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• W2025875897 abstract "Central venous catheters (CVCs) are indispensable in healthcare. For many years, CVCs were used predominantly in the ICU but they are now encountered increasingly outside the ICU setting. Insertion of a CVC can be difficult and failure rates of up to 12% have been described.1,2 In addition, insertion of a CVC can cause pneumothorax, local haematoma, arterial puncture or cardiac tamponade. The risk of these immediate mechanical complications can be minimised by using ultrasound imaging to guide insertion of the catheter.2–4 Although many studies about this topic are of limited methodological quality, ultrasound-guided insertion is now standard in many institutions.5 The principal nonimmediate complication of CVCs is central line-associated bloodstream infection (CLABSI). The risk of CLABSI is related to the catheter type, the duration of catheterisation and the reason for use of the catheter.6–8 Many hospitals have a surveillance strategy in place, often focussing on CLABSI per catheter-days as a measure of catheter infection.9,10 Incidence rates vary from 1.7 for arterial catheters, 2.1 for peripherally inserted CVCs and up to 2.7 for nontunnelled short-term CVCs.6 Most surveillance and intervention studies of CVCs have been performed in the ICU.9–12 A small number of studies that have included data from outside the ICU have found similar rates in non-ICU settings.13,14 For a long time, CLABSI reduction was the domain of technology. Catheters were impregnated with heparin or antimicrobials such as chlorhexidine, chlorhexidine-silver-sulfadiazine, silver or a range of antibiotics. Now, only catheters impregnated with chlorhexidine-silver-sulfadiazine or minocycline-rifampicin, or silver-integrated CVCs, are used regularly. Although catheters impregnated with minocycline-rifampicin consistently performed better than nontreated catheters, the efficacy of chlorhexidine-silver-sulfadiazine-coated catheters is still a matter of debate, especially when catheters are in place for a prolonged time.15,16 The claimed efficacy of silver-integrated catheters is derived from a small study and more evidence is needed before this catheter can be recommended as an infection prevention strategy.17 A recent randomised trial showed that chlorhexidine-impregnated sponges were highly effective in CLABSI reduction.18 Although this device is likely to reduce contamination at the exit site and, thus, is expected to be effective in short-term infection prevention, the sponge also performed well when CVCs remained in place for 2 weeks or more.19 The sutureless securing device is a novel technology and a few studies have shown the potential for CLABSI prevention.20 Although further studies are warranted to confirm effectiveness, the British Committee for Standards in Haematology already states that securing devices are preferable to stitches for fixation of CVCs.21 The use of technology in CLABSI prevention is expensive, and compared to what can be achieved by complying with evidence-based insertion and care procedures, such ‘gadgets’ are unlikely to be cost-effective. Most studies relating to the use of technology for CLABSI prevention had relatively high baseline rates of catheter-associated infections. Due to current multimodal intervention programmes, the incidence of CLABSI is relatively low.11,12 Such programmes include actions for which effectiveness has been shown either alone or in combination with other interventions. The selection of actions may vary, but a multimodal strategy is always a comprehensive approach with the aim of behaviour change. One of the first published multimodal interventions was initiated by motivated healthcare workers within the ICU, was then taken up by the ICU management and was supported by the infection control team.11 This bottom-up/top-down approach facilitated acceptance by the ICU team, assured professionalism and granted authority. Similarly, the infection control team of another group co-operated extensively with the ICU team before launching a multilevel intervention for CLABSI reduction.7 Because many hospitals struggle to apply guidelines, implementation research has become a focus in medicine. Gurses et al.22 recently presented the Barrier Identification and Mitigation Tool. They confirmed that success of prevention programmes depends on behaviour change. Once structures are addressed, adoption and implementation is achieved by introducing a comprehensive education and training programme supported by pragmatic audits, surveillance and feedback. The Michigan project implementing a 5-item bundle was flanked by a strategy called CUSP (Comprehensive Unit-based Safety Program) and insertion of catheters was monitored using a checklist.12,23 The CUSP tool, originally intended to improve safety culture, facilitated adoption and implementation of the intervention strategy by strengthening leadership and inviting the hospital board to be an active part of the project.24 Simulation-based training of catheter insertion allows easy adoption of evidence-based techniques.25–28 ‘See one – do one – teach one’ is not likely to change practice. Learning and behaviour change come from training in a safe and controlled environment, similar in concept to the training of pilots in simulators. Checklists for catheter insertion may further help clinicians to conform to evidence-based practice.29 Reducing complications from central lines has a long tradition and the efforts that have been made to prevent complications exemplify the complexity of the problem but also the creativity and – most recently – success. Although ‘zero’ tolerance for CLABSI may not seem a realistic goal, the number of hospitals approaching this idealistic threshold is growing. Technology alone is not effective. The evidence is now clear that CLABSI can be reduced most effectively by behavioural change, including ‘state-of-the-art’ insertion technique and catheter care. Consequently, we must concentrate our efforts on training and team building to adopt and implement best practices in insertion and care procedures. ‘Gadgets’ may help to reduce complications further, but their effectiveness may have to be reconsidered once the incidence of CLABSI is low as a result of optimised procedures and a good safety climate. Acknowledgements W.Z. received support from the European Commission (EC, FP7 Collaborative project – 241928) and the Swiss National Foundation (SNF; CRSI33_125408/1); B.W. received support from the Swiss National Foundation (SNF; K-23K1-122264/1), Swiss Accident Company and the Bangerter-Rhyner Foundation. The funding agencies had no role in the preparation, review or approval of the manuscript. The authors have no conflicts of interest. This article was checked and accepted by the Editors, but was not sent for external peer-review." @default.
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• W2025875897 title "Reduction of central line complications: think ‘procedure’ before ‘gadget’" @default.
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