Effectiveness of bundled behavioural interventions to control healthcare-associated infections: a systematic review of the literature

Prospective pilot study on the incidence of infections caused by peripheral venous catheters at a general surgical ward

Device-associated infections comprise a significant proportion of all nosocomial infections. In this prospective, observational pilot study the incidence of infections in 89 peripheral venous catheters (PVCs) was documented on a general surgical ward employing an infection data sheet developed by the Institute of Hygiene and Environmental Medicine, Greifswald in adherence to CDC standards for infections.

16 of 20 infections were documented during a four-week time period when medical students in the first four months of their practical year performed their compulsory rotation on the general surgical ward. Insufficient knowledge of adequate hygienic measures as well as non-compliance to aseptical procedural measures prior to and following insertion of a peripheral venous catheter are the assumed instigators of these infections. In order to ensure a uniform hygienic standard in the performance of applied procedures, it is essential that medical students during this practical year receive not only theoretical, but also hands-on schooling prior to initiation of their subsequent official residency.

Addressing the need for an infection prevention and control framework that incorporates the role of surveillance: a discussion paper

AIM

To present a discussion on theoretical frameworks in infection prevention and control.

BACKGROUND

Infection prevention and control programmes have been in place for several years in response to the incidence of healthcare-associated infections and their associated morbidity and mortality. Theoretical frameworks play an important role in formalizing the understanding of infection prevention activities.

DESIGN

Discussion paper.

DATA SOURCES

A literature search using electronic databases was conducted for published articles in English addressing theoretical frameworks in infection prevention and control between 1980-2012.

RESULTS

Nineteen papers that included a reference to frameworks were identified in the review. A narrative analysis of these papers was completed. Two models were identified and neither included the role of surveillance.

DISCUSSION

To reduce the risk of acquiring a healthcare-associated infection, a multifaceted approach to infection prevention is required. One key component in this approach is surveillance. The review identified two infection prevention and control frameworks, yet these are rarely applied in infection prevention and control programmes. Only one framework considered the multifaceted approach required for infection prevention. It did not, however, incorporate the role of surveillance. We present a framework that incorporates the role of surveillance into a biopsychosocial approach to infection prevention and control.

CONCLUSION

Infection prevention and control programmes and associated research are led primarily by nurses. There is a need for an explicit infection prevention and control framework incorporating the important role that surveillance has in infection prevention activities. This study presents one framework for further critique and discussion.

Time lag for posting transmission-based isolation precaution signs

BACKGROUND

Rapid identification and isolation of patients colonized or infected with virulent pathogens is essential to minimize risk of exposure to other patients, visitors, and health care workers.

OBJECTIVE

Our objective was to determine the time lag between when a patient is identified as requiring isolation precautions and when an isolation sign is posted outside of their room.

METHODS

Patients requiring assessment of isolation precautions because of a new positive culture, readmission, or transfers within the institution were identified through an electronic surveillance system. Observers recorded the presence of isolation signs at the patient's door at time (T) 0hr, T2hr, T4hr, T24hr, and T48hr or until an isolation sign was posted.

RESULTS

The majority of patients was adults in nonintensive care units. Isolation signs were present for 79.0% of the patients at T0hr and increased to 83.8% by T48hr. No difference was seen between the unit type or indications for isolation. The most common organisms for which isolation was indicated were influenza and resistant enterococci, Staphylococcus aureus; isolation sign postings at T0hr were 87.9%, 85.7%, and 80.7%, respectively. There was a significant difference seen in compliance among the adult (82.8%) and pediatrics (66.7%) sites (P = .0268).

CONCLUSION

Isolation precautions are indicated to prevent transmission of virulent pathogens; however, their implementation in a timely manner can be challenging. In this study, approximately 20% of patients for whom isolation was needed had no sign posted within the first 24 hours, and there were only minimal increases thereafter. Simple processes are needed for early identification of patients, communication of the protective equipment needed, and continuous monitoring of adherence to guidelines.

Compliance with hygiene guidelines: the effect of a multimodal hygiene intervention and validation of direct observations

BACKGROUND

Good compliance with hygiene guidelines is essential to prevent bacterial transmission and health care-associated infections. However, the compliance is usually <50%.

METHODS

A multimodal and multidisciplinary hygiene intervention was launched once the baseline compliance was determined through direct observations in 4 departments of obstetrics and gynecology. Detailed evaluations of the compliance rates were performed at point of stability (at 80%) and follow-up (3 years after hygiene intervention). Validation of direct observations was performed using blinded double appraisal and multiappraisal.

RESULTS

At baseline, the compliance with barrier precautions and the dress code at the 4 departments were 39% to 47% and 79% to 98%, respectively. Point of stability was reached approximately 1 year after the hygiene intervention was launched. The compliance with barrier precautions was significantly higher at follow-up compared with baseline in 3 departments. In the validation by double appraisal, 471 of 483 components were judged identical between observers. In the multiappraisal, 95% to 100% of the observers correctly judged the 7 components.

CONCLUSION

It is possible to improve compliance with hygiene guidelines, but, to ensure a long-lasting effect, a continuous focus on barrier precautions is required. Observation is a valid method to monitor compliance.

Interventions to improve professional adherence to guidelines for prevention of device-related infections

BACKGROUND

Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. There are specific risk profiles for each device, but in general, the breakdown of aseptic technique during insertion and care for the device, as well as the duration of device use, are important factors for the development of these serious and costly infections.

