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Hontoria-Alcoceba R, López-López C, Hontoria-Alcoceba V, Sánchez-Morgado AI. Implementation of Evidence-Based Practice in Peripheral Intravenous Catheter Care. J Nurs Care Qual 2023; 38:226-233. [PMID: 36727916 DOI: 10.1097/ncq.0000000000000688] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Inserting a peripheral intravenous (PIV) catheter is a common health care procedure; however, risks include phlebitis, extravasation, and accidental dislodgement. Using evidence-based practices (EBPs) can reduce these risks. PURPOSE The purpose of this study was to implement an evidence-based PIV catheter care bundle and a decision-making algorithm. METHODS A quasi-experimental study design was used. A care bundle and an evidence-based decision-making algorithm were implemented on a medical unit. Outcomes included length of PIV catheter dwell time, phlebitis and other complications, and health professionals' adherence to the interventions. RESULTS A total of 364 PIV catheters were assessed. PIV catheter dwell time decreased from 3.6 to 2.9 days ( P < .001), and phlebitis rates decreased from 14.8% to 4.9% ( P < .05). Health professionals' adherence increased from 84.3% to 91.8%. CONCLUSIONS Implementing EBPs can improve care provided to patients with PIV catheters.
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Affiliation(s)
- Rocío Hontoria-Alcoceba
- Internal Medicine Service (Mss R. Hontoria-Alcoceba and Sánchez-Morgado) and Emergency and Trauma Intensive Care Unit (Dr López-López), Hospital Universitario 12 de Octubre, Madrid, Spain; Researcher of Care Research Group (InveCuid), Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain (Dr López-López); Faculty of Nursing, Physiotherapy and Podiatry, Complutense University of Madrid, Madrid, Spain (Dr López-López); and Emergency Medical Service of Madrid SUMMA 112, Madrid, Spain (Ms V. Hontoria-Alcoceba)
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What fuels suboptimal care of peripheral intravenous catheter-related infections in hospitals? A qualitative study of decision-making among Spanish nurses. Antimicrob Resist Infect Control 2022; 11:105. [PMID: 35986398 PMCID: PMC9389778 DOI: 10.1186/s13756-022-01144-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 08/14/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Peripheral intravenous catheters (PIVC) are commonly used in hospital worldwide. However, PIVC are not exempt from complications. Catheter-related bloodstream infections (CRBSI) increase morbidity and mortality rates, and costs for the healthcare organization. PIVC care is shaped by the complex mix of professional and organizational culture, such as knowledge gaps, low perception of impact of PIVCs on patient safety, or lack of hospital guidelines.
Aim
To explore determinants of decision-making about the prevention of PIVC-BSI among nurses in Spanish hospitals.
Methods
We conducted a descriptive qualitative study with semi-structured interviews in three public hospitals, the Balearic Islands Health Care Service in Spain. We considered hospital ward nurses working routinely with inpatients at any of the three hospitals for enrolment in the study. We approached relevant informants to identify suitable participants who recruited other participants through a ‘snowball’ technique. Fourteen inpatient nurses from the hospital took part in this study between September and November 2018. We employed several triangulation strategies to underpin the methodological rigour of our analysis and conducted the member checking, showing the information and codes applied in the recording of the interviews to identify the coherence and any discrepancies of the discourse by participants. We used the COREQ checklist for this study.
Findings
We identified four major themes in the analysis related to determinants of care: The fog of decision-making in PIVC; The taskification of PIVC care; PIVC care is accepted to be suboptimal, yet irrelevant; and chasms between perceived determinants of poor PIVC care and its solutions.
Conclusion
The clinical management of PIVCs appear ambiguous, unclear, and fragmented, with no clear professional responsibility and no nurse leadership, causing a gap in preventing infections. Furthermore, the perception of low risk on PIVC care impact can cause a relevant lack of adherence to the best evidence and patient safety. Implementing facilitation strategies could improve the fidelity of the best available evidence regarding PIVC care and raise awareness among nurses of impact that excellence of care.
