Technical Review, No. 9: Closing the Quality Gap Vol. 6: Prevention of Healthcare-Associated Infections
Objective: To determine the effects of quality improvement strategies on promoting adherence to interventions for prevention of selected (surgical site infections (SSI), central line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infections (CAUTI)) healthcare-associated infections (HAIs), and on HAI rates.
Data Sources: MEDLINE® and Cochrane Collaboration's Effective Practice and Organisation of Care registry. We also reviewed the reference lists of systematic reviews and included studies, and contacted experts.
Search Strategy and Inclusion Criteria: We included randomized and quasi-randomized controlled trials, controlled before-after studies, interrupted time series, and simple before-after studies that reported either HAI rates or rates of adherence to target preventive quality improvement (QI) interventions for any of the four target HAIs. QI strategies were classified as clinician education, patient education, audit and feedback, clinician reminders, organizational change (including revision of professional roles, staffing changes, and total quality management/continuous quality improvement), and financial or regulatory incentives. We targeted hand hygiene as a preventive intervention for all HAIs.
The target preventive interventions specific to SSI were appropriate perioperative antibiotic prophylaxis (including appropriate antibiotic selection, timing, and duration), perioperative glucose control, and decreasing shaving of the operative site. For CLABSI, we targeted adherence to maximal sterile barrier precautions, use of chlorhexidine for skin antisepsis, and avoidance of femoral catheterization. For VAP, we targeted semirecumbent patient positioning and daily assessment of readiness for ventilator weaning. For CAUTI, we targeted reduction in unnecessary catheter use and adherence to aseptic catheter insertion and catheter care.
Our primary outcomes were the rate of HAI (defined as infections per 100 cases for SSI and infections per 1,000 device-days for CLABSI, VAP, and CAUTI) and the rate of adherence to preventive interventions (defined as the percentage of patients at risk who received the preventive intervention). Secondary outcomes included effects on costs and adverse effects associated with the interventions.
Data Collection and Analysis: Two reviewers independently abstracted data. Due to heterogeneity in study populations, QI strategies, preventive interventions, and outcomes, no formal quantitative analysis was attempted. We assessed study quality based on prespecified criteria for internal and external validity.
Main Results: Sixty-four studies met all inclusion criteria; 28 studies addressed prevention of SSI, 19 CLABSI prevention, 12 VAP prevention, and 10 CAUTI prevention. Three studies targeted prevention of multiple HAIs. The study methodologic quality was generally poor, as 52 of 64 included studies were simple before-after studies, and most of these (33 of 52) reported data at only one time point before and after the intervention. The majority of included studies reported infection rates, but did not report rate of adherence to preventive interventions.
Baseline HAI rates were generally above the median rates reported by the Centers for Disease Control and Prevention's National Nosocomial Infection Surveillance System (NNIS).
- Studies addressing surgical site infections: The majority of studies targeted provision of appropriate antibiotic prophylaxis (22 of 28 studies), using combinations of educational interventions, audit and feedback, and clinician reminders. Sixteen of these studies reported data on adherence to appropriate antibiotic prophylaxis guidelines. Clinician reminders were effective at improving appropriate prophylaxis in two controlled studies; educational interventions with audit and feedback were effective in three multicenter studies (two interrupted time series and one simple before-after study.) No QI strategies were clearly effective at reducing SSI rates or improving adherence to other targeted preventive interventions.
- Studies addressing central line-associated bloodstream infection: Active educational interventions for clinicians appeared effective at reducing CLABSI rates, based on two controlled before-after studies, one interrupted time series, and four simple before-after studies of relatively good methodologic quality. Two of these studies combined education with an explicit checklist for adherence to insertion site practices and allowed nurses to stop the procedure if the checklist was not followed, a strategy worthy of future study.
- Studies addressing ventilator-associated pneumonia: Active educational interventions (including use of Web-based and video tutorials) appeared to reduce VAP rates, based on evidence from two simple before-after studies. Conclusions in this area are especially limited as we did not identify any controlled studies.
- Studies addressing catheter-associated urinary tract infection: Printed or computer-based reminders to physicians, coupled with an "automatic stop order", appear to be effective at reducing the duration of urethral catheterization (based on two controlled studies and three simple before-after studies.)
Conclusion: The evidence for quality improvement strategies to improve adherence to preventive interventions for healthcare-associated infections is generally of suboptimal quality, consisting primarily of single-center, simple before-after studies of limited internal and external validity. Thus, we were unable to reach any firm conclusions regarding actionable QI strategies to prevent HAIs.
Based on the limited available data, we suggest that the following strategies are worthy of future study, and possibly wider implementation:
- Use of printed or computer-based reminders with automatic stop orders to reduce unnecessary urethral catheterization.
- Printed or computer-based reminders to improve surgical antibiotic prophylaxis.
- Active educational interventions with use of of checklists to improve adherence to central line insertion practices.
- Active educational interventions such as tutorials to improve adherence to preventive interventions for ventilator-associated pneumonia.
Higher quality studies of QI strategies for HAI prevention are urgently needed.
Closing The Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 6—Prevention of Healthcare-Associated Infections
Evidence-based Practice Center: University of California at San Francisco (UCSF)-Stanford
Topic Nominator: Agency for Healthcare Research and Quality (AHRQ)