OBJECTIVES

To assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device-related infection rates and measures of adherence.

SEARCH METHODS

We searched the following electronic databases for primary studies up to June 2012: the Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. We searched reference lists and contacted authors of included studies. We also searched the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies that complied with the Cochrane EPOC Group methodological criteria, and that evaluated interventions to improve professional adherence to guidelines for the prevention of device-related infections.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane EPOC 'Risk of bias' tool. We contacted authors of original papers to obtain missing information.

MAIN RESULTS

We included 13 studies: one cluster randomised controlled trial (CRCT) and 12 ITS studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards, and more than 3504 patients and 1406 healthcare professionals. Six of the included studies targeted adherence to guidelines to prevent central line-associated blood stream infections (CLABSIs); another six studies targeted adherence to guidelines to prevent ventilator-associated pneumonia (VAP), and one study focused on interventions to improve urinary catheter practices. We judged all included studies to be at moderate or high risk of bias.The largest median effect on rates of VAP was found at nine months follow-up with a decrease of 7.36 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). The one included cluster randomised controlled trial (CRCT) observed, improved urinary catheter practices five weeks after the intervention (absolute difference 12.2 percentage points), however, the statistical significance of this is unknown given a unit of analysis error. It is worth noting that N = 6 interventions that did result in significantly decreased infection rates involved more than one active intervention, which in some cases, was repeatedly administered over time, and further, that one intervention involving specialised oral care personnel showed the largest step change (-22.9 cases per 1000 ventilator days (standard error (SE) 4.0), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002)) among the included studies. We attempted to combine the results for studies targeting the same indwelling medical device (central line catheters or mechanical ventilators) and reporting the same outcomes (CLABSI and VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among included studies (I(2) up to 97%), we did not retain these analyses. Six of the included studies reported post-intervention adherence scores ranging from 14% to 98%. The effect on rates of infection were mixed and the effect sizes were small, with the largest median effect for the change in level (interquartile range (IQR)) for the six CLABSI studies being observed at three months follow-up was a decrease of 0.6 (-2.74 to 0.28) cases per 1000 central line days (six studies and 36 sites). This change was not sustained over longer follow-up times.

AUTHORS' CONCLUSIONS

The low to very low quality of the evidence of studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions involving more than one active element and that are repeatedly administered over time, and interventions employing specialised personnel, who are focused on an aspect of care that is supported by evidence e.g. dentists/dental auxiliaries performing oral care for VAP prevention.

Patient and provider perspectives on methicillin-resistant Staphylococcus aureus: a qualitative assessment of knowledge, beliefs, and behavior

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of healthcare-associated infection. Individuals with spinal cord injuries and disorders (SCI/D) are at high risk of MRSA colonization and infection. The Department of Veterans Affairs (VA) released guidelines to prevent the spread of MRSA in Veterans with SCI/D; however, available patient educational materials did not address the unique issues for this population.

OBJECTIVE

To assess perceptions of SCI/D providers and Veterans with SCI/D regarding MRSA and their educational needs about MRSA prevention, with an ultimate goal of developing patient educational materials that address the issues unique to SCI/D.

METHODS

Purposive samples of SCI/D providers (six groups) and Veterans with SCI/D (one group) at two VA facilities participated in 60-90-minute focus group sessions. Qualitative data were analyzed using latent content and constant comparative techniques to identify focal themes.

PARTICIPANTS

Thirty-three providers (physicians and nurses working in inpatient, outpatient, and homecare settings) and eight Veterans participated.

RESULTS

Three overarching themes emerged from the analysis: knowledge about MRSA, hand hygiene, and barriers to educating Veterans with SCI/D.

CONCLUSIONS

SCI/D providers and Veterans with SCI/D identified gaps in general MRSA knowledge, gaps in knowledge of good hand hygiene practices and of required frequency of hand hygiene, and barriers to educating Veterans with SCI/D during inpatient stays. Future educational materials and strategies should address these gaps.

Implementation of stroke Dysphagia screening in the emergency department

Early detection of dysphagia is critical in stroke as it improves health care outcomes. Administering a swallowing screening tool (SST) in the emergency department (ED) appears most logical as it is the first point of patient contact. However, feasibility of an ED nurse-administered SST, particularly one involving trial water swallow administration, is unknown. The aims of this pilot study were to (1) implement an SST with a water swallow component in the ED and track nurses' adherence, (2) identify barriers and facilitators to administering the SST through interviews, and (3) develop and implement a process improvement plan to address barriers. Two hundred seventy-eight individuals with stroke symptoms were screened from October 2009 to June 2010. The percentage of patients screened increased from 22.6 in October 2009 to a high of 80.8 in March 2010, followed by a decrease to 61.9% in June (Cochran-Armitage test z = −5.1042,  P < 0.0001). The odds of being screened were 4.0 times higher after implementation compared to two months before implementation. Results suggest that it is feasible for ED nurses to administer an SST with a water swallow component. Findings should facilitate improved quality of care for patients with suspected stroke and improve multidisciplinary collaboration in swallowing screening.

Improving hand hygiene adherence among nursing staff

This quasi-experimental study explored initial and sustained effects of educational and behavioral interventions on hand hygiene adherence and the relationships between hand hygiene adherence and health care-associated infections. Education paired with positive reinforcement behavioral interventions significantly improved hand hygiene adherence after the first month (χ² = 4.27; P = .039); however, the improvement was not sustained over 6 months. There were no significant differences in infection rates between the treatment and control groups.