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Blanco-Mavillard I, de Pedro-Gómez JE, Rodríguez-Calero MÁ, Bennasar-Veny M, Parra-García G, Fernández-Fernández I, Bujalance-Hoyos J, Moya-Suárez AB, Cobo-Sánchez JL, Ferrer-Cruz F, Castro-Sánchez E. Multimodal intervention for preventing peripheral intravenous catheter failure in adults (PREBACP): a multicentre, cluster-randomised, controlled trial. LANCET HAEMATOLOGY 2021; 8:e637-e647. [PMID: 34450101 DOI: 10.1016/s2352-3026(21)00206-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND 2 billion peripheral intravenous catheters (PIVC) are inserted into inpatients worldwide each year. Almost one in two PIVCs fail before completion of intravenous therapy. We aimed to determine the efficacy and costs of a multimodal intervention to reduce PIVC failure among hospitalised patients. METHODS PREBACP was a cluster-randomised, controlled trial done at seven public hospitals in Spain. Clusters (hospital wards) had at least 70% permanent staff and data were collected from patients aged 18 years and older with one or more PIVCs at the start of intravenous therapy. Clusters were randomly assigned (1:1) to the multimodal intervention or control group using a centralised, web-based randomisation software, and stratified by type of setting. We concealed randomisation to allocation, without masking patients or professionals to the intervention. An intervention using a multimodal model and dissemination of protocols, education for health-care professionals and patients, and feedback on performance was implemented for 12 months in the intervention group. The control group received usual care. The primary outcome was all-cause PIVC failure at 12 months (phlebitis, extravasation, obstruction, or infections). Subsequently, through an amendment to the protocol approved on July 25, 2021, we included dislodgement as part of PIVC failure. Analysis was by modified intention to treat, which included all randomly assigned hospital wards for whom data on the primary endpoint were available. This trial is registered with the ISRCTN Registry, ISRCTN10438530. FINDINGS Between Jan 1, 2019, and March 1, 2020, we randomly assigned 22 eligible clusters to receive the multimodal intervention (n=11 clusters; 2196 patients, 2235 PIVCs, and 131 nurses) or usual practice in the control group (n=11 clusters; 2282 patients, 2330 PIVCs, and 138 nurses). At 12 months, the proportion of PIVC failures was lower in the intervention group than in the control group (37·10% [SD 1·32], HR 0·81 [95% CI 0·72 to 0·92] vs 46·49% [2·59], HR 1·23 [1·04 to 1·39]; mean difference -9·39% [95% CI -11·22 to -7·57]; p<0·0001). Per-protocol-prespecified analysis of the primary outcome excluding dislodgement also showed the intervention significantly reduced PIVC failure compared with the control group at 12 months (33·47% [SD 2·98], HR 0·85 [95% CI 0·75 to 0·96] vs 41·06% [4·62], HR 1·18 [1·04 to 1·33]; mean difference -7·59% [95% CI -11·05 to -4·13]; p<0·0001). INTERPRETATION A multimodal intervention reduced PIVC failure, thereby reducing potentially serious complications for hospitalised patients. The findings of PREBACP enabled a deeper understanding of decision making, knowledge mobilisation, and sense making in routine clinical practice. FUNDING The College of Nurses of the Balearic Islands. TRANSLATION For the Spanish translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Ian Blanco-Mavillard
- Quality, Teaching and Research Unit, Hospital de Manacor, Manacor, Spain; Department of Nursing and Physiotherapy, Universitat de les Illes Balears, Palma, Spain; Care, Chronicity and Evidence in Health Research Group, Health Research Institute of the Balearic Islands, Palma, Spain.
