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

  1. Gerd Flodgren1,*,
  2. Lucieni O Conterno2,
  3. Alain Mayhew3,
  4. Omar Omar4,
  5. Cresio Romeu Pereira5,
  6. Sasha Shepperd1

Editorial Group: Cochrane Effective Practice and Organisation of Care Group

Published Online: 28 MAR 2013

Assessed as up-to-date: 16 JUL 2012

DOI: 10.1002/14651858.CD006559.pub2


How to Cite

Flodgren G, Conterno LO, Mayhew A, Omar O, Pereira CR, Shepperd S. Interventions to improve professional adherence to guidelines for prevention of device-related infections. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD006559. DOI: 10.1002/14651858.CD006559.pub2.

Author Information

  1. 1

    University of Oxford, Department of Public Health, Oxford, Oxfordshire, UK

  2. 2

    Marilia Medical School, Department of General Internal Medicine and Clinical Epidemiology Unit, Marilia, São Paulo, Brazil

  3. 3

    Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, Centre for Practice-Changing Research, Ottawa, Ontario, Canada

  4. 4

    Centre for Statistics in Medicine, Oxford, UK

  5. 5

    Municipal Health Department, Infection Control, Ilhabela, SP, Brazil

*Gerd Flodgren, Department of Public Health, University of Oxford, Rosemary Rue Building, Old Road Campus, Headington, Oxford, Oxfordshire, OX3 7LF, UK. gerd.flodgren@dph.ox.ac.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 28 MAR 2013

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Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

 
Summary of findings for the main comparison.

Interventions to improve professional adherence to guidelines for the prevention of device-related infections compared with standard care

Patient or population: patients with an indwelling device

Settings: hospital

Intervention: interventions to improve professional adherence to guidelines for the prevention of device-related infections

Comparison: standard care

OutcomesChange in level effect (step change)

Median infection rate per quarter (range) per 1000 device days
Number of sites

(number of studies) *
Change in trend (slope)

Median change in infection rate between pre- and post-intervention trends (range)
Quality of the evidence
(GRADE)

CLABSI rate up to 12 months

 
-0.6 to +0.06 cases per 1000 central line days7 to 36 sites (5 to 6 studies)+0.21 (0.43) cases per 1000 central line days

Number of pre-intervention data points (range): 3 to 11

Number of post-intervention data points (range): 4 to 8
⊕⊝⊝⊝
very low

CLABSI rate more than 12 months+0.65 to 2.6 cases per 1000 central line days4 to 6 sites (2 to 4 studies)⊕⊝⊝⊝
very low

VAP rate up to 12 months-2.55 to -7.3610 to 15 sites (3 to 6 studies)-0.14 (5.8) cases per 1000 ventilator days

Number of pre-intervention data points (range): 3 to 9

Number of post-intervention data points (range): 3 to 6
⊕⊝⊝⊝
very low

* All data reanalysed by review authors
CI: Confidence interval

* The quality of the evidence, which was based on reanalysed interrupted time series studies only, was downgraded to very low due to unexplained heterogeneity, imprecision and high risk of bias in 9 out of the 13 studies from the intervention either not being independent of other changes, or this being unclear.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 Abbreviations
CLABSI: central line-associated blood stream infection
VAP: ventilator-associated pneumonia

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Healthcare-associated infections (HAIs) are a major threat to patient safety and are associated with mortality rates varying from 5% to 35% (Klevens 2007; Rosenthal 2006; Umscheid 2011). Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, indwelling urinary catheters and mechanical ventilators) that breach the body's normal defence mechanisms (Rosenthal 2006; Safdar 2005), and poor staff adherence to infection prevention practices during insertion and care for these devices when in place. HAIs are considered an avoidable risk to patient safety, and recommendations have been issued from professional and national agencies to focus on their prevention (Burke 2003; Pittet 2006; Yokoe 2008a). However, there is concern that healthcare professionals do not always adhere to guidelines, or to quality improvement interventions, to prevent device-related infections in these vulnerable patients.

 

Description of the condition

A healthcare-associated infection (HAI) is defined by Horan 2008 as "an infection that occurs during a hospital admission, for which there is no evidence that it was present or incubating at admission, and that meets body site-specific criteria". Most HAIs are endemic, and some of them can be associated with inappropriate patient care (Pittet 2006). Although invasive devices are frequently required for optimal patient care, the possibility exists that they are overused (Conterno 2011). Often invasive devices do not meet appropriate indications for their use or they remain in place beyond what is deemed necessary, or both (Gowardman 1998; Saint 2000).

Central line-associated blood stream infection (CLABSI) is associated with a number of risk factors: the experience of the health professional performing the insertion, not using maximal sterile techniques, placement of a vascular catheter in the internal jugular or femoral vein rather than in the subclavian vein, the type of catheter used, the nurse-to-patient ratio in the intensive care unit (ICU), contamination of the catheter hub, as well as the frequency of catheter manipulation and duration of catheter placement (Safdar 2002). Several risk factors are associated with the development of ventilator-associated pneumonia (VAP): admitting diagnosis of burns, trauma, central nervous system disease, respiratory disease, cardiac disease, gastroesophageal reflux, use of paralytic drugs, nasotracheal intubation compared to orotracheal intubation, and duration of mechanical ventilation. Specific risk factors for catheter-associated urinary tract infections (CAUTIs) are: female sex, catheter insertion outside operating room, the duration of catheterisation, diabetes mellitus, and colonisation of drainage bag, or catheter or tissues surrounding the urethra, or both (Bernard 2012; Tambyah 2012). Some of these factors can be considered modifiable and related to failure to adhere to the recommended care process, which may lead to infection (Alp 2006; Muscedere 2008).

