Table 6eArticles addressing prevention of central line-associated bloodstream infections: simple before-after studies of poor methodologic quality

AuthorSetting and Hospital TypeStudy periodLength of follow-upPreventive InterventionsQuality improvement interventionResults
Bijma 199998 The NetherlandsNot specified6 monthsHand hygiene QI Strategies: Clinician education; organizational change Infection rate prior to intervention: 15.0 CLABSI per 1,000 catheter-days
Tertiary care or university hospitalThe following fivefold intervention was consecutively implemented during a 12-month period:
1.

A propanol/isopropanol solution containing a quaternary ammonium compound and an emollient to prevent excessive drying of the skin was introduced as a hand disinfecting agent.

2.

An adhesive, non-woven, island-type gauze was introduced as CVC dressing.

3.

A “one bag” TPN system was introduced.

4.

A small needleless closed IV connection device was incorporated in every SICU patient's IV system.

5.

Implementation of the aforementioned measures was carried out by and under continuous surveillance of the SICU's infection control practitioner (ICP).

Checking protocol compliance required the ICP's daily presence on the SICU.

Infection rate after intervention: 8.0 CLABSI per 1,000 catheter-days
P=NS
*Lam 200462 Hong KongNot specified10 monthsHand hygiene QI Strategies: Clinician reminder; organizational change Infection rate prior to intervention: 6.8 CLABSI per 1,000 catheter-days
Tertiary care or university hospitalNurses and physicians received an educational program targeting hand hygiene. A hand hygiene protocol was implemented as part of the orientation for new staff. Face-to-face educational seminars were conducted for nurses and physicians where solutions to overcome obstacles to hand washing were provided; 2 sessions were provided for physicians and 10 for nurses. A task-oriented analysis was performed to identify strategies for hand washing during complex procedures. Demonstrations were conducted at regular intervals, and reminder pictures were posted at each hand washing basin.Infection rate after intervention: 1.2 CLABSI per 1,000 catheter-days
p=NS
Compliance with hand hygiene:
Before intervention: 40%
After intervention: 53%
p<0.01
Lobo 2005101 Brazil1/01 through 12/0220 monthsHand hygiene QI Strategies: Clinician education; audit and feedback, clinician reminder Infection rate prior to intervention: 20 CLABSI per 1,000 catheter-days
Tertiary care or university hospitalMaximal sterile barrier precautionsAn education program was developed by a multidisciplinary task force focusing on CVC insertion, manipulation, and care. 3 infection control nurses, a physician, and the entire unit staff were on the task force.Infection rate after intervention: 11 CLABSI per 1,000 catheter-days
p value not reported
Adherence to appropriate use of maximal sterile barrier precautions:
Before intervention: 91%
after intervention: 100%
p=NS
Penne 200290 United StatesJanuary 1997-July 1998,Not specifiedHand hygiene QI Strategies: Clinician education; audit and feedback; clinician reminder; organizational change Number of CLABSI before intervention: 39
Tertiary care or university hospitalAugust 1998-March 2000Maximal sterile barrier precautionsA nurse educator performed individual education sessions with each staff member and demonstrated dressing change to ensure sterile technique and proper application of dressing to prevent risk of infectionNumber of CLABSI after intervention: 24
Note: number of catheter-days not supplied
Puntis 1991104 UKNot specifiedNot specifiedHand hygiene QI Strategies: Clinician education Infection rate prior to intervention: 45% of catheters infected
Not specifiedThe nutritional care team at a children's hospital instituted an education program for care of catheters used for parenteral nutrition. Hand hygiene was emphasized, and new guidelines for catheter care were drawn up emphasizing use of aseptic technique and proper technique for changing feeding bags. Demonstrations of line care and bag changing were organized for nursing staff at which attendance was compulsory. A video of proper technique was also shown.Infection rate after intervention: 8% of catheters infected
This educational intervention was delivered to junior medical staff and nurses.
Rosenthal 2003102 ArgentinaBernal Medical center: 4/1999–5/1999;22 monthsHand hygiene QI Strategies: Clinician education; audit and feedback Infection rate prior to intervention: 45.94 CLABSI per 1,000 catheter-days
