A national implementation project to prevent healthcare-associated infections in intensive care units: a collaborative initiative using the Breakthrough Series model

Multifaceted Control Interventions for Healthcare-associated Infections in a Kidney Transplant Intensive Care Unit: Clinical Outcome Improvement and Bundle Adherence

Background

Healthcare-associated infections (HAIs) are preventable complications that overwhelm the healthcare system. The implementation of multifaceted control intervention actions in the intensive care setting modifies clinical outcomes, but its effectiveness has not been specifically investigated for high-risk patients, such as kidney transplant recipients (KTRs).

Methods

This observational retrospective natural experiment evaluated the effectiveness of multifaceted control interventions (bundles) in reducing HAIs in a KTR intensive care unit. We also measured the bundle adherence rate during 16 mo in the after era.

Results

We included 1257 KTRs, 684 before and 573 in the postintervention period. After the bundle implementation, the incidence density of device-associated HAIs decreased from 8.5 to 3.9 per 1000 patient-days (relative risk [RR] = 0.46; 95% confidence interval [CI], 0.25-0.85; P = 0.01), primarily because of the reduction in central line-associated bloodstream infection from 8.0 to 3.4 events per 1000 catheter-days (RR = 0.43; 95% CI, 0.22-0.83; P = 0.012). Reductions in catheter-associated urinary tract infection (2.5 versus 0.6 per 1000 catheter-days; RR = 0.22; 95% CI, 0.03-1.92; P = 0.17) and ventilator-associated pneumonia (3.4 versus 1.0 per 1000 ventilator-days; RR = 0.29; 95% CI, 0.03-2.63; P = 0.27) were not significant. Central venous (P = 0.53) and urinary catheter (P = 0.47) insertion adherence were stable during 16 mo, whereas central venous (P < 0.001) and urinary catheter (P = 0.004) maintenance gradually increased. Finally, ventilator-associated pneumonia prevention bundle adherence slightly decreased over time (P = 0.06).

Conclusions

The implementation of comprehensive multifaceted control intervention actions in an intensive care unit dedicated to KTR care was effective in significantly reducing device-associated infections. The impact was in line with the reductions observed in populations that have not undergone transplantation, underscoring the effectiveness of these interventions across different patient groups.

Improving Safety through a Virtual Learning Collaborative

Background

Frontline healthcare safety leaders require expertise and confidence to manage local safety programs effectively yet are confronted with substantial challenges in identifying risk and reducing harm.

Methods

We convened a multidisciplinary safety learning collaborative in a children's hospital pediatric department and used the Institute for Healthcare Improvement's Breakthrough Series model. Participants attended four virtual education sessions over 13 months (September 2020-September 2021) focused on identifying harm and using tools to improve safety. We analyzed departmental safety data monthly throughout the collaborative. The primary outcome was the development of improvement projects using direct application of the session content. The secondary outcome was participant confidence in improving safety via pre- and postsurveys.

Results

Seventy clinicians and quality consultants participated. Fifteen divisional safety improvement projects were initiated. The percentage of survey respondents who reported feeling "completely confident" in their ability to improve safety increased from 26% (n = 39) to 58% (n = 26) from September 2020 to September 2021 (P = 0.01) and maintained at 65% 1 year after the end of the collaborative. We observed a decrease in the mean rate of reported inpatient preventable and possibly preventable moderate/serious/catastrophic events per 1000 bedded days from 1.10 (baseline) to 0.71 (intervention period).

Conclusions

Through a collaborative effort in a virtual learning environment, we facilitated the development of fifteen safety projects, increased leaders' confidence in improving safety, and saw improved inpatient safety. This approach, which involves healthcare professionals from various disciplines, may be effectively adapted to other settings.

Using active learning strategies during a quality improvement collaborative: exploring educational games to enhance learning among healthcare professionals

BACKGROUND

The Breakthrough Series model uses learning sessions (LS) to promote education, professional development and quality improvement (QI) in healthcare. Staff divergences regarding prior knowledge, previous experience, preferences and motivations make selecting which pedagogic strategies to use in LS a challenge.

AIM

We aimed to assess new active-learning strategies: two educational games, a card game and an escape room-type game, for training in healthcare-associated infection prevention.

METHODS

This descriptive case study evaluated the performance of educational strategies during a Collaborative to reduce healthcare-associated infections in Brazilian intensive care units (ICUs). A post-intervention survey was voluntarily offered to all participants in LS activities.

