and suddenly you have an infected catheter. Infected with MRSA and your sick patient is in significantly deeper doo-doo than before. Between 1990 and 2010, US hospitals logged 25,000 central line infections CLI every year. Half a million events is data, and the Center for Disease Control CDC in Atlanta compiled a list of 90 interventions that they believed to reduce the likelihood of CLIs. Dr Peter Pronovost, working in the ICU at Johns Hopkins U. in Baltimore was determined to get to the bottom of the epidemic, at least on his watch, in his hospital. For him, a raw list of 90 possible things to avoid was far too long for busy doctors and nurses to read with attention: surely some were more useful than others? surely some were essentially the same as others? So he dug a little, thought a little, consulted a little, researched a little and came up with a shorter list:
  • wash hands
  • cover staff and patient in sterile clothing
  • swab chlorhexidine locally
  • avoid groin-area [eeeuw] catheters [so no femoral vein, pls]
  • remove unused catheters 
and empowered and trained the nurses to own CVCs and keep them clean; even if that meant calling out doctors who didn't follow the short-list. But he also created CVC carts that had all the necessary supplies at hand - to make it easier to do the right thing. CLIs fell by 50% within 90 days and by 70% within six months. Other ICU staff in other hospitals read the literature, implemented similar check-lists and saw their infection rates plummet as well.

The article also points out the virtue of hospitals being prepared to admit error and engaging with the relatives of those mistakes. Doing this
  • shows compassion 
  • helps prevent further similar cases
  • and reduces the likelihood of a costly legal case against the hospital. 
What we've seen in Ireland, again and again, is that the parents of dead children don't want money, they want an assurance that no other family will suffer as they have.

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