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Background: Central line-associated bloodstream infections (CLABSIs) have decreased significantly over the last decade. Further reductions in CLABSI rates should be possible. We describe a multidisciplinary approach to the reduction of CLABSIs., Methods: This was an observational study of critically ill patients requiring central venous catheters in 8 intensive care units in a tertiary medical center. We implemented a catheter bundle that included hand hygiene, education of providers, chlorhexidine skin preparation, use of maximum barrier precautions, a dedicated line cart, checklist, avoidance of the femoral vein for catheter insertion, chlorhexidine-impregnated dressings, use of anti-infective catheters, and daily consideration of the need for the catheter. Additional measures included root cause analyses of all CLABSIs, creation of a best practice atlas for internal jugular catheters, and enhanced education on blood culture collection. Data were analyzed using the Poisson test and regression., Results: CLABSI, catheter use, and microbiology were tracked from 2004 to 2012. There was a 92% reduction in CLABSIs (95% lower confidence limit: 67.4% reduction, P < 0.0001). Central venous catheter use decreased significantly from 2008 to 2012 (P = 0.032, -151 catheters per year, 95% confidence limits: -277 to -25), whereas peripherally inserted central catheter use increased (P = 0.005, 89 catheters per year, 95% confidence limits: 50 to 127). There was no apparent association between unit-specific Acute Physiology And Chronic Health Evaluation III/IV scores and CLABSI. Three units have not had a CLABSI in more than a year. The most common organism isolated was coagulase-negative staphylococcus. Since the implementation of minocycline/rifampin catheters, no cases of methicillin-resistant Staphylococcus aureus CLABSI have occurred., Conclusions: The implementation of a standard catheter bundle combined with chlorhexidine dressings, minocycline/rifampin catheters, and other behavioral changes was associated with a sustained reduction in CLABSIs.

Background: Although patients with sleep apnea (SA) are considered to be at increased risk for postoperative complications, evidence supporting increased risk of perioperative pulmonary morbidity is limited. The objective of this study, therefore, was to analyze perioperative demographics and pulmonary outcomes of patients with SA after orthopedic and general surgical procedures using a population-based sample. We hypothesized that SA is an independent risk factor for perioperative pulmonary complications, thus providing a basis for an increase in the utilization of resources, including intensive monitoring and development of strategies to prevent and treat these events., Methods: National Inpatient Sample data for each year between 1998 and 2007 were accessed. Orthopedic and general surgical procedures were included and discharges with a diagnosis code for SA were identified. Patients with the diagnosis of SA were matched to those without the disease based on demographic variables using the propensity scoring method. Aspiration pneumonia, adult respiratory distress syndrome (ARDS), pulmonary embolism (PE), and the need for intubation and mechanical ventilation were the primary outcomes. Odds ratio (OR) and absolute risk reduction along with 95% confidence interval were reported., Results: We identified 2,610,441 entries for orthopedic and 3,441,262 for general surgical procedures performed between 1998 and 2007. Of those, 2.52% and 1.40%, respectively, carried a diagnosis of SA. Patients with SA developed pulmonary complications more frequently than their matched controls after both orthopedic and general surgical procedures, respectively (i.e., aspiration pneumonia: 1.18% vs 0.84% and 2.79% vs 2.05%; ARDS: 1.06% vs 0.45% and 3.79% vs 2.44%; intubation/mechanical ventilation: 3.99% vs 0.79% and 10.8% vs 5.94%, all P values <0.0001). Comparatively, PE was more frequent in SA patients after orthopedic procedures (0.51% vs 0.42%, P = 0.0038) but not after general surgical procedures (0.45% vs 0.49%, P = 0.22). SA was associated with a significantly higher adjusted OR of developing pulmonary complications after both orthopedic and general surgical procedures, respectively, with the exception of PE (OR for aspiration pneumonia: 1.41 [1.35, 1.47] and 1.37 [1.33, 1.41]; for ARDS: 2.39 [2.28, 2.51] and 1.58 [1.54, 1.62]; for PE: OR 1.22 [1.15, 1.29] and 0.90 [0.84, 0.97]; for intubation/mechanical ventilation: 5.20 [5.05, 5.37] and 1.95 [1.91, 1.98])., Conclusion: SA is an independent risk factor for perioperative pulmonary complications. Our results may be used for hypothesis generation for clinical studies targeted to improve perioperative outcomes in this patient population.

Background: There is a paucity of perioperative outcomes data for patients with chronic pulmonary hypertension (PHTN) undergoing noncardiac surgery. Clinicians, therefore, have little information on which to evaluate the risk for morbidity and mortality in this patient population. In this study, we evaluated the incidence and risks of perioperative morbidity and mortality in patients with PHTN undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA)., Methods: Using the largest inpatient database in the United States (National Inpatient Sample), we identified entries for THA and TKA between the years of 1998 and 2006. Patients with the diagnosis of PHTN were identified and matched to those without the disease based on health-related demographic variables. Perioperative mortality was considered the primary outcome. Multivariate logistic regression models were fitted to assess the impact of PHTN on in-hospital mortality., Results: We identified 670,516 entries for TKA and 360,119 for THA. Of those patients, 2184 (0.3%) and 1359 (0.4%), respectively, had the diagnosis of PHTN (average annual rate of 1180 for TKA [range, 507-2073] and 739 for THA [range, 467-1054]). Patients with PHTN undergoing THA experienced an approximately 4-fold increased adjusted risk of mortality (2.4% vs 0.6%), and those undergoing TKA a 4.5-fold increased adjusted risk of mortality (0.9% vs 0.2%) compared with patients without PHTN in the matched sample (P < 0.001 for each comparison). Patients with primary PHTN undergoing THA experienced the highest mortality rate (5% [95% CI, 2.3%-7.7%])., Conclusions: This analysis demonstrates that patients with PHTN are at increased risk for perioperative mortality after THA and TKA.