Risk factors common to all device-related infections include: the severity of underlying illness, which often prolongs the length of hospital stay, increasing rates of antimicrobial resistance, the development of progressively more complex medical procedures and high bed occupancy (Chalmers 2006; Emmerson 1996; Gravel 2007; Griffiths 2009). Between 5% to 10% of patients admitted to acute care hospitals in high-income countries acquire one or more infections (Emmerson 1996; Gravel 2007; Weinstein 1998; WHO 2011), and in healthcare settings with limited resources, reported HAI rates are higher, varying from 5.7% to 19.1% (Allegranzi 2011). CLABSI, VAP, and CAUTI (as well as surgical site infections, which are outside the scope of this review) together account for more than 80% of all HAIs. The most common sites of HAIs vary according to hospital characteristics, but between 60% and 87% of primary bloodstream infections are CLABSIs, 86% of hospital acquired pneumonia occurrences are VAPs, and 80% to 95% of urinary tract infections are CAUTIs (Emmerson 1996; Gravel 2007; Klevens 2007; Richards 1999).

HAIs may have numerous clinical and resource implications including long-term disability, increased resistance of microorganisms to antimicrobials, excess deaths, prolonged hospital stay, additional financial burden for health systems, and high costs for patients and their families (Klevens 2007; Stone 2005; Umscheid 2011). According to a report on device-associated infections in 173 ICUs from 25 countries in Latin America, Asia, Africa, and Europe, crude excess mortality in adult patients was 18.5%, 23.6%, and 29.3% for CAUTI, CLABSI, and VAP respectively (Rosenthal 2010). In ICUs in the United States, approximately 500 to 4000 patients die annually from CLABSIs (Mermel 2000), and the cost of caring for a patient with CLABSI is estimated as USD 36,441 (hospital costs in 2002 USD in Stone 2005). Between 10% and 20% of patients receiving more than 48 hours of mechanical ventilation develop VAP. According to Safdar 2005 the crude death rates of patients with VAP is unknown, since some studies show increased mortality and some do not, but patients who do develop VAP incur more than USD 10,019 (in 2003 USD) in additional hospital costs; cost estimates included increased length of hospital stay, laboratory tests, and antimicrobial treatment. CAUTI is the most frequent and preventable HAI (Umscheid 2011). Each episode of CAUTI costs at least USD 600 (in 1998 USD) (Saint 2000; Tambyah 2002); cost estimates included increased length of hospital stay, laboratory tests and antimicrobial treatment. Each episode of urinary tract-related bacteraemia (bloodstream infections secondary to CAUTI) costs at least USD 2800 (in 1998 USD) (Saint 2000).

 

Description of the intervention

Quality improvement strategies to change clinical practice may be classified into four different main categories according to the EPOC taxonomy (http://epoc.cochrane.org/sites/epoc.cochrane.org/files/uploads/datacollectionchecklist.pdf): i) professional interventions (e.g. distribution of educational material, educational meetings, local consensus processes, educational outreach visits, local opinion leaders, patient mediated interventions, audit and feedback and reminders); ii) financial interventions; iii) organisational interventions (e.g. revision of professional roles, clinical multidisciplinary teams, skill mix changes etc); and iv) regulatory interventions. These quality improvement strategies may be used either alone or in combination when attempting to improve health professionals' adherence to infection control guidelines.

In 2006, the Institute for Healthcare Improvement in the United States developed the concept of a care bundle (Hareden 2006). These bundles are used to monitor, assess, improve performance and increase the consistency of care. Care bundles were first developed for intensive care settings and are a set of evidence based practices that, when performed collectively and reliably, should improve patient outcomes. Care bundles do not cover all the clinical actions that may take place in a period of care, but generally focus on three to five key evidence based practices (http://www.hps.scot.nhs.uk/haiic/ic/bundles.aspx). Several care bundles have been developed to decrease HAIs (Yokoe 2008b). Evidence from one systematic review (Aboelela 2007), suggests that bundled interventions are effective in decreasing HAIs, while another systematic review, focusing on the ventilator bundle only, suggests that the existing evidence is of too low quality for any conclusions to be drawn about its effectiveness (Zilberberg 2009). Both reviews relied on evidence from non-randomised studies only. Further evidence from a cross-sectional study evaluating the compliance with a CLABSI care bundle in 250 hospitals, suggests that the bundle is associated with lower infection rates only when the hospital had a policy, monitored compliance and where compliance was high (Furuya 2011).