| | - Joan Ernest de Pedro-Gómez
- Department of Nursing and Physiotherapy, Universitat de les Illes Balears, Palma, Spain; Care, Chronicity and Evidence in Health Research Group, Health Research Institute of the Balearic Islands, Palma, Spain
| | - Miguel Ángel Rodríguez-Calero
- Department of Nursing and Physiotherapy, Universitat de les Illes Balears, Palma, Spain; Care, Chronicity and Evidence in Health Research Group, Health Research Institute of the Balearic Islands, Palma, Spain; Health Care Office, Balearic Islands Health Service, Palma, Spain
| | - Miquel Bennasar-Veny
- Department of Nursing and Physiotherapy, Universitat de les Illes Balears, Palma, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | | | | | | | - Ana Belén Moya-Suárez
- Department of Nursing, Agencia Sanitaria Costa del Sol, Marbella, Málaga, Spain; Biomedical Research Institute of Málaga, Málaga, Spain
| | | | | | - Enrique Castro-Sánchez
- City, University of London, London, UK; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
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Blanco-Mavillard I, Parra-García G, Fernández-Fernández I, Rodríguez-Calero MÁ, Personat-Labrador C, Castro-Sánchez E. Care of peripheral intravenous catheters in three hospitals in Spain: Mapping clinical outcomes and implementation of clinical practice guidelines. PLoS One 2020; 15:e0240086. [PMID: 33007001 PMCID: PMC7531784 DOI: 10.1371/journal.pone.0240086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/19/2020] [Indexed: 12/26/2022] Open
Abstract
Background Peripheral intravenous catheters (PIVCs) are the most widely used invasive devices worldwide. Up to 42% of PIVCs are prematurely removed during intravenous therapy due to failure. To date, there have been few systematic attempts in European hospitals to measure adherence to recommendations to mitigate PIVC failures. Aim To analyse the clinical outcomes from clinical practice guideline recommendations for PIVC care on different hospital types and environments. Methods We conducted an observational study in three hospitals in Spain from December 2017 to April 2018. The adherence to recommendations was monitored via visual inspection in situ evaluations of all PIVCs inserted in adults admitted. Context and clinical characteristics were collected by an evaluation tool, analysing data descriptively. Results 646 PIVCs inserted in 624 patients were monitored, which only 52.7% knew about their PIVC. Regarding PIVC insertion, 3.4% (22/646) patients had at least 2 PIVCs simultaneously. The majority of PIVCs were 20G (319/646; 49.4%) and were secured with transparent polyurethane dressing (605/646; 93.7%). Most PIVCs (357/646; 55.3%) had a free insertion site during the visual inspection at first sight. We identified 342/646 (53%) transparent dressings in optimal conditions (clean, dry, and intact dressing). PIVC dressings in medical wards were much more likely to be in intact conditions than those in surgical wards (234/399, 58.7% vs. 108/247, 43.7%). We identified 55/646 (8.5%) PIVCs without infusion in the last 24 hours and 58/646 (9.0%) PIVCs without infusion for more than 24 hours. Regarding PIVC failure, 74 (11.5%) adverse events were identified, all of them reflecting clinical manifestation of phlebitis. Conclusions Our findings indicate that the clinical outcome indicators from CPG for PIVC care were moderate, highlighting differences between hospital environments and types. Also, we observed that nearly 50% of patients did not know what a PIVC is.
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Affiliation(s)
- Ian Blanco-Mavillard
- Hospital Manacor, Manacor, Spain
- Universitat de les Illes Balears, Palma, Spain
- Care, Chronicity and Evidence in Health Research Group (CurES), Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- * E-mail:
| | | | | | - Miguel Ángel Rodríguez-Calero
- Universitat de les Illes Balears, Palma, Spain
- Care, Chronicity and Evidence in Health Research Group (CurES), Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Servei de Salut de les Illes Balears, Palma, Spain
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Laan BJ, Maaskant JM, Spijkerman IJB, Borgert MJ, Godfried MH, Pasmooij BC, Opmeer BC, Vos MC, Geerlings SE. De-implementation strategy to reduce inappropriate use of intravenous and urinary catheters (RICAT): a multicentre, prospective, interrupted time-series and before and after study. THE LANCET. INFECTIOUS DISEASES 2020; 20:864-872. [PMID: 32151333 DOI: 10.1016/s1473-3099(19)30709-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 09/29/2019] [Accepted: 11/27/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Catheter-associated bloodstream infections and urinary tract infections are frequently encountered health care-associated infections. We aimed to reduce inappropriate use of catheters to reduce health care-associated infections. METHODS In this multicentre, interrupted time-series and before and after study, we introduced a de-implementation strategy with multifaceted interventions in seven hospitals in the Netherlands. Adult patients admitted to internal medicine, gastroenterology, geriatic, oncology, or pulmonology wards, and non-surgical acute admission units, and who had a (central or peripheral) venous or urinary catheter were eligible for inclusion. One of the interventions was that nurses in the participating wards attended educational meetings on appropriate catheter use. Data on catheter use were collected every 2 weeks by the primary research physician during the baseline period (7 months) and intervention period (7 months), which were separated by a 5 month transition period. The primary outcomes were percentages of short peripheral intravenous catheters and urinary catheters used inappropriately on the days of data collection. Indications for catheter use were based on international guidelines. This study is registered with Netherlands Trial Register, NL5438. FINDINGS Between Sept 1, 2016, and April 1, 2018, we screened 6157 patients for inclusion, of whom 5696 were enrolled: 2650 patients in the baseline group, and 3046 in the intervention group. Inappropriate use of peripheral intravenous catheters occurred in 366 (22·0%, 95% CI 20·0 to 24·0) of 1665 patients in the baseline group and in 275 (14·4%, 12·8 to 16·0) of 1912 patients in the intervention group (incidence rate ratio [IRR] 0·65, 95% CI 0·56 to 0·77, p<0·0001). Time-series analyses showed an absolute reduction in inappropriate use of peripheral intravenous catheters from baseline to intervention periods of 6·65% (95% CI 2·47 to 10·82, p=0·011). Inappropriate use of urinary catheters occurred in 105 (32·4%, 95% CI 27·3 to 37·8) of 324 patients in the baseline group compared with 96 (24·1%, 20·0 to 28·6) of 398 patients in the intervention group (IRR 0·74, 95% CI 0·56 to 0·98, p=0·013). Time-series analyses showed an absolute reduction in inappropriate use of urinary catheters of 6·34% (95% CI -12·46 to 25·13, p=0·524). INTERPRETATION Our de-implementation strategy reduced inappropriate use of short peripheral intravenous catheters in patients who were not in the intensive care unit. The reduction of inappropriate use of urinary catheters was substantial, yet not statistically significant in time-series analysis due to a small sample size. The strategy appears well suited for broad-scale implementation to reduce health care-associated infections. FUNDING Netherlands Organisation for Health Research and Development.