Improving staff compliance with isolation precautions through use of an educational intervention and behavioral contract

Hospital-acquired infections negatively impact patient outcomes, length of stay, and the economy. Health care systems must find ways to decrease the spread of infection and the development of infection with the use of isolation precautions in an acute care setting. All staff members must be aware of ways to decrease or prevent the spread of infection by the appropriate use of isolation precautions. This article describes a successful program that improved the use of isolation precautions among nursing personnel through the implementation of an educational intervention and behavioral contract.

Effect of feedback on ventilator care bundle compliance: before and after study

BACKGROUND

Care bundles cluster together several evidence-based practices and, in the intensive care setting, the ventilator care bundle (VCB) has been applied widely.

AIM

To determine the effect of monthly feedback on VCB compliance.

DESIGN

Before and after study: primary outcome measure VCB compliance.

METHODS

Data were collected for 1 year from two metropolitan general intensive care units (ICU) on one randomly allocated day per week. Baseline data from adult ventilated patients were collected during the first 6 months (phase 1). During the second 6 months (phase 2), monthly compliance data were provided to each ICU regarding both ICUs' performance.

RESULTS

Both 'all or nothing' compliance (when all four VCB elements were complied with) and overall compliance (the average compliance of the four elements) increased between the two phases. These increases were mostly small and statistically insignificant. Although both measures increased in ICU B, both fell in ICU A. ICU B's overall compliance increase was statistically significant (p = 0·005), but its 'all or nothing' compliance increase (19%), whilst arguably clinically significant, did not reach statistical significance. ICU B achieved increased compliance with all four VCB elements in phase 2, whereas ICU A achieved increases in two elements (deep vein thrombosis and gastric ulcer prophylaxis). Both ICUs achieved 100% compliance with gastric ulcer prophylaxis for all of phase 2. Head of bed elevation was the least complied with element in phase 1, and increased in ICU B only in phase 2.

CONCLUSIONS

Although the compliance rates with individual elements are encouraging, the results regarding the effect of feedback on VCB compliance were variable. The finding of relatively poor compliance with head of bed elevation is consistent with previous research.

RECOMMENDATIONS

Further research is needed to determine the effects of audit and feedback, and which strategies are most effective.

Bundling hand hygiene interventions and measurement to decrease health care-associated infections

Proper performance of hand hygiene at key moments during patient care is the most important means of preventing health care-associated infections (HAIs). With increasing awareness of the cost and societal impact caused by HAIs has come the realization that hand hygiene improvement initiatives are crucial to reducing the burden of HAIs. Multimodal strategies have emerged as the best approach to improving hand hygiene compliance. These strategies use a variety of intervention components intended to address obstacles to complying with good hand hygiene practices, and to reinforce behavioral change. Although research has substantiated the effectiveness of the multimodal design, challenges remain in promoting widespread adoption and implementation of a coordinated approach. This article reviews elements of a multimodal approach to improve hand hygiene and advocates the use of a "bundled" strategy. Eight key components of this bundle are proposed as a cohesive program to enable the deployment of synergistic, coordinated efforts to promote good hand hygiene practice. A consistent, bundled methodology implemented at multiple study centers would standardize processes and allow comparison of outcomes, validation of the methodology, and benchmarking. Most important, a bundled approach can lead to sustained infection reduction.

Strategies for prevention of health care-associated infections in the NICU

Health care-associated infections in the NICU result in increased morbidity and mortality, prolonged lengths of stay, and increased medical costs. Neonates are at high risk of acquiring health care-associated infections because of impaired host-defense mechanisms, limited amounts of protective endogenous flora on skin and mucosal surfaces at time of birth, reduced barrier function of their skin, use of invasive procedures and devices, and frequent exposure to broad-spectrum antibiotic agents. This clinical report reviews management and prevention of health care-associated infections in newborn infants.

Hand hygiene improvement in the community: a systems approach

Hand hygiene compliance, which is influenced in part by human behaviour, is central to infection prevention in all care settings. This article focuses specifically on the importance of a multimodal strategy for continued hand hygiene improvement, and its relevance to community nursing. Additionally, the article addresses the challenges and opportunities of infection prevention and control in a community context, and highlights current national and international guidelines that offer a framework and set of principles for implementation and sustainability with a specific focus on the multimodal strategy associated with the WHO Guidelines on Hand Hygiene in Health Care (2009). The authors conclude with some considerations for community nurses when addressing translation of these principles into their everyday working context.

Features of educational interventions that lead to compliance with hand hygiene in healthcare professionals within a hospital care setting. A BEME systematic review: BEME Guide No. 22

BACKGROUND

In the United Kingdom, there are approximately 300,000 healthcare-associated infections (HCAI) annually, costing an estimated £1 billion. Up to 30% of all HCAI are potentially preventable by better application of knowledge and adherence to infection prevention procedures. Implementation of Department of Health guidelines through educational interventions has resulted in significant and sustained improvements in hand hygiene compliance and reductions in HCAI.

AIM

To determine the features of structured educational interventions that impact on compliance with hand hygiene in healthcare professionals within a hospital care setting.

METHODS

Sixteen electronic databases were searched. Outcomes were assessed using Kirkpatrick's hierarchy and included changes in hand hygiene compliance of healthcare professionals, in service delivery and in the clinical welfare of patients involved.

