Tag Archives: Incidence/Prevalence

Are occlusive dressings effective for preventing central line infections?

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Webster J, et al. Gauze and tape and transparent polyurethane dressings for central venous catheters. Cochrane Database Syst Rev. 2011 Nov 9;(11):CD003827.
Reviewed six studies; “four compared gauze and tape with transparent polyurethane dressings (total participants – 33) and two compared different transparent polyurethane dressings (total participants = 126).” A four-fold increase in CLABSIs was found with polyurethane dressings. However, because of a risk of bias and wide confidence intervals the “true effect could be as small as 2% or as high as 17-fold.”

McCann M, Moore ZE. Interventions for preventing infectious complications in haemodialysis patients with central venous catheters. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006894.
Includes review of one study (n=58) on use of polyurethane transparent dressings and gauze in hemodialysis patients. There was no statistically significant difference in incidence of central line site infection or central-line associated bacteremia between gauze and polyurethane.

Gillies D, et al. Central venous catheter dressings: a systematic review. J Adv Nurs. 2003 Dec;44(6):623-32.
Searched Cochrane databases, Medline, CINAHL, and CancerLit.  Identified and reviewed 8 studies that evaluate various dressings in the incidence of CVC-related infection and in catheter-related sepsis in hospitalized patients.
RESULTS: Studies included comparison of gauze/tape v. Opsite IV 3000; Opsite v. Opsite IV 3000; Tegaderm v. Opsite IV 3000; Tegaderm v. Opsite.
In the 6 studies with pooled data, odds ratios did not favor either group for incidence of infection. Review was limited in that all studies had small populations.
See Table 4 for summary of meta-analysis.

Hoffman K, et al. Transparent polyurethane film as an intravenous catheter dressing. A meta-analysis of the infection risks. JAMA. 1992 Apr 15;267(15):2072-6
This is a systematic review of 7 studies, but a couple of the studies compared gauze plus a topical antiseptic preparation to occlusive dressing without the topical.

Reviewed and updated 4/24/2014 ldt

What is the national benchmark for restraint use in acute rehabilitation facilities?

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ait Bottom line: No national benchmark for restraint use in rehabilitation facilities was identified in the NDNQI, but one study published data on prevalence (restraint use per 100 patient days) of physical restraints prior to implementing a reduction program in this setting.

Minnick AF, et al. Prevalence and variation of physical restraint use in acute care settings in the US. J Nurs Scholarsh. 2007;39(1):30-37.
Prevalence of physical restraint on 18 randomly selected days found a prevalence of 50 uses per 1,000 patient days.

Amato S, et al. Physical restraint reduction in the acute rehabilitation setting: a quality improvement study. Rehabil Nurs. 2006;31(6):235-241.
This prospective study measured restraint use before and after a multi-pronged approach to decreasing the use of restraints in a stroke rehabilitation unit and a brain injury rehabilitation unit. Restraint use before the intervention started:
Stroke Rehab Unit: 216.6 hours per 100 patient days
Brain Injury Rehab Unit: 1054.3 hours per 100 patient days

Kwok T, et al. Does access to bed-chair pressure sensors reduce physical restraint use in the rehabilitative care setting?  J Clin Nurs. 2006 May;15(5):581-7.
Reports on use of physical restraints by providing the percentage of patients who were physically restrained for some portion of their hospital stay.

Gallinagh R, et al. The use of physical restraints as a safety measure in the care of older people in four rehabilitation wards: findings from an exploratory study. Int J Nurs Stud. 2002;39(2):147-156.
Uses percentages of patients and not restraint use/1000 patient days.

Reviewed 4/10/2014

Are physical restraints safe and effective for preventing unplanned extubation in non-ICU, vented patients?

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Bottom line:  In ICU units many intubated patients who remove their own tubes do so while some type of physical restraint is in use.

A search of PubMed, CINAHL and EMBASE retrieved only studies of patients in intensive care.  No direct published evidence addresses efficacy of restraints at reducing self-extubations in patients outside of ICU units.  The following systematic review addresses association between use of restraints and self-extubation in patients on ICU units.

da Silva PS, Fonseca MC. Unplanned endotracheal extubations in the intensive care unit: systematic review, critical appraisal, and evidence-based recommendations. Anesth Analg. 2012;114(5):1003-1014.
Seventeen of the fifty studies that were included in this systematic review examined the incidence of unplanned extubation in physically restrained patients. The percentage of restrained patients under physical restraint at the time of unplanned extubations ranged from 25%” to 87%. Only one study identified the use of physical restraints as a risk factor for unplanned extubations on multivariate analysis (OR 3.1, 95% CI 1.71–5.7). The article concluded that use of physical restraints remains controversial.

Reviewed and updated 4/10/2014 ldt

 

Are there randomized controlled trials of multi-pronged interventions to reduce falls in acute care settings?

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There are two randomized controlled trials on multiple interventions to prevent falls in acute care settings.

Dykes PC, et al.  Fall prevention in acute care hospitals : A randomized trial.  JAMA. 2010;304(17):1912-1918.
This study randomly assigned nursing units 1) to use an intervention including a specific risk assessment tool, care plan based on the assessment, patient and family education materials or 2) to provide usual care (control). Baseline characteristics of units were similar. Table 3 (p. 1916) summarizes differences in fall rates (per 1,000 patient days) for all patients as well as specifically for patients aged 65+. Significant differences favored the units using the intervention.