 

How the intervention might work

Avoiding the use of invasive devices and reducing the duration of use, coupled with aseptic insertion and maintenance techniques could reduce the rate of device-related infections. There are numerous clinical recommendations developed by various government institutions and scientific societies to prevent infections related to invasive medical devices (NHMRC 2010; O'Grady 2011; Pratt 2007; Yokoe 2008b). Guidelines for the prevention of device-related infections make general recommendations about educating and training the healthcare personnel who insert and maintain indwelling devices, as well as clinical recommendations. For CLABSI prevention according to O'Grady 2011 the main preventive recommendations are: i) use maximal sterile barriers during central venous catheter (CVC) insertion; ii) use of > 0.5% Chlorhexidine skin preparation with alcohol for skin antisepsis; iii) avoidance of routine replacement of CVCs as a strategy to prevent infection; iv) avoidance of the femoral insertion site in adults; v) changing dressings in a timely manner (when wet, soiled or dislodged) using aseptic techniques; and vi) performance of daily audits to assess whether each central line is still needed (O'Grady 2011). Clinical interventions to prevent VAP include: i) promoting hand hygiene using alcohol based antiseptics before manipulating the airways; ii) implementing ventilator circuit changes only when clinically indicated; iii) incorporating sedation control protocols; iv) oral care with Chlorhexidine 0.12% every eight hours; and v) intra-cuff pressure control to reduce leakage of oropharyngeal secretions to the lower airways tract (Rello 2012). Other important clinical recommendations to prevent VAP include: head of bed elevation (with 30º or more); daily “sedation vacation”; and daily assessment of readiness to extubate.

Guidelines to prevent CAUTIs include the following clinical interventions: i) assessing the need for using a catheter; ii) the selection of catheter type and system; iii) catheter insertion in the operating room; iv) maintaining a sterile closed system of drainage; and v) the education of patients, relatives, and healthcare professionals (Pratt 2007). All guidelines for the prevention of device-related infections identify hand hygiene and aseptic techniques as important preventive interventions. There is evidence for the effectiveness of some of these clinical interventions from systematic reviews (Chlebicki 2007; Phipps 2006; Ramritu 2008); e.g. the use of maximum sterile barriers while placing CVCs (Ramritu 2008); continuous aspiration of subglottic secretions (Shojania 2001); oral decontamination with Chlorhexidine (Chlebicki 2007); and earlier removal of urinary catheters following urogenital surgery (Phipps 2006).

One systematic review (Ranji 2007) evaluated the effects of quality improvement strategies (e.g. clinician and patient education, audit and feedback, reminder systems, organisational change, and financial or regulatory incentives for patients or clinicians), on adherence with clinical interventions for the prevention of selected HAIs. No definitive conclusions regarding actionable quality improvement strategies to prevent HAIs could be reached due to the poor quality of included studies, however, based on the limited evidence, the authors suggested that the following strategies might be worthy of further study: use of printed or computer based reminders with automatic stop orders to reduce unnecessary urethral catheterisation; active educational interventions with the use of checklists to improve adherence to central line insertion practices; and active educational interventions such as tutorials to improve adherence to preventive clinical interventions for VAP. Another systematic review (Wilson 2009) suggested that staff education on urinary catheter management, combined with regular monitoring of CAUTI rates could reduce the incidence. A third review (Ramritu 2008), that evaluated risk reduction of CLABSIs in ICUs, concluded that strategies to reduce CLABSIs should include staff education, multifaceted infection control programmes and performance feedback. The design and implementation of interventions to improve adherence with guidelines depends on successful behaviour change interventions (Mitchie 2011), which in turn, require an appropriate method for characterising interventions and linking them to an analysis of the targeted behaviour (Grimshaw 2004; Grimshaw 2012).

Although there is evidence on how to prevent device-related infections, a significant evidence-to-practice gap still remains. Guideline implementation strategies can improve processes of care, but the impact on outcomes of care is understudied (Garg 2005; Grimshaw 2006). Implementation strategies may be passive or active. Passive strategies include the distribution of educational materials, posters and visual aids; active strategies include reminders, audit and feedback, interactive workshops, and one-to-one academic detailing. One systematic review of the effectiveness of guideline implementation strategies suggested that passive interventions could have modest beneficial effects but they did not result in sustained behaviour change; while active multifaceted strategies of selected interventions, additive in their benefit, appeared to have the greatest impact (Grimshaw 2004).

 

Why it is important to do this review

HAI is the most frequent adverse event in healthcare delivery worldwide. Hundreds of millions of patients are affected each year, leading to significant mortality and costs for health systems (WHO 2011). HAIs are more frequent in resource-limited settings. The prevalence of HAI varies between 5.7% and 19.1% in low- and middle-income countries (Allegranzi 2011). The European Centre for Disease Prevention and Control reports an average prevalence of 7.1% in European countries. These infections annually account for 37,000 attributable deaths in Europe and for 99,000 deaths in the United States. Annual financial costs due to HAIs are estimated at approximately EUR 7 billion in Europe, including direct costs only and reflecting 16 million extra days of hospital stay, and at about USD 6.5 billion in the United States (WHO 2011).

Not all HAIs are avoidable. However recent estimates suggest that up to 65% to 70% of all CLABSI and CAUTI cases and 55% of VAP and surgical site infection cases may be preventable if current evidence based strategies of infection prevention are used during the insertion and maintenance of invasive devices (Umscheid 2011). There is therefore potentially a lot to gain, in terms of decreased burden of HAI, deaths and healthcare costs, if professionals can be persuaded to change their behaviour and to always adhere to infection control guidelines.

Several Cochrane systematic reviews (e.g. Flodgren 2011; Forsetlund 2009; Giguere 2012; Ivers 2012; O'Brien 2007; Shojania 2009) have assessed the effectiveness of educational and organisational interventions on overall practice, but they did not specifically focus on interventions to improve adherence to guidelines for preventing device-related infections. Another systematic review (Grimshaw 2004) that evaluated the effectiveness and efficiency of guideline dissemination and implementation strategies to improve professional practice in general, concluded that the evidence base to support decisions about which strategies are likely to be efficient in different circumstances is inadequate. It is therefore of interest to review the existing evidence regarding the effectiveness of interventions to improve professional adherence with infection control guidelines, in order to inform decision makers and policy makers alike on the most effective ways to prevent these serious and costly infections.