RESULTS

A total of 8845 articles were reviewed, of which 30 articles met the inclusion criteria. Delivery of education was separated into six groups.

CONCLUSIONS

It was not possible to identify individual features of educational interventions due to each study reporting multicomponent interventions. However, multiple, continuous interventions were better than single interventions in terms of eliciting and sustaining behaviour change. Data were not available to determine the time, nature and type of booster sessions with feedback needed for a permanent change in compliance.

The ventilator care bundle and its impact on ventilator-associated pneumonia: a review of the evidence

AIMS AND OBJECTIVES

The aim of this review was to critically analyse recent research that has investigated ventilator care bundle (VCB) use, with the objective of analysing its impact on ventilator-associated pneumonia (VAP) outcomes.

BACKGROUND

The VCB is a group of four evidence-based procedures, which when clustered together and implemented as an 'all or nothing' strategy, may result in substantial clinical outcome improvement. VAP is a nosocomial lung infection associated with endotracheal tube use in ventilated patients. Since the VCB was introduced there have been several studies that have reported significant VAP rate reductions.

SEARCH STRATEGY

A comprehensive search for research, published between 2004 and 2009, was conducted using Medline and PubMed. Key words were used to identify English language studies reporting VCB implementation within adult intensive care units (ICU) and associated clinical outcomes. Studies that implemented bundle variations that did not include all four elements were excluded.

CONCLUSIONS

Because of the limitations of the observational designs used in the studies retrieved, a definitive causal relationship between VCB use and VAP reduction cannot be stated. However, the evidence to date is strongly indicative of a positive association. Several studies reported the use of additional VCB elements. In these cases it is difficult to establish which elements are related to the measured outcomes. Further research is recommended to establish baseline outcome measures using the four-element VCB, before adding further processes singly, as well as research investigating the effect of audit and feedback on VCB compliance and its effect on clinical outcomes.

RELEVANCE TO CLINICAL PRACTICE

A reduction in VAP is associated with VCB use. The evidence to date, whilst not at the highest experimental level, is at the highest ethically permissible level. In the absence of contradictory research, the current evidence suggests that use of the VCB represents best practice for all eligible adult ventilated patients in ICU.

Back to the future: rising to the Semmelweis challenge in hand hygiene

Hand hygiene is the single most important intervention for reducing healthcare associated infections and preventing the spread of antimicrobial resistance. This sentence begins most publications regarding hand hygiene in the medical literature. But why - as we mark 150 years since the publication of Ignaz Semmelweis' landmark monograph on the subject - do we continue to repeat it? One might be tempted to regard it as a truism. However, while tremendous progress has certainly been made in this field, a significant amount of work is yet to be done in both strengthening the evidence regarding the impact of hand hygiene and maximizing its implementation. Hand hygiene cannot yet be taken for granted. This article summarizes historical perspectives, dynamics of microbial colonization and efficacy of hand cleansing methods and agents, elements and impacts of successful hand hygiene promotion, as well as scale-up and sustainability. We also explore hand hygiene myths and current challenges such as monitoring, behavior change, patient participation and research priorities.

Effectiveness of comprehensive implementation of individualized bundling infection control measures for prevention of health care-associated infections in general medical wards

BACKGROUND

The prevalence of health care-associated infections (HAIs) in general medical wards at Siriraj Hospital in Bangkok, Thailand remains at 10% even after infection control measures were launched. The present study aimed to determine the effectiveness of comprehensive individualized bundling infection control measures in reducing HAIs and to identify the lowest possible rate of HAIs in general medical wards.

METHODS

This was a cluster randomized controlled study conducted in 8 general medical wards (4 control wards and 4 intervention wards) at Siriraj Hospital. The patients hospitalized in the control wards received regular health care, as well as regular measures for preventing HAIs. The patients hospitalized in the intervention wards received additional measures. Each patient in the intervention wards was visited by the infection control team once a day until he or she left the hospital. The infection control team identified risk factors for developing HAI in each patient, coordinated with the local health care team to eliminate or minimize such risk factors, and encouraged responsible personnel to comply with the appropriate infection control measures for each patient.

RESULTS

Between January and April 2009, there were 954 patients (9,650 hospitalization-days) in the intervention wards and 920 patients (9,777 hospitalization-days) in the control wards. The patient characteristics were comparable in the 2 groups. The prevalence of HAI was significantly lower in the intervention wards compared with the control wards (5.6% vs. 9.2%; P = .003). Six episodes of HAI in patients in the intervention wards could have been avoided.

CONCLUSION

Comprehensive individualized bundling infection control measures were effective in reducing the prevalence of HAIs in general medical wards. The target overall prevalence of HAIs in general medical wards should not exceed 4.9%.

An integrative review of infection prevention and control programs for multidrug-resistant organisms in acute care hospitals: a socio-ecological perspective

BACKGROUND

The infection rates of multidrug-resistant organisms (MDRO) are increasing in Canada and the United States. The prevention and control of MDRO infections remain an important issue in acute care hospitals. Although comprehensive infection prevention and control programs have been recommended, there is little evidence to date of their effectiveness or of what aspects are most important.

OBJECTIVES

Our objectives were to review and critique the literature on the relationship between an MDRO infection and control program and MDRO rates in acute care hospitals.

METHODS

Studies including original research published between January 1, 1998, and May 14, 2009, were identified through MEDLINE, CINAHL, EMBASE, PUBMED, The Cochrane Library, and expert consultation. A comprehensive search strategy was developed with a librarian to find studies that covered the main subject areas of this integrative review.