Non-teaching community hospitalColegiales Medical Center, 9/2000–12/2000Maximal sterile barrier precautionsA surveillance and educational intervention was implemented at 2 ICUs in Argentina. Health care workers in the study ICUs underwent training for central venous catheter care based on CDC guidelines (at the time, these included hand hygiene, maximal sterile barrier precautions, appropriate insertion site selection and prompt removal of unnecessary catheters; however, chlorhexidine skin sterilization was not part of the guidelines.) Subsequently, performance feedback on catheter site care was provided to the ICU staff on a monthly basis. Compliance rates with catheter care were also provided to ICU administrators. This intervention was referred to as phase 2 (phase 1 being the pre-intervention period.) A separate intervention to encourage hand washing was implemented simultaneously; all health care workers received a comprehensive infection control manual. Hand washing compliance was observed covertly in the ICU by an infection control practitioner and monthly meetings were held at which hand washing rates were displayed and fed back to providers. Hand washing rates were also posted monthly in the ICUs and reported to the ICU manager and administrator.Infection rate after intervention: 9.90 CLABSI per 1,000 catheter-days
Appropriate insertion site selectionThe hand washing guideline was also posted in the ICU. Educational classes were given in 1-hour group sessions for each shift daily for 1 week (attendance was voluntary).p<0.01
Prompt removal of unnecessary cathetersParticipants underwent a posttest to evaluate retention of the educational material. In addition, infection control review classes were held to answer questions and share surveillance data.Adherence to protocols for hand hygiene before intervention: 23.1%
after intervention: 64.5%
p<0.01
Wall 200595 United Statesbegan 11/20022 yearsHand hygiene QI Strategies: Clinician education; audit and feedback Infection rate prior to intervention: 7.0 CLABSI per 1,000 catheter-days
Tertiary care or university hospitalMaximal sterile barrier precautionsA continuous quality improvement intervention was conducted in a medical intensive care unit. An interdisciplinary team consisting of the MICU director and nurse manager, MICU nurses and physicians, epidemiologist, infection control practitioner and QI experts was assembled and decided to focus on central line insertion practices (after reviewing relevant prevention literature). The intervention primarily targeted house staff physicians. A nurse observed central line insertions to determine the baseline quality gap. A checklist for central line insertion was developed that mandated: hand hygiene, maximal sterile barrier precautions, chlorhexidine skin preparation, and proper supervision of trainees. (These steps could be skipped if the insertion was considered an emergency.)Infection rate after intervention: 3.8 CLABSI per 1,000 catheter-days
Chlorhexidine skin sterilizationProviders were educated on the checklist and supporting evidence through a web-based tutorial with self-assessment exam; house staff was required to complete the tutorial. Infection rates and rates of compliance with process measures were fed back to the front line staff.
**Berg 199560 Guatemala3 months1 yearHand hygiene QI Strategies: Clinician education Infection rate prior to intervention: 14% of patients
Tertiary care or university hospitalA multifaceted intervention was used to target nosocomial infections in the ICU, with both general measures and measures targeting VAP and CA-UTI.Infection rate after intervention: 13% of patients
Nurses and physicians received 15 educational sessions on aseptic technique, stressing proper hand washing. The educational sessions used lectures and demonstrations, and individual clinicians also received positive and negative feedback and reminder signs at the bedside. The VAP intervention targeted proper use of sterile rinse water and improvement in aseptic technique for suctioning. Providers received more than 15 interactive conferences on the detection, management, and prevention of nosocomial pneumonia; these included lectures, demonstrations, individual instruction and feedback, and contests. The CA-UTI intervention consisted of changing open urinary drainage systems to closed systems (aseptic catheter care), with an educational session on the new catheter. The intervention did not specifically target surgical site infections, but those outcomes are reported.p=NS
Adherence to protocols for hand hygiene:
before intervention: 5%
after intervention: 63%
p<0.01
*

This study addresses prevention of central line-associated bloodstream infections and ventilator-associated pneumonia.

**

This study addresses prevention of surgical site infections, central line-associated bloodstream infections, ventilator-associated pneumonia and catheter-associated urinary tract infections.

From: 3, Results

Cover of Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 6: Prevention of Healthcare–Associated Infections)
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 6: Prevention of Healthcare–Associated Infections).
Technical Reviews, No. 9.6.
Ranji SR, Shetty K, Posley KA, et al.

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