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

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.

The specific objectives are to determine the effectiveness of interventions targeting health professionals or the organisation of healthcare in order to:

  1. avoid the use of invasive medical devices;
  2. reduce the duration of invasive medical device use; and
  3. improve the adoption of adequate procedures for insertion, and maintenance of invasive medical devices, and thereby the prevention of device-related infections.

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies (with contemporaneous data collection and at least two interventions and two control sites) and interrupted time series (ITS) studies (with a defined point in time when the intervention occurred and at least three data points before and after implementation of the intervention) according to Cochrane Effective Practice and Organisation of Care (EPOC) Group criteria (Ballini 2010).

 

Types of participants

Healthcare professionals involved with the insertion or the maintenance of invasive devices, or both.

 

Types of interventions

We considered any intervention to avoid the use, or decrease the length of use of invasive medical devices (i.e. urinary catheters, central line catheters, mechanical ventilators), or interventions to improve adoption of measures to prevent device-related infections. The comparative groups received no intervention or different interventions compared to the experimental group.

We classified interventions according to the EPOC taxonomy (http://epoc.cochrane.org/sites/epoc.cochrane.org/files/uploads/datacollectionchecklist.pdf) as follows.

  • Professional interventions: distribution of educational materials, educational meetings, local consensus processes, educational outreach visits, local opinion leaders, patient mediated interventions, audit and feedback, reminders, marketing, and mass media.
  • Organisational interventions: revision of professional roles, clinical multidisciplinary teams, formal integration of services, and skill mix changes.
  • Financial interventions.
  • Regulatory interventions.

 

Types of outcome measures

We included any objective measure of provider performance or patient outcomes.

 

Primary outcomes

  • Compliance with infection control recommendations for the insertion and maintenance of invasive medical devices, and the prevention of device-related infections (for example, observed increases in adoption of device-related infection control recommendations)
  • Proportion/rate of invasive device-related infections

 

Secondary outcomes

  • Number of patients in which the device was inserted
  • Length of device use
  • Length of hospital stay
  • Mortality
  • Costs

 

Search methods for identification of studies

M. Fiander and Doug Salzwedel, Trials Search Co-ordinators (TSCs) for the EPOC Group, designed search strategies in consultation with the authors. Search strategies for this review were developed and used in 2008 and revised and used between April and June 2012. The revised search strategy included additional terms for infection and employed an up-to-date methodological filter. All searches were from the database start date. Strategies run in 2012 are in Appendix 1, Appendix 2, Appendix 3, Appendix 4, Appendix 5 and Appendix 6; strategies run prior to 2012 are in Appendix 7, Appendix 8 and Appendix 9. We searched the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects (DARE), related systematic reviews and the databases listed below for primary studies.

 

Electronic searches

  • EPOC Group, Specialised Register, Reference Manager
  • EBM Reviews, Cochrane Central Register of Controlled Trials (CENTRAL ), April 2012, OvidSP
  • MEDLINE, 1947-In-Process; Daily Update, OvidSP
  • EMBASE, 1947-, OvidSP
  • CINAHL (Cumulative Index to Nursing and Allied Health Literature), 1980- , EbscoHost
  • EBM Reviews, Cochrane Database of Systematic Reviews, 2005 to May 2012, OvidSP
  • EBM Reviews, Database of Abstracts and Reviews, 2nd Quarter, 2012, OvidSP
  • EBM Reviews, Health Technology Assessment, 2nd Quarter 2012, OvidSP
  • EBM Reviews, NHS Economic Evaluation Database, 2nd Quarter 2012, OvidSP Cochrane Central Register of Controlled Trials (CENTRAL), Issue 6, 2012, Wiley
  • Science Citation Index (ISI Web of Knowledge) (cited reference searches)

 

Searching other resources

We searched the reference lists of all included studies and relevant reviews for additional studies. We contacted authors of included studies regarding any further published or unpublished work. We contacted authors of other reviews in the field of effective professional practice concerning the prevention of device-related infections regarding relevant studies that they may be aware of. We searched the ISI Web of Science for papers which cite studies included in the review.

 

Data collection and analysis

 

Selection of studies

We downloaded all titles and abstracts retrieved by the electronic searches to the reference management database EndNote, and removed duplicates. Two review authors (from LOC, AM and CRP) independently screened all titles and abstracts retrieved by the search to identify relevant papers. We directly excluded papers that did not meet the eligibility criteria. We retrieved full-text copies of all papers that were potentially relevant, and two review authors independently assessed them against the eligibility criteria. Any disagreements were resolved by discussion between the review authors.

 

Data extraction and management

Two review authors (from LOC, AM, GF and CRP) independently undertook data extraction, using a modified version of the EPOC Data Extraction Form and the Data Collection Checklist (http://epoc.cochrane.org/epoc-author-resources). Any disagreements were resolved by discussion between the review authors.

For time series analyses, when information on the value of individual observations over time was only reported graphically in the original paper, we derived data by importing the graphs into Microsoft Paint. First, we electronically measured the location of each data point on the y-axis (in pixels) and then we used a scale factor to calculate the value of the data point in natural units.