RESULTS

Of the 1,382 papers retrieved, 47 were reviewed, and 32 studies met the inclusion criteria. The interventions in the included studies were assessed using the tier 1/tier 2 framework. A total of 18 (56.25%) studies had an administrative measure as an intervention; 20 (62.5%) studies had education and training of health care personnel; 8 (25.0%) studies had judicious use of antimicrobial agents; 17 (53.1%) studies used surveillance; 24 (75.0%) studies had infection control precautions to prevent transmission; 7 studies (21.9%) introduced environmental measures; and 9 (28.1%) studies used patient decolonization. Although all the 32 studies were quasiexperimental studies, only 2 (5.9%) studies provided sample size calculations, and only 5 studies reported confounding factors. Whereas 27 used an interrupted time series design and 2 were controlled pre- and post-intervention designs, 3 were pre- and post-intervention without control groups.

CONCLUSION

This integrative review demonstrated that the evidence of the relationship between MDRO infection prevention and control programs and the rates of MDRO is weak. Although major methodologic weaknesses exist in the published literature making it not possible to exclude other plausible explanations for the reduction of the acquisition of MDRO, the overall evidence does support the use of multiple interventions to reduce the rates of MDRO in acute care hospitals. Whereas it is unclear which bundles of interventions are effective, there is a clear suggestion that multiple simultaneous interventions can be effective in reducing MDRO infections. In addition, despite the limitations of interrupted time series, multiple studies employing active surveillance cultures were associated with reduced MDRO infections. Future individual reports of outbreaks and intervention studies should be written in a standardized manner using the recommended Outbreak Reports and Intervention Studies of Nosocomial Infection (ORION) guidelines. Further research is needed on the proposed tier 1/tier 2 framework clearly indicating all the interventions implemented.

Reduced resident "code blue" experience in the era of quality improvement: new challenges in physician training

PURPOSE

Emergency resuscitation or "code blue" is a clinical event through which responding medical residents gain experience and proficiency. A retooling of practice has occurred at academic medical centers since the emergence of quality improvement initiatives and resident duty hours limits. The authors investigated how these changes may impact code blue frequency and resident opportunities to gain clinical experience.

METHOD

The authors conducted a single-center, retrospective (2002-2009) review of monthly code blue frequency. They compared code blue frequency with corresponding monthly first-year internal medicine resident call schedules (2002-2008 academic years). Using a Monte Carlo simulation they estimated annual code blue experience, and using Poisson regression, they estimated annual trends in resident code blue experience.

RESULTS

The authors detected a 41% overall reduction in code blue events between 2002 and 2008; code blue events decreased by 13% annually (P < .001). These trends persisted, even after accounting for hospital census fluctuations: Rates fell from approximately 12 code blue events/1,000 admissions in 2002 to 3.8 events/1,000 in 2008. Overall, the model of code blue frequency and resident call schedules shows a dramatic reduction in the predicted number of code blue experiences, falling from 29 events (empirical 95% CI 18-40) in academic year 2002 to 5 events (CI 1-9) in 2008.

CONCLUSIONS

Physicians-in-training at one facility are seeing far fewer code blue events than their predecessors. Whether current numbers of in-hospital code blue events are sufficient to provide adequate experience without supplemental practice for trainees is unclear.

Implementing a better bundle to achieve and sustain a zero central line-associated bloodstream infection rate

The objective of every health care facility is achieving and maintaining a zero central line-associated bloodstream infection (CLABSI) rate. Interventions to enhance care were put into place, and changes in CLABSI rates were tracked. Data were collected from January 2003 through June 2009. The interventions included the following: a dedicated vascular access team; swabbable clear positive displacement needleless connector; chlorhexidine-impregnated disk; flushing with 20 mL of normal saline; rigorous central line care education; increased use of peripherally inserted central catheters; and daily review of necessity. A significant drop to zero CLABSIs occurred after the introduction of several new central line care practices.

A qualitative assessment of participation in a rapid scale-up, diagonally-integrated MDG-related disease prevention campaign in Rural Kenya

BACKGROUND

Many countries face severe scale-up barriers toward achievement of MDGs. We ascertained motivational and experiential dimensions of participation in a novel, rapid, "diagonal" Integrated Prevention Campaign (IPC) in rural Kenya that provided prevention goods and services to 47,000 people within one week, aimed at rapidly moving the region toward MDG achievement. Specifically, the IPC provided interventions and commodities targeting disease burden reduction in HIV/AIDS, malaria, and water-borne illness.

METHODS

Qualitative in-depth interviews (IDI) were conducted with 34 people (18 living with HIV/AIDS and 16 not HIV-infected) randomly selected from IPC attendees consenting to participate. Interviews were examined for themes and patterns to elucidate participant experience and motivation with IPC.

FINDINGS

Participants report being primarily motivated to attend IPC to learn of their HIV status (through voluntary counseling and testing), and with receipt of prevention commodities (bednets, water filters, and condoms) providing further incentive. Participants reported that they were satisfied with the IPC experience and offered suggestions to improve future campaigns.

INTERPRETATION

Learning their HIV status motivated participants along with the incentive of a wider set of commodities that were rapidly deployed through IPC in this challenging region. The critical role of wanting to know their HIV status combined with commodity incentives may offer a new model for rapid scaled-up of prevention strategies that are wider in scope in rural Africa.