RESULTS

Seven regional 2-day LS were held between October and December 2022 (six for adult ICUs and one for paediatric/neonatal ICUs). Of 194 institutions participating in a nationwide QI initiative, 193 (99.4%) participated in these activities, totalling 850 healthcare professionals. From these, 641 participants responded to the survey (75.4%). The post-intervention survey showed that the participants responded positively to the educational activities.

CONCLUSION

The participants perceived the various pedagogical strategies positively, which shows the value of a broad and diverse educational approach, customised to local settings and including game-based activities, to enhance learning among healthcare professionals.

Estimating the savings of a national project to prevent healthcare-associated infections in intensive care units

BACKGROUND

Healthcare-associated infections (HAIs) have a significant impact on patients' morbidity and mortality, and have a detrimental financial impact on the healthcare system. Various strategies exist to prevent HAIs, but economic evaluations are needed to determine which are most appropriate.

AIM

To present the financial impact of a nationwide project on HAI prevention in intensive care units (ICUs) using a quality improvement (QI) approach.

METHODS

A health economic evaluation assessed the financial results of the QI initiative 'Saúde em Nossas Mãos' (SNM), implemented in Brazil between January 2018 and December 2020. Among 116 participating institutions, 13 (11.2%) fully reported the aggregate cost and stratified patients (with vs without HAIs) in the pre-intervention and post-intervention periods. Average cost (AC) was calculated for each analysed HAI: central-line-associated bloodstream infections (CLABSIs), ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTIs). The absorption model and time-driven activity-based costing were used for cost estimations. The numbers of infections that the project could have prevented during its implementation were estimated to demonstrate the financial impact of the SNM initiative.

RESULTS

The aggregated ACs calculated for each HAI from these 13 ICUs - US$8480 for CLABSIs, US$10,039 for VAP, and US$7464 for CAUTIs - were extrapolated to the total number of HAIs prevented by the project (1727 CLABSIs, 3797 VAP and 2150 CAUTIs). The overall savings of the SNM as of December 2020 were estimated at US$68.8 million, with an estimated return on investment (ROI) of 765%.

CONCLUSION

Reporting accurate financial data on HAI prevention strategies is still challenging in Brazil. These results suggest that a national QI initiative to prevent HAIs in critical care settings is a feasible and value-based approach, reducing financial waste and yielding a significant ROI for the healthcare system.

Adapting lean management to prevent healthcare-associated infections: a low-cost strategy involving Kamishibai cards to sustain bundles' compliance

Lean healthcare visual management has been successfully integrated into infection control programs, leading to lower healthcare-associated infection (HAI) rates and greater provider compliance with evidence-based prevention practices; however, its implementation during quality improvement (QI) initiatives in limited-resource settings has not yet been well exploited. We aimed to describe a low-cost strategy involving Kamishibai cards to sustain bundles' adherence to prevent HAIs in a middle-income country. This descriptive case study evaluated the implementation of a lean healthcare visual management tool-Kamishibai board (K-board)-during a nationwide QI collaborative preventing three critical HAIs in 189 adult and pediatric/neonatal intensive care units (ICUs) from September 2021 to January 2023. Considering a limited-resource setting, our team adapted a K-board using simple, cheap, and easy-to-handle materials for routine monitoring of QI procedures, including safety bundles' compliance. After test prototypes, the final K-board version was implemented. The chart materials and assembly cost BRL 80.00 (USD 15.48). Before launching, expert working group meetings were held to shape the contents, refine technical issues, and prepare the ICU teams for implementation. After starting, plan-do-study-act cycles were conducted according to the Breakthrough Series model. Participating ICU teams, including leaders and front-line health workers, performed bedside audits following a weekly chronogram. Two indicators were calculated: the percentage of ICUs in which K-boards were being implemented and whether bundles' compliance was addressed in the K-board. Audit data were recorded in 'SimpleQI'. After 17 months of this initiative, 177 (93.7%) participating ICUs had included this visual management tool in their daily care routines. When more than 94 (>50%) ICUs posted K-board data, the mean compliance for the bundles for each HAI was sustained above 85%. A lean healthcare visual management tool can be adapted to local settings, including healthcare facilities with limited resources. K-board seems to be a feasible method for auditing evidence-based practices in medical care, including safety bundles to simultaneously prevent three types of HAIs.

The impact of the coronavirus disease 2019 (COVID-19) pandemic on a national project preventing healthcare-associated infections in intensive care units

Beginning in 2018, a quality improvement collaborative initiative in Brazil successfully reduced the baseline incidence density of healthcare-associated infections in intensive care settings after 2 years. We describe the adaptations of the quality improvement interventions as the COVID-19 pandemic emerged and how the pandemic affected the project outcomes.