 

Assessment of risk of bias in included studies

Two review authors (from LOC, AM, GF and CRP) independently assessed the risk of bias of included studies using the EPOC 'Risk of bias' tool described in detail in the EPOC module http://www.epoc.cochrane.org/sites/epoc.cochrane.org/files/uploads/Suggested%20risk%20of%20bias%20criteria%20for%20EPOC%20reviews.pdf

Disagreements were resolved by discussion between review authors.

We assessed the risk of bias of RCTs using nine standard criteria: (i) adequate allocation sequence generation; (ii) adequate concealment of allocation; (iii) similar baseline outcome measures; (iv) similar baseline characteristics; (v) blinding of outcome assessment; (vi) adequately addressed incomplete outcome data; (vii) adequate protection against contamination; (viii) free from selective reporting; and (ix) free of other risk of bias (Higgins 2011).

For ITS studies, we used the following criteria: (i) intervention independent of other changes; (ii) shape of the intervention prespecified; (iii) intervention unlikely to affect data collection; (iv) knowledge of the allocated interventions adequately prevented; (v) incomplete outcome data adequately addressed; (vi) free from selective outcome reporting; and (vii) free from other risks of bias.

 

Measures of treatment effect

For each study we reported the main results in natural units and calculated the change data for both the change in level and change in slope if it was not reported.

For the included RCT study we reported pre-intervention and post-intervention percentages for both study and control groups, and calculated the absolute change from baseline with 95% confidence intervals (CIs).

For ITS studies we extracted data on infection rates from graphs in original papers in order to obtain effect sizes. We calculated the means for quarterly infection rates for all studies with monthly reported data, except for Cocanour 2006 in which too few data points before and after the interventions were reported to permit calculations of quarterly rates.

For the purpose of a meta-analysis we standardised the data by dividing the outcome and standard error (SE) by the pre-intervention standard deviation (SD) as recommended in Ramsay 2001.

We reported the results for the main outcomes in  Summary of findings for the main comparison.

 

Handling methodological issues in primary studies

We identified twelve ITS studies which we reanalysed to take into account secular trends using time series regression techniques. We used segmented time series regression analysis to estimate the effect of the intervention, whilst taking into account time trend and autocorrelation among the observations. We obtained estimates for regression coefficients corresponding to two standardised effect sizes for each study: a change in level and a change in trend before and after the intervention. A change in level was defined as the difference between the observed level at the first intervention time point and that predicted by the pre-intervention time trend. A change in trend was defined as the difference between post- and pre-intervention slopes (Ramsay 2003). A negative change in level and slope indicates an intervention effect in terms of a reduction in infection rates. We evaluated the direct effect of the intervention using the quarter after the intervention started. We also reported the level effects at six months, nine months, yearly, 18 and 21 months time points when possible.

We identified one RCT that had not taken into account the effect of clustering in the analysis, we did not attempt reanalysis of this study as the intracluster correlation coefficient and average number of patients per cluster were not reported.

 

Grading the quality of evidence

We used the GRADE grading tool for assessing the quality of evidence of included studies (GRADE 2004): in this assessment of the studies, we took into account risk of bias, along with inconsistency, imprecision, indirectness and risk of publication bias.

 

Dealing with missing data

We requested additional data from authors of original papers by email; we sent one email reminder. One reply was received from the first author of Abbott 2006a but unfortunately the data was no longer available.

 

Assessment of heterogeneity

We assessed statistical heterogeneity using I2 and Chi2 statistics. We intended to quantitatively explore the potential sources of heterogeneity by (i) type and characteristics of devices; ii) type of health professionals; iii) patient's age, diagnosis, and severity of condition; iv) categories of interventions based on the EPOC taxonomy; v) setting, for example the type of ICU and ward, community or university affiliated hospitals; and vi) high versus low risk of bias. We were however unable to carry out a quantitative assessment of heterogeneity due to few included studies; instead we report our qualitative assessment of the potential sources of heterogeneity in the Discussion.

 

Assessment of reporting biases

We intended to examine funnel plots corresponding to meta-analysis of the primary outcome in order to assess the potential for small study effects such as publication bias. However, we were unable to carry out this analysis due to the small numbers of CLABSI and VAP studies identified.

 

Data synthesis

As planned, we attempted pooling the reanalysed results of VAP studies and CLABSI studies respectively using the generic inverse variance method of Review Manager 5.1 (RevMan 2011). We used the standardised changes in level and trend as effect measures in the analysis. However, due to very high heterogeneity among studies, we did not retain the meta-analyses.

The main findings (VAP and CLABSI rates) are presented as the median step change (interquartile range, (IQR)) and the median change in slope (IQR) in the text, and as standardised means in forest plots without summary estimates. The results of the reanalysis for the individual studies are reported in  Table 1 and  Table 2. We used Stata 11 (Stata 2009) for all statistical reanalyses and Review Manager 5.1 (RevMan 2011) for creating the forest plots.

We present the median effect sizes (range) for the main outcomes: VAP rate and CLABSI rate in  Summary of findings for the main comparison.

 

Subgroup analysis and investigation of heterogeneity

We attempted a subgroup analysis of VAP and CLABSI studies, by the complexity of the intervention used: i) simple interventions (i.e. interventions involving only one active element) versus ii) interventions involving more than one active element. However, heterogeneity was too high to retain the analyses.