Educating healthcare workers to optimal hand hygiene practices: addressing the need

The education of healthcare workers is essential to improve practices and is an integral part of hand hygiene promotional strategies. According to the evidence reviewed here, healthcare worker education has a positive impact on improving hand hygiene and reducing healthcare-associated infection. Detailed practical guidance on steps for the organization of education programmes in healthcare facilities and teaching-learning strategies are provided using the World Health Organization (WHO) Guidelines for Hand Hygiene in Health Care as the basis for recommendations. Several key elements for a successful educational programme are also identified. A particular emphasis is placed on concepts included in the tools developed by WHO for education, monitoring and performance feedback.

Cost-effectiveness of a central venous catheter care bundle

Background

A bundled approach to central venous catheter care is currently being promoted as an effective way of preventing catheter-related bloodstream infection (CR-BSI). Consumables used in the bundled approach are relatively inexpensive which may lead to the conclusion that the bundle is cost-effective. However, this fails to consider the nontrivial costs of the monitoring and education activities required to implement the bundle, or that alternative strategies are available to prevent CR-BSI. We evaluated the cost-effectiveness of a bundle to prevent CR-BSI in Australian intensive care patients.

Methods and Findings

A Markov decision model was used to evaluate the cost-effectiveness of the bundle relative to remaining with current practice (a non-bundled approach to catheter care and uncoated catheters), or use of antimicrobial catheters. We assumed the bundle reduced relative risk of CR-BSI to 0.34. Given uncertainty about the cost of the bundle, threshold analyses were used to determine the maximum cost at which the bundle remained cost-effective relative to the other approaches to infection control. Sensitivity analyses explored how this threshold alters under different assumptions about the economic value placed on bed-days and health benefits gained by preventing infection. If clinicians are prepared to use antimicrobial catheters, the bundle is cost-effective if national 18-month implementation costs are below $1.1 million. If antimicrobial catheters are not an option the bundle must cost less than $4.3 million. If decision makers are only interested in obtaining cash-savings for the unit, and place no economic value on either the bed-days or the health benefits gained through preventing infection, these cost thresholds are reduced by two-thirds.

Conclusions

A catheter care bundle has the potential to be cost-effective in the Australian intensive care setting. Rather than anticipating cash-savings from this intervention, decision makers must be prepared to invest resources in infection control to see efficiency improvements.

Electronic surveillance systems in infection prevention: organizational support, program characteristics, and user satisfaction

BACKGROUND

The use of electronic surveillance systems (ESSs) is gradually increasing in infection prevention and control programs. Little is known about the characteristics of hospitals that have a ESS, user satisfaction with ESSs, and organizational support for implementation of ESSs.

METHODS

A total of 350 acute care hospitals in California were invited to participate in a Web-based survey; 207 hospitals (59%) agreed to participate. The survey included a description of infection prevention and control department staff, where and how they spent their time, a measure of organizational support for infection prevention and control, and reported experience with ESSs.

RESULTS

Only 23% (44/192) of responding infection prevention and control departments had an ESS. No statistically significant difference was seen in how and where infection preventionists (IPs) who used an ESS and those who did not spend their time. The 2 significant predictors of whether an ESS was present were score on the Organizational Support Scale (odds ratio [OR], 1.10; 95% confidence interval [CI], 1.02-1.18) and hospital bed size (OR, 1.004; 95% CI, 1.00-1.007). Organizational support also was positively correlated with IP satisfaction with the ESS, as measured on the Computer Usability Scale (P = .02).

CONCLUSION

Despite evidence that such systems may improve efficiency of data collection and potentially improve patient outcomes, ESSs remain relatively uncommon in infection prevention and control programs. Based on our findings, organizational support appears to be a major predictor of the presence, use, and satisfaction with ESSs in infection prevention and control programs.

Prevention and control of health care-associated infections through improved hand hygiene

Determined actions are required to address the burden due to health care-associated infections worldwide and improve patient safety. Improving hand hygiene among health care workers is an essential intervention to achieve these goals. The World Health Organization (WHO) First Global Patient Safety Challenge, Clean Care is Safer Care, pledged to tackle the problem of health care-associated infection at its launch in 2005 and has elaborated a comprehensive set of guidelines for use in both developed and developing countries worldwide. The final version of the WHO Guidelines on Hand Hygiene in Health Care was issued in March 2009 and includes recommendations on indications, techniques, and products for hand hygiene. In this review, we discuss the role of hands in the transmission of health care-associated infection, the benefits of improved compliance with hand hygiene, and the recommendations, implementation strategies and tools recommended by WHO. We also stress the need for action to increase the pace with which these recommendations are implemented in facilities across India.

Decreasing central line associated bloodstream infection in neonatal intensive care

Central Line Associated Bloodstream Infections (CLABSIs) have come to be recognized as preventable adverse events that result from lapses in technique at multiple levels of care. CLABSIs are associated with increased mortality and adverse outcomes that may have lifelong consequences. This review provides a summary of evidence-based strategies to reduce CLABSI in the newborn intensive care unit that have been described in the literature over the past decades. Implementation of these strategies in "bundles" is also discussed, citing examples of successful quality improvement collaboratives. The methods of implementation require an understanding of the scientific data and technical developments, as well as knowledge of how to influence change within the unique and complicated milieu of the newborn intensive care unit.