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Affiliation(s)
- Bart J Laan
- Infectious Diseases, Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
| | - Jolanda M Maaskant
- Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Ingrid J B Spijkerman
- Medical Microbiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marjon J Borgert
- Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Mieke H Godfried
- Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Berend C Pasmooij
- Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Brent C Opmeer
- Clinical Research Unit, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Margreet C Vos
- Medical Microbiology and Infectious Diseases, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Suzanne E Geerlings
- Infectious Diseases, Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Pérez-Granda MJ, Bouza E, Pinilla B, Cruces R, González A, Millán J, Guembe M. Randomized clinical trial analyzing maintenance of peripheral venous catheters in an internal medicine unit: Heparin vs. saline. PLoS One 2020; 15:e0226251. [PMID: 31905205 PMCID: PMC6944354 DOI: 10.1371/journal.pone.0226251] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 08/12/2019] [Indexed: 01/28/2023] Open
Abstract
Background Peripheral venous catheters (PVCs) require adequate maintenance based on heparin or saline locks in order to prevent complications. Heparin has proven effective in central venous catheters, although its use in PVCs remains controversial. Our hypothesis was that saline locks are as effective as heparin locks in preventing problems with PVCs. The objective of the present study was to compare phlebitis and catheter tip colonization rates between PVCs locked with saline and those locked with heparin in patients admitted to an internal medicine department (IMD). Methods We performed a 19-month prospective, controlled, open-label, randomized clinical study of patients with at least 1 PVC admitted to the IMD of our hospital. The patients were randomized to receive saline solution (PosiFlush®, group A) or heparin (Fibrilin®, group B) for daily maintenance of the PVC. Clinical and microbiological data were monitored to investigate the frequency of phlebitis, catheter tip colonization, and catheter-related bloodstream infection (C-RBSI), as well as crude mortality, days of hospital stay, and days of antimicrobial treatment. Results We assessed 339 PVCs (241 patients), of which 192 (56.6%) were locked with saline (group A) and 147 (43.4%) with heparin (group B). The main demographic characteristics of the patients were distributed equally between the 2 study groups. The median (IQR) catheter days was 5 (3–8) for both groups (p = 0.64). The frequency of phlebitis was 17.7% for group A and 13.3% for group B (p = 0.30). The frequency of colonization of PVC tips was 14.6% and 12.2% in groups A and B, respectively (p = 0.63). Only 2 episodes of C-RBSI were detected (1 patient in group A). Saline lock was not an independent factor for phlebitis or catheter colonization. Conclusions Our study revealed no statistically significant differences in the frequency of phlebitis and catheter tip colonization between PVCs locked with saline and PVCs locked with heparin. We suggest that PVC can be maintained with saline solution, as it is safer and cheaper than heparin.