 

Sensitivity analysis

We did not perform a sensitivity analysis due to the high levels of heterogeneity.

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of studies awaiting classification.

See Characteristics of included studies; Characteristics of excluded studies.

 

Results of the search

The electronic searches conducted in the years 2007, 2008 and 2010 retrieved a total of 6049 potentially relevant studies once duplicates were removed. In addition, we identified 12 studies from searching the reference lists. From these, we identified 13 papers that met the inclusion criteria of this review (see the Characteristics of included studies table). From the June 2012 search, we retrieved an additional 727 potentially relevant studies, and from these studies we identified 16 potentially eligible studies (listed in the Studies awaiting classification table). We identified one additional study by contacting authors (also recorded in the Studies awaiting classification table). In total, we screened 6789 studies, assessed the full-text of 185 studies, included 13 studies, and listed 17 studies in the Studies awaiting classification table (Figure 1).

 FigureFigure 1. Study flow diagram.

 

Included studies

 

Study design

We included 13 studies in this review; one cluster RCT (Ching 1990) and a total of twelve ITS studies (Beathard 2003; Cocanour 2006; Coopersmith 2002; Kaye 2000; Miller 2010; Parra 2010; Salahuddin 2004; Sannoh 2010; Sona 2009; Warren 2004; Zack 2002). One of the ITS studies reported the results for five different ICUs separately; only four settings were eligible for this review. Each ICU is treated as a separate dataset although the interventions are similar (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4).

The twelve ITS studies described the exact time point for when the intervention occurred, but 11 out of 12 studies reported only the means of device-associated infection rates before and after the intervention, ignoring any secular (trend) changes in the analysis. However, since these studies included graphic presentations of the results, and more than three time points before and after the intervention, this allowed us to extract the data and reanalyse these studies using time regression techniques. One of the ITS studies (Miller 2010) did take into account secular trends in their analysis but it was unclear what correlation structure they used. Since this study did not report step and slope changes for effects at three, six, nine or 12 months, we reanalysed the data to allow comparisons with the other ITS studies.

In two studies, more than one intervention was implemented with a time interval, but only the effectiveness of the first intervention could be reanalysed, due to an insufficient number of time points in-between the first and second groups of interventions (Cocanour 2006), or an unbalanced number of time points between the first and subsequent interventions (Coopersmith 2002). In Cocanour 2006, after the failure of the ventilator bundle to decrease VAP rates, daily compliance with the ventilator bundle, weekly compliance feedback and in-service education were instituted; and in Coopersmith 2002, based on bedside audit, a behavioural intervention which stressed compliance with all facets of best practice of CVC maintenance and insertion was implemented (Coopersmith 2004).

 

Participants and settings

 
Providers

The number of health professionals targeted by the intervention was reported in four studies: 939 nurses in Ching 1990; 49 nurses, one attending physician and two critical care fellows in Coopersmith 2002; 125 nurses and 30 physicians in Parra 2010; and 114 respiratory care practitioners and 146 nurses in Zack 2002, resulting in a total of 1406 health professionals. Nine studies did not report the number of healthcare professionals who were targeted by the intervention.

Only two of the included studies (Ching 1990; Parra 2010) reported on the characteristics of healthcare professionals: Ching 1990 reported that nurses in the intervention and control groups were similar with respect to gender, number of years postgraduate education and rank; and Parra 2010 reported that years of work experience were similar for participating nurses and physicians.

In four studies, the intervention targeted all healthcare staff (Beathard 2003; Cocanour 2006; Miller 2010; Parra 2010). The study with four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) and Kaye 2000 targeted nurses, respiratory therapists and other medical staff. Four studies targeted primarily nurses (Ching 1990; Coopersmith 2002; Sannoh 2010; Sona 2009). In Salahuddin 2004, all ICU nursing staff and junior medical staff were targeted, and in Warren 2004 all nurses and physicians. In Zack 2002 the intervention was directed towards respiratory care practitioners and nurses.

 
Patients

The studies in the review (see Characteristics of included studies table) included more than 3504 patients with invasive devices in total. Over 1073 patients were studied with a central line: 700 patients in Beathard 2003 and 373 in Sannoh 2010. Coopersmith 2002 only reported the total number of patients admitted at the ICU, without specifying how many had a vascular catheter inserted; the number of patients was not reported in three CLABSI studies (Miller 2010; Parra 2010; Warren 2004), or in the one study looking at the non-adherence to guidelines for the care of indwelling urinary catheters (Ching 1990). Over 2431 patients were on continuous mechanical ventilation: 106 patients in the four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4), 677 patients in Salahuddin 2004, and 1648 in Sona 2009. The number of patients was not reported in three VAP studies (Cocanour 2006; Kaye 2000; Zack 2002).

Five studies reported on patient characteristics but in varying detail. The mean age (56.6 years) was similar in both pre- and post-intervention groups in Sona 2009. Gender distribution was reported not to differ significantly between pre- (40.2% females) and post-intervention periods (44.7% females) in Coopersmith 2002. The most common diagnoses were equally distributed between groups in Salahuddin 2004: sepsis (16% and 19%); pneumonia (10% and 8%); neurosurgical conditions (7% and 7%); and chronic obstructive pulmonary disease (COPD) (6% and 6%) in pre- and post-intervention groups respectively. The severity of the condition as indicated by the mean APACHE II score (i.e. the acute physiology and chronic health evaluation score, according to Knaus 1985) in Sona 2009 was similar in pre- (17.7) and post-intervention periods (18.1). In the four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4), the mean age of patients was 49 years; 33% were females, with a mean APACHE score of 16, 83% had enteral feeding, and a mean 1.6 years of respiratory disease. However, no data were provided for the pre- and post-intervention periods separately. In Sannoh 2010 the pre- and post-intervention groups were similar with respect to birth weight, percentage of extremely low birth infants, and all other demographic and clinical characteristics.