Bundled care for septic shock: an analysis of clinical trials

CONTEXT

Sepsis bundles have been developed to improve patient outcomes by combining component therapies. Valid bundles require effective components with additive benefits. Proponents encourage evaluation of bundles, both as a whole and based on the performance of each component.

OBJECTIVE

Assess the association between outcome and the utilization of component therapies in studies of sepsis bundles.

DATA SOURCE

Database searches (January 1980 to July 2008) of PubMed, Embase, and the Cochrane Library, using the terms sepsis, bundles, guidelines, and early goal directed therapy.

DATA EXTRACTION

Inclusion required comparison of septic adults who received bundled care vs. nonprotocolized care. Survival and use rates for individual interventions were abstracted.

MAIN RESULTS

Eight unblinded trials, one randomized and seven with historical controls, were identified. Sepsis bundles were associated with a consistent (I2 = 0%, p = .87) and significant increase in survival (odds ratio, 1.91; 95% confidence interval, 1.49-2.45; p < .0001). For all studies reporting such data, there were consistent (I2 = 0%, p > or = .64) decreases in time to antibiotics, and increases in the appropriateness of antibiotics (p < or = .0002 for both). In contrast, significant heterogeneity was seen across trials for all other treatments (antibiotic use within a specified time period; administration of fluids, vasopressors, inotropes, and packed red blood cells titrated to hemodynamic goals; corticosteroids and human recombinant activated protein C use) (all I2 > or = 67%, p < .002). Except for antibiotics, sepsis bundle components are still being investigated for efficacy in randomized controlled trials.

CONCLUSION

Bundle use was associated with consistent and significant improvement in survival and antibiotic use. Use of other bundle components changed heterogeneously across studies, making their impact on survival uncertain. However, this analysis should be interpreted cautiously as these studies were unblinded, and only one was randomized.

Intervention with an infection control bundle to reduce transmission of influenza-like illnesses in a thai preschool

BACKGROUND

Infection-control interventions are needed to minimize transmission of influenza-like illness (ILI) and other infections in settings where children are in close proximity.

SETTING

A 240-children Thai kindergarten.

METHODS

Three-year, quasi-experimental study was conducted to assess the association between the use of a bundle of 4 infection control interventions and the incidence of ILI, diarrheal illnesses, and hand-foot-mouth infections among preschool children. The numbers of incident infections were calculated for the preintervention year (period 1), the immediate postintervention year (period 2), and the sustained postintervention year (period 3).

RESULTS

The monthly incidence of ILI in period 1 (mean, 124 episodes per month) was 25.8 cases per 1,000 child-days; in period 2, it was 10.1 cases per 1,000 child-days (a reduction of 60.8%; P = .008); and in period 3, it was 8.2 cases per 1,000 child-days (a further reduction of 19%; P = .002). The monthly incidence of diarrheal illnesses in period 1 was 14 cases per 1,000 child-days; in period 2, it was 4 cases per 1,000 child-days (P = .01); and in period 3, it was 3 cases per 1,000 child-days (P = .007). The yearly incidence of hand-foot-mouth infection in period 1 was 10 cases per 1,000 child-days; in period 2, it was 1 case per 1,000 child-days (P = .01); and in period 3, it was 0.5 cases per 1,000 child-days per year (P = .007).

CONCLUSION

Use of the infection control intervention bundle was associated with reduced incidence of ILI at the Thai preschool.

The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations

The World Health Organization's Guidelines on Hand Hygiene in Health Care have been issued by WHO Patient Safety on 5 May 2009 on the occasion of the launch of the Save Lives: Clean Your Hands initiative. The Guidelines represent the contribution of more than 100 international experts and provide a comprehensive overview of essential aspects of hand hygiene in health care, evidence- and consensus-based recommendations, and lessons learned from testing their Advanced Draft and related implementation tools.

Storytelling: its place in infection control education

It is generally accepted that hand hygiene is the single most effective measure to prevent health care associated infection. Similarly, education is thought to be the cornerstone of effective practice. While common sense supports the notion that hand hygiene compliance would be enhanced by producing a well informed health care worker, traditional didactic methods of teaching are often poor at invoking and sustaining behaviour change. Storytelling is gaining popularity as an educational activity as it is said to stimulate thought, reflection and enhance the learning experience. This paper, describes one way in which storytelling may be used within a hand hygiene improvement strategy.

Infection control, ethics and accountability

Health care-associated infections (HAIs) are a major clinical and economic problem in Australian hospitals, and a significant proportion are preventable. HAIs are the result of complex environmental, microbiological, pathological, behavioural and organisational factors, and prevention requires a multifaceted ("bundled") approach, including appropriate policies, educational programs for health care workers, and adequate resources to implement them effectively. Failure to protect patients from avoidable harm, including HAIs, has significant ethical implications; it often reflects both organisational systems failure and non-compliance of health care workers with evidence-based policies, including hand hygiene. If implemented with appropriate safeguards, infection control "bundles" that include sanctions for poor compliance with hand hygiene and other infection control policies, will achieve sustained improvements where previous approaches have failed.