Ang E, Mordiffi SZ, Wong HB. Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized controlled trial. J Adv Nurs. 2011;67(9):1984-1992.
There were 912 and 910 participants in the control and intervention groups, respectively. Intervention group patients received usual care and targeted multiple interventions based on individual risk factors of the Hendrich II Falls Risk Model; unfortunately, the article does not provide examples of interventional techniques. The fall incidence rates were 1·5% (95% CI: 0·9-2·6) and 0·4% (95% CI: 0·2-1·1) in the control and intervention groups, respectively. The relative risk estimate of 0·29 (95% CI: 0·1-0·87) favors the intervention group.

Reviewed and updated 4/10/2014 ldt

Does hourly or intentional rounding reduce the rate of accidental falls in acute care facilities?

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Bottom line:  Intentional rounding and hourly rounding are associated with reduced fall rates, but higher quality study designs are needed to determine the extent of benefit in various settings.

Summary:
Halm MA.  Hourly rounds: What does the evidence indicate? Am J Crit Care 2009;18:581-584.
Seven of nine studies in which falls were evaluated found a decrease in fall rates upon implementation of hourly rounding. Table 1 (p. 582) of this review summarizes effect on fall rates, as well as patient satisfaction and other indicators, in recent studies on hourly rounding.

Meade C, et al. (2006) is a highly cited study included in the review by Halm. This quasi-experimental, non-randomized study compared fall rates among units assigned to one of three groups:  1) hourly rounding 7am-3pm & every 2 hours 3pm-7am, 2) rounding every 2 hours, or 3) no specific procedure for rounding.  Groups 1 and 2 had specific procedure to follow.
RESULTS: Group 1 (hourly) – 25 falls during baseline period reduced to 12 falls during study period (p=0.01); Group 2 (every 2 hours) – 19 falls reduced to 13 falls; Group 3 (control) – 18 falls reduced to 17 falls.

Of the 11 articles not included in the review by Halm listed here, eight found a reduction in falls upon implementation of intentional rounds; note that some of the ten articles’ institutions implemented other fall prevention strategies in addition to intentional rounds. Only one of the eight articles stated that the reduction in falls was significant (Saleh et al., 2013). For the two remaining articles, the difference in the number of falls was not found to be significant in one article due to the infrequency of falls (Krepper et al., 2014), one did not experience consistently improved outcomes (Dyck et al, 2013), and the total number of falls did not change but the number of falls with injury was reduced (Sherrod, 2012). Dyck et al. (2013) discusses how they sustained participation in the program despite inconsistent outcomes.

Reviewed and updated 4/15/2014 ldt

What are the most common factors associated with accidental falls in acute care facilities?

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All four systematic reviews determined that impaired mental status and a history of falls are common factors associated with accidental falls in acute settings. See below for other risk factors.

Summary:

Arch Phys Med Rehabil. 2014 Jan;95(1):50-57.
After conducting a systematic review of the literature to identify risk factors, researchers linked the 88 factors to 66 International Classification of Functioning, Disability, and Health (ICF) categories and 5 personal factors (see Appendix 1). Twenty multidisciplinary participants from different institutions completed three rounds of rating the importance of each category and factor regarding falls in acute rehabilitation settings using a 5-point Likert scale.
RESULTS: Thirty-four ICF categories and two personal factors achived threshold values of importance, and their scores are listed in Table 1. Of these, items scored 4.9 or 5.0 include four body functions (consciousness fuctions (i.e. confusion/disorientation), sensations association with hearing and vestibular function (i.e. dizziness/vertigo), muscle power functions (i.e. motor status related to stroke), and gait pattern functions (i.e. gait stability)), one activity (walking), and one personal factor (previous falls).

Arch Gerontol Geriatr. 2013 May-Jun;56(3):407-415.
Systematic review with ten studies that met the inclusion criteria for studies on older hospital patients. When there were at least 3 studies investigating a factor in a comparable way in a specific setting, researchers computed the pooled odds ratio (OR) using random effect models.
RESULTS: Six risk factors for older hospital inpatients (HI) were considered, and the strongest association was a history of falls (OR=2.85). Other risk factors that were significantly associated with falls were cognitive impairment (OR = 1.52 overall, OR = 1.65 multivariate), use of sedatives (OR = 1.89 overall and multivariate), and use of antidepressants (OR = 1.98 overall and multivariate).

Age Ageing. 2004 Mar;33(2):122-30.
This is a systematic review of thirteen studies that described risk factors in a variety of inpatient settings.
RESULTS: A small number of factors were repeatedly found to be significant: gait instability, lower limb weakness, previous fall history, medications, toileting factors (urinary incontinence/frequency or need for assistance), and agitation/confusion or impaired judgement. See Table 3 for odds ratios and confidence intervals for all risk factors.

Int J Nurs Pract. 2001 Feb;7(1):38-45
This is a systematic review of 13 case-control and 5 cohort studies of patient falls in hospitals.
RESULTS: Factors associated with increased risk of falling included special toileting needs (incontinence, needing assistance, having diarrhea), impaired mobility or use of mobility aid, impaired mental status, and history of falling. Doesn’t provide any numerical risk data.

Reviewed and updated 4/10/2014 ldt

Communicating about evidence-based practice in patient care

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Welcome. This blog facilitates communication on issues of evidence-based practice by Emory Healthcare Nursing Quality Initiatives teams. Questions posed by the teams and information to address those questions will be documented in these posts.