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Affiliation(s)
- María Jesús Pérez-Granda
- Department of Clinical Microbiology and Infectious Diseases, H.G.U. Gregorio Marañón, Madrid, Spain
- Department of Nursing, School of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
- * E-mail: (MG); (MJP-G)
| | - Emilio Bouza
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- Infection Study Group of the Sociedad Española de Medicina Interna, Madrid, Spain
| | - Blanca Pinilla
- Infection Study Group of the Sociedad Española de Medicina Interna, Madrid, Spain
- Department of Internal Medicine, H.G.U. Gregorio Marañón, Madrid, Spain
| | - Raquel Cruces
- Department of Clinical Microbiology and Infectious Diseases, H.G.U. Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ariana González
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Jesús Millán
- Department of Internal Medicine, H.G.U. Gregorio Marañón, Madrid, Spain
| | - María Guembe
- Department of Clinical Microbiology and Infectious Diseases, H.G.U. Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- * E-mail: (MG); (MJP-G)
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Blanco-Mavillard I, Rodríguez-Calero MÁ, de Pedro-Gómez J, Parra-García G, Fernández-Fernández I, Castro-Sánchez E. Incidence of peripheral intravenous catheter failure among inpatients: variability between microbiological data and clinical signs and symptoms. Antimicrob Resist Infect Control 2019; 8:124. [PMID: 31367345 PMCID: PMC6647274 DOI: 10.1186/s13756-019-0581-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 07/17/2019] [Indexed: 11/13/2022] Open
Abstract
Background Peripheral intravenous catheters (PIVCs) are the most widely used invasive devices among inpatients. Catheter-related bloodstream infections (CRBSI) are serious yet preventable events for patients. Although the contribution of PIVCs towards these infections is gradually being recognised, its role in the Spanish setting is yet to be determined. We aimed to estimate the rate and incidence of PIVC failure at Manacor hospital (Spain) as baseline within a wider quality improvement initiative. Methods Tips from all PIVC removed during December 2017 and January 2018 in hospital wards were cultured semiquantitatively. The study population included all PIVCs inserted in adult patients admitted to any of three medical and one surgical wards, emergency department, critical care unit and operating rooms. Clinical, microbiological and ward information was collected by clinical researchers for each PIVC from insertion to removal on the study sites. CRBSI was defined per international guidelines (i.e., Centers for Disease Control and Prevention, USA). Data was analysed descriptively. Results Seven hundred and eleven tips were cultured, with 41.8% (297/711) reported as PIVC failure. The PIVC failure rate density-adjusted incidence for hospital length of stay (HLOS) was 226.2 PIVC failure/1000 HLOS. 5.8% (41/711) tips yielded positive isolates, with most frequent microorganisms Staphylococcus spp (S. epidermidis 29/41, 70.7%, S. aureus 2/41, 4.9%, S. hominis 2/41, 4.9%), and Acinetobacter baumannii (1/41, 2.4%). One S. aureus isolate was methicillin-resistant. 53.6% (22/41) positive cultures were obtained from patients with local signs and symptoms compatible with catheter-related infection (CRI), 2.4% (1/41) were compatible with CRBSI type 2 and that clinical signs improve within 48 h of catheter removal (density-adjusted incidence for hospital stays of 16.7 PIVC-CRI/1000 hospital-stays and 0.76 PVC-BSI/1000 hospital-stays respectively) and no patients were diagnosed CRBSI type 3 with a bacterial growth concordant in tip and blood cultures. Most cases responded favourably to catheter removal and management. Conclusions Our findings show that almost 42% PIVCs resulted in unplanned removal, amplifying the importance in terms of morbidity, mortality and patient safety. A high number of positive tip cultures without clinical signs and symptoms was observed. We underpin the importance to remove unnecessary PIVCs for the prevention of CRBSI.
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Affiliation(s)
- Ian Blanco-Mavillard
- Quality, Teaching and Research Unit, Hospital Manacor, Cra. de Manacor-Alcudia s/n, 07500 Manacor, Spain.,3Universitat de les Illes Balears, Palma, Spain.,Care, Chronicity and Evidence in Health Research Group, Health Institute of Health Sciences, Palma, Spain
| | - Miguel Ángel Rodríguez-Calero
- 2Servei de Salut de les Illes Balears, Palma, Spain.,3Universitat de les Illes Balears, Palma, Spain.,Care, Chronicity and Evidence in Health Research Group, Health Institute of Health Sciences, Palma, Spain
| | - Joan de Pedro-Gómez
- 3Universitat de les Illes Balears, Palma, Spain.,Care, Chronicity and Evidence in Health Research Group, Health Institute of Health Sciences, Palma, Spain
| | | | - Ismael Fernández-Fernández
- Quality, Teaching and Research Unit, Hospital Manacor, Cra. de Manacor-Alcudia s/n, 07500 Manacor, Spain
| | - Enrique Castro-Sánchez
- 6NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London, London, UK
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