Objective: To determine the effects of quality improvement strategies on promoting adherence to interventions for prevention of selected (surgical site infections (SSI), central line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), and catheterassociated urinary tract infections (CAUTI)) healthcare-associated infections (HAIs), and on HAI rates.
Data Sources: MEDLINE® and Cochrane Collaboration's Effective Practice and Organisation of Care registry. We also reviewed the reference lists of systematic reviews and included studies, and contacted experts.
Search Strategy and Inclusion Criteria: We included randomized and quasi-randomized controlled trials, controlled before-after studies, interrupted time series, and simple before-after studies that reported either HAI rates or rates of adherence to target preventive quality improvement (QI) interventions for any of the four target HAIs. QI strategies were classified as clinician education, patient education, audit and feedback, clinician reminders, organizational change (including revision of professional roles, staffing changes, and total quality management/continuous quality improvement), and financial or regulatory incentives. We targeted hand hygiene as a preventive intervention for all HAIs. The target preventive interventions specific to SSI were appropriate perioperative antibiotic prophylaxis (including appropriate antibiotic selection, timing, and duration), perioperative glucose control, and decreasing shaving of the operative site. For CLABSI, we targeted adherence to maximal sterile barrier precautions, use of chlorhexidine for skin antisepsis, and avoidance of femoral catheterization. For VAP, we targeted semirecumbent patient positioning and daily assessment of readiness for ventilator weaning. For CAUTI, we targeted reduction in unnecessary catheter use and adherence to aseptic catheter insertion and catheter care. Our primary outcomes were the rate of HAI (defined as infections per 100 cases for SSI and infections per 1,000 device-days for CLABSI, VAP, and CAUTI) and the rate of adherence to preventive interventions (defined as the percentage of patients at risk who received the preventive intervention). Secondary outcomes included effects on costs and adverse effects associated with the interventions.
Data Collection and Analysis: Two reviewers independently abstracted data. Due to heterogeneity in study populations, QI strategies, preventive interventions, and outcomes, no formal quantitative analysis was attempted. We assessed study quality based on prespecified criteria for internal and external validity.
Main Results: Sixty-four studies met all inclusion criteria; 28 studies addressed prevention of SSI, 19 CLABSI prevention, 12 VAP prevention, and 10 CAUTI prevention. Three studies targeted prevention of multiple HAIs. The study methodologic quality was generally poor, as 52 of 64 included studies were simple before-after studies, and most of these (33 of 52) reported data at only one time point before and after the intervention. The majority of included studies reported infection rates, but did not report rate of adherence to preventive interventions. Baseline HAI rates were generally above the median rates reported by the Centers for Disease Control and Prevention's National Nosocomial Infection Surveillance System (NNIS).