 
Setting

Studies included in this review (see Characteristics of included studies table) covered a total of 51 ICUs and 27 wards located in 40 hospitals. Nine of the included studies were performed in hospitals affiliated to universities or teaching hospitals (Ching 1990; Cocanour 2006; Coopersmith 2002; Kaye 2000; Parra 2010; Salahuddin 2004; Sona 2009; Warren 2004; Zack 2002).

Ten studies including the study with four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) were conducted in the United States (Beathard 2003; Cocanour 2006; Coopersmith 2002; Kaye 2000; Miller 2010; Sannoh 2010; Sona 2009; Warren 2004; Zack 2002), one in Hong Kong (Ching 1990), one in Spain (Parra 2010) and one in Pakistan (Salahuddin 2004).

Five studies were carried out in a single ICU: a 20 bed shock-trauma ICU (Cocanour 2006), an 18 bed surgical-burn-trauma ICU (Coopersmith 2002), a 10 bed medical-surgical ICU (Salahuddin 2004), a 24 bed surgical-trauma-burn ICU (Sona 2009) and a 19 bed medical ICU (Warren 2004). Three studies included more than one adult ICU at the same hospital: four medical-surgical ICUs (the number of beds was not reported) (Kaye 2000), three ICUs (one medical, one post-surgery and one cardiac surgery) (Parra 2010), and five ICUs (one medical, one surgical-trauma-burn, one medical-surgical, one neurology-neurosurgical and one surgical-cardiothoracic) (Zack 2002). One study involved five ICUs at two hospitals (one burn ICU, one medical ICU, one surgical ICU and two trauma ICUs) but only four settings provided sufficient data to be included (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4). One study (Miller 2010) was conducted in 29 paediatric ICUs (PICUs) located in 27 hospitals (12 PICUs with 10 to 16 beds; 13 PICUs with 17 to 27 beds and four PICUs with 28 to 36 beds). Most of these PICUs were mixed paediatric and cardiac PICUs, with two being solely paediatric cardiac ICUs. One study was conducted in a 50 bed neonatal ICU (Sannoh 2010), another study in 27 wards at the same hospital (Ching 1990) and a third study in a single haemodialysis facility (Beathard 2003).

 

Description of the intervention

See Characteristics of included studies table.

All of the included studies implemented a clinical practice guideline, a protocol or a care bundle for the prevention of device-related hospital acquired infections (see  Table 3 and  Table 4), and all used some type of core educational intervention targeted at the healthcare professional to support its adoption. Additional interventions to support the adoption of the guidance were active (e.g. champion leaders, multidisciplinary teams, audit and feedback etc.) or passive (e.g. fact sheets, pictorials, posters, etc.), or both. Some studies also implemented interventions at the organisational level, for example instituting policy changes (Kaye 2000; Sannoh 2010; Sona 2009; Zack 2002), purchasing and updating of equipment (Abbott 2006 dataset 2; Kaye 2000), or employing dedicated specialists to the care team. For example, in Abbott 2006 dataset 2 a dentist and dental hygienist performing oral care were added to the team, and an infection control liaison nurse was employed in Ching 1990.

 
Type of indwelling medical device

The types of medical devices used in the studies were central line catheters (six studies), mechanical ventilators (six studies), and urinary catheters (one study). The central line catheters used in the included studies were cuffed tunnelled dialysis catheters (Beathard 2003), Chlorhexidine and Silver sulphadiazine-impregnated catheters (1% to 2%) and quadruple-lumen, antibiotic-impregnated catheters (Coopersmith 2002), polyurethane or Teflon central venous catheter (Miller 2010), umbilical artery catheters, umbilical vein catheters and peripherally inserted central venous catheters (Sannoh 2010), and standard catheters (CVCs, dialysis catheters, pulmonary artery catheters) without antimicrobial or antiseptic coatings (Warren 2004). The type of catheter was not reported in one study (Parra 2010).

A majority of the included studies did not describe the central line insertion sites, only Warren 2004 described the proportion of femoral vein insertions before and after the intervention.

None of the VAP studies reported the type of mechanical ventilator or ventilator equipment used. Ching 1990 did not describe the type of urinary catheters used.