Comparison of national and subnational guidelines for hand hygiene

Hand hygiene promotion is considered as the cornerstone for healthcare-associated infection prevention. Over the past years, hand hygiene guidelines have been developed by different agencies at international, national and subnational levels. A comparison of these documents could help in understanding recommendations in different parts of the world and the methods used for their development. Guidelines were identified through search engines, electronic libraries, and personal contacts, and their content was analysed using an adapted version of a tool from the European DG XII-funded HARMONY project. Twenty-two guidelines were retrieved and 21 were evaluated. Documents varied in scope, approach, content and terminology. Some were primarily advisory directives, whereas others focused on the technical issues of why, when, and how to perform hand hygiene. The extent to which evidence was collected and assessed varied considerably and details were provided only in very few. Grading systems and definitions to indicate the strength of evidence and recommendations also differed. The intended outcome was to improve hand hygiene practices in healthcare, thus leading to a reduction of healthcare-associated infections and/or antimicrobial resistance. Although overall agreement on indications and procedures was noted, the range and depth of recommendations on best practices and implementation varied. Essential aspects such as compliance measurement and audits to assess guideline effectiveness were neglected in most documents. In conclusion, there is a need for a more consistent approach leading to recommendations based on a thorough evaluation of evidence and applicable worldwide. Aspects related to implementation and impact monitoring deserve greater attention.

Implementing the MRSA recommendations made by the Commission for Hospital Hygiene and Infection Prevention (KRINKO) of 1999 - current considerations by the DGKH Management Board

In Germany, recommendations on dealing with patients who are colonised with methicillin-resistant S. aureus (MRSA) for the inpatient sector have been published in 1999 by the Commission for Hospital Hygiene and Infection Prevention (KRINKO). Some challenges arise with regard to the practical implementation of the KRINKO recommendations. These challenges do not principally question the benefit of the recommendations but have come into criticism from users. In this commentary the German Society for Hospital Hygiene (DGKH) discusses some controversial issues and adds suggestions for unresolved problems regarding the infection control management of MRSA in healthcare settings.

Who is steering the ship? External influences on infection control programs

Over the past decade, hospital infection control programs have begun to face new external influences that affect day-to-day practice. The mainstream media's interest in hospital-acquired infection sparked consumer interest, which resulted in more legislative activity and government regulation. Industry's influence is also increasing. To meet the increased demands of external agencies, infection control programs will need additional resources, and the infection control community will need to be more proactive in educating the public and defining the priorities for practice and research.

Prevention of hospital-acquired infections: review of non-pharmacological interventions

Hospital-acquired (nosocomial) infections (HAIs) increase morbidity, mortality and medical costs. In the USA alone, nosocomial infections cause about 1.7 million infections and 99 000 deaths per year. HAIs are spread by numerous routes including surfaces (especially hands), air, water, intravenous routes, oral routes and through surgery. Interventions such as proper hand and surface cleaning, better nutrition, sufficient numbers of nurses, better ventilator management, use of coated urinary and central venous catheters and use of high-efficiency particulate air (HEPA) filters have all been associated with significantly lower nosocomial infection rates. Multiple infection control techniques and strategies simultaneously ('bundling') may offer the best opportunity to reduce the morbidity and mortality toll of HAIs. Most of these infection control strategies will more than pay for themselves by saving the medical costs associated with nosocomial infections. Many non-pharmacological interventions to prevent many HAIs will also reduce the need for long or multiple-drug antibiotic courses for patients. Lower antibiotic drug usage will reduce risk of antibiotic-resistant organisms and should improve efficacy of antibiotics given to patients who do acquire infections.

Compliance and infection control guidelines: a complex phenomenon

Healthcare-acquired infection has become a global health phenomenon affecting approximately 8.7% of the world's population. Despite a plethora of evidence-based guidelines, policies and procedures, knowledge of these can be poor, and when this is the case, sub-optimum care may follow. Historically, enhancement strategies have focused on the provision of education by making the tacit assumption that an increase in knowledge will result in an improvement in compliance. However, compliance is a multi-dimensional, abstract, complex concept that is difficult to define. Decision-making is rarely objective and the capacity of personal experience to outweigh scientific evidence is a hallmark of the post-modern times in which we live. It is well established in social psychology research that when faced with complex encounters, individuals turn to simple reasoning rules called 'heuristics', to make decisions. These heuristics are potentially dangerous as they can introduce flawed probability judgements in relation to compliance behaviour. If the raison-d'être of infection control nursing is to attain compliance with the best available evidence, organizations need to reject a reductionist, cause-and-effect view of compliance and acknowledge that compliance and infection control practice is a complex social construct.

‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene

Hand hygiene is a core element of patient safety for the prevention of healthcare-associated infections and the spread of antimicrobial resistance. Its promotion represents a challenge that requires a multi-modal strategy using a clear, robust and simple conceptual framework. The World Health Organization First Global Patient Safety Challenge 'Clean Care is Safer Care' has expanded educational and promotional tools developed initially for the Swiss national hand hygiene campaign for worldwide use. Development methodology involved a user-centred design approach incorporating strategies of human factors engineering, cognitive behaviour science and elements of social marketing, followed by an iterative prototype test phase within the target population. This research resulted in a concept called 'My five moments for hand hygiene'. It describes the fundamental reference points for healthcare workers (HCWs) in a time-space framework and designates the moments when hand hygiene is required to effectively interrupt microbial transmission during the care sequence. The concept applies to a wide range of patient care activities and healthcare settings. It proposes a unified vision for trainers, observers and HCWs that should facilitate education, minimize inter-individual variation and resource use, and increase adherence. 'My five moments for hand hygiene' bridges the gap between scientific evidence and daily health practice and provides a solid basis to understand, teach, monitor and report hand hygiene practices.