PubMed · 9544076
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H A Scholefield. 1998. Advanced practice and consent.. https://pubmed.ncbi.nlm.nih.gov/9544076/
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Intensive care is one of the largest, most expensive, and complex components of U.S. health care. Errors and the resulting adverse events are, however, common in intensive care units (ICUs). Theories about errors in high-risk environments, developed by aviation and other industries, provide insight into why ICUs are prone to errors. Complex systems--of which ICUs are certainly an example--are breeding grounds for errors because interdependent components interact in unexpected ways. To achieve favorable outcomes, ICUs require that many processes occur in sequence. For example, patients are cared for by many providers with varying levels of expertise across several disciplines, and these providers use highly sensitive and potentially dangerous technologies and medications. Such complex systems require careful planning, excellent teamwork and communication, and designed redundancies to recheck for proper care processes. This paper provides a practical framework for improving patient safety.
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Catheter-related sepsis (CRS) is a major cause of morbidity in patients receiving chemotherapy and prolonged parenteral nutrition. To determine whether avoiding emergency insertions by using a planned elective list and adopting a 'no-touch' technique has a role in reducing CRS, all cuffed central venous catheters inserted by the open method between 1999 and 2000 were prospectively followed for a total duration of 12 months. The incidence of early sepsis (within 30 catheter days) that could be attributed to surgical factors was studied. CRS was defined as the presence of any two of the following: (1) signs of clinical sepsis without an obvious focus; (2) positive cultures in blood obtained from the catheter; and (3) clinical improvement following removal. A total of 146 catheters were inserted in 130 patients; 15 had a second and 1 had a third catheter inserted. Early CRS was encountered in 13 cases (9%); 95 catheters were inserted on an elective list and 51 on an emergency basis. The distributions of age, sex, number of lumens, neutrophil count, and underlying diagnosis were similar between the groups. There was no significant difference (P = 1) between elective (9/95) and emergency (4/51) insertions. A total of 47 catheters were inserted by the 'no-touch' technique and 48 by the manual technique. There was no significant difference in early sepsis (P = 0.7) between the two techniques (6/47 vs 3/48). Thus avoiding emergency insertion or adopting a 'no-touch' technique does not reduce early CRS. Larger prospective studies are warranted to identify surgical risk factors.