Reduced Severity of Arterial Catheter-Associated Proximal Ischemic Injuries Through a Quality Improvement Initiative
Mark D Weber1,2, Eileen Nelson3, Lauren Brennan4
1Department of Anesthesiology and Critical Care Medicine, School of Nursing at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA.
Insights
A quality improvement initiative reduced severe arterial catheter-associated proximal ischemic injuries (ACAPII) in pediatric intensive care unit patients. Implementing enhanced surveillance and topical nitroglycerin (TNG) for mild injuries significantly lowered ACAPII rates.
Area of Science:
- Pediatric critical care medicine
- Vascular access management
- Quality improvement science
Background:
- Severe arterial catheter-associated proximal ischemic injuries (ACAPII) pose a significant risk to critically ill children.
- Standardized protocols for arterial catheter care are essential to mitigate patient harm.
Purpose of the Study:
- To define and reduce the incidence of severe ACAPII in a pediatric intensive care unit (PICU).
- To evaluate the impact of a quality improvement initiative on ACAPII rates.
Main Methods:
- A quality improvement initiative was implemented in a university-affiliated PICU.
- Phase I involved defining ACAPII and daily vascular access team rounding.
- Phase II introduced standardized recommendations and topical nitroglycerin (TNG) for mild injuries.
Main Results:
- The cumulative severe ACAPII incidence rate decreased from 5.65 to 2.11 per 1000 line-days.
- Topical nitroglycerin (TNG) use in Phase II was associated with increased arterial line-days per catheter for mild injuries.
- The number of line-days between severe ACAPII events significantly increased.
Conclusions:
- A defined harm index (ACAPII) and enhanced surveillance improved awareness and reduced severe injuries.
- Protocolized management, including TNG, sustained the reduction in severe ACAPII rates.
- Quality improvement strategies are effective in improving patient safety in the PICU.
Objectives:
To define and reduce the incidence of severe arterial catheter-associated proximal ischemic injuries (ACAPII).
Design:
Quality improvement (QI) initiative.
Setting:
University affiliated PICU in a quaternary children's hospital.
Patients:
All patients with indwelling arterial catheters (ACs) in the PICU at the Children's Hospital of Philadelphia from January 2020 to December 2022.
Interventions:
Phase I (January 2021 to December 2021) included defining ACAPII and daily rounding on all ACs by a dedicated PICU-specific vascular access team. Phase II (January 2022 to December 2022) introduced standardized recommendations and interventions including the use of topical nitroglycerin ointment (TNG) as a therapeutic option for mild injuries.
Measurements And Main Results:
From January 2021 to December 2022, the rounding team evaluated 1916 ACs for a total of 5793 rounding episodes (line-days). During phase I, the overall number of ACAPII increased compared with prior year pre-QI (35 vs. 11, 318%). During phase II, the administration of TNG was associated with an increase in arterial line-days per AC in patients with mild injury (6.58 line-days per line, 158 d/24 lines) compared with pre-QI, phase I, and phase II mild injuries without use of TNG (3.27, 198/61; incident rate difference [95% CI], 3.31 [2.11-4.51]; p < 0.001). Special cause indicators shifted centerline from a weighted average 33.0-342.3 line-days between severe injuries. The cumulative severe ACAPII incidence rate decreased from its peak early in phase I (April 2021: 5.65 per 1000 line-days) to the end of phase II (December 2022: 2.11 per 1000 line-days). The overall rate of arterial line-days per AC during phase II increased compared with pre-QI ( p < 0.01) and phase I ( p < 0.01).
Conclusions:
The development of a newly defined measurable harm index, ACAPII, and implementation of increased surveillance resulted in increased awareness and reduction of severe injury as measured by rates and line-days between severe injuries in our critically ill patients. Protocolized management during phase II, including introducing TNG as a therapeutic option, resulted in increased AC line-days per catheter with sustained reduction in severe ACAPII rates.
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