 
Evidence base of recommendations

The study with four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) and two others; (Kaye 2000; Sona 2009) made recommendations for the prevention of device-related infections based on a literature review; eight studies were based wholly or partially on Centers for Disease Control (CDC) and National Nosocomial Infections Surveillance (NNIS) guidelines for prevention of HAIs (Cocanour 2006; Coopersmith 2002; Miller 2010; Parra 2010; Salahuddin 2004; Sannoh 2010; Warren 2004; Zack 2002); and two studies based their recommendations on guidelines from scientific societies with some local adaptations (Beathard 2003; Ching 1990),

The seven main evidence based recommendations for VAP prevention by a European expert panel (Chlebicki 2007; Rello 2012; Shojania 2001) are presented in  Table 5. These recommendations were to varying degrees included in some of the clinical practice guidelines/bundles in the included studies. These recommendations include head of bed elevation of 30 degrees or more (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Cocanour 2006; Salahuddin 2004; Zack 2002); implementing ventilator circuit changes only when clinically indicated (no study); continuous suctioning of subglottic secretions (Cocanour 2006); daily ‘sedation vacation’ and assessment of readiness for weaning (Cocanour 2006); oral care (with Chlorhexidine 0.12% every eight hours), oral care (but unclear if Chlorhexidine was used) in Abbott 2006 dataset 1, Abbott 2006 dataset 2, Abbott 2006 dataset 3 and Abbott 2006 dataset 4, oral care with Chlorhexidine baths twice weekly in Cocanour 2006, oral care with a Chlorhexidine-based oral rinse at least daily in Salahuddin 2004, oral care using Chlorhexidine twice daily in Sona 2009, and oral care with Chlorhexidine only for patients undergoing cardiac surgery in Zack 2002; and intra-cuff pressure control to prevent aspiration (Salahuddin 2004). The four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) and three other studies (Cocanour 2006; Kaye 2000; Salahuddin 2004) included general advice on handwashing in their clinical practice guidelines. Two studies did not provide any hand hygiene recommendations (Sona 2009; Zack 2002).

The six main evidence based recommendations for CLABSI prevention (O'Grady 2011) are presented in  Table 6. The recommendations that were included in the respective clinical practice guidelines varied across studies: the use of maximal sterile barriers during catheter insertion (Miller 2010; Warren 2004); the use of Chlorhexidine skin preparation with alcohol for skin antisepsis (Miller 2010; Parra 2010); the avoidance of the femoral insertion site in adults (Parra 2010; Warren 2004) (this is not however a requirement for paediatric patients (Miller 2010) or neonates (Sannoh 2010)); the timely changing of dressings using aseptic techniques (all studies); and daily assessment of the need for the central line (Miller 2010). In Coopersmith 2002 "aseptic technique and routine catheter site care" was recommended but it was unclear what was included in 'routine care'; in Warren 2004 "aseptic technique and appropriate skin antisepsis" was recommended, but again it was unclear whether or not this involved the use of Chlorhexidine for skin antisepsis. None of the clinical practice guidelines of the included studies provided recommendations to avoid routine placement of CVCs.

In Coopersmith 2002, catheter insertion recommendations were not covered by the clinical practice guideline. In Miller 2010, an insertion and maintenance bundle, both specific to PICUs, were included. In Parra 2010 and Warren 2004, both insertion and maintenance guidance were included, while in Sannoh 2010 the recommendations included only a hub care and dressing policy ( Table 3 and  Table 4).

Baseline infection rates

Among the CLABSI studies, Beathard 2003 was conducted at a dialysis facility, that according to the authors had 'unacceptable high' infection rates (6.18 cases per 1000 central line days), as compared with catheter-related bacteraemia rates ranging from 2.2 to 5.5 per 1000 catheter days reported in the literature. Coopersmith 2002 compared their infection rate (10.8 cases per 1000 central line days) with the NNIS mean rate of 5.8 cases per 1000 central line days in surgical/burn/trauma ICUs nationwide. The baseline infection rate in paediatric patients in Miller 2010 was around the mean NNIS rate (5.7 cases per 1000 central line days). In Parra 2010 the baseline infection rate was low (3.8 cases per 1000 central line days), and according to the authors acceptable as compared with national rates. In the neonates in Sannoh 2010 the infection rate at baseline (14.8 cases per 1000 central line days) was six times higher than the 50th percentile infection rate reported by the National Healthcare Safety Network (NHSN). Warren 2004 did not compare the baseline infection rate at their medical ICU (9.1 cases per 1000 central line days) with national statistics.

In most VAP studies an unacceptable high infection rate was the rationale for implementing the interventions to improve professional adherence with infection control guidelines. In Abbott 2006 dataset 1, Abbott 2006 dataset 2, Abbott 2006 dataset 3 and Abbott 2006 dataset 4, the ICUs were experiencing a sustained VAP rate (between 6.9 to 26.1 cases per 1000 ventilator days the quarter before the intervention started) above the NNIS mean rate. In the trauma ICU in Cocanour 2006 the VAP rate was hovering at the NNIS 90th percentile (30.3 cases per 1000 ventilator days), and in the medical-surgical ICU in Kaye 2000 the infection rate had significantly exceeded the NNIS 90th percentile (21.2 cases per 1000 device days) at the time the intervention was implemented. Salahuddin 2004 reported an outbreak situation before the intervention with a mean infection rate of 16 cases per 1000 ventilator days. In one study (Zack 2002) the infection rate (12.6 cases per 1000 ventilator days) was hovering just above the NNIS mean VAP rate (11.8 per 1000 ventilator days). The baseline infection rate in Sona 2009 was relatively low (5.34 cases per 1000 ventilator days), and the aim of implementing the intervention was to decrease it even further.

Interventions to improve professional adherence to guidelines to prevent device-related infections

We defined 'active' interventions as those that require some form of interaction with targeted healthcare professionals e.g. educational meetings, one-to-one teaching, and verbal audit and feedback. We defined 'passive' interventions as interventions that do not require an individual to convey the intervention e.g. self-study modules, posters, information sheets, visual aids, and educational videos etc.

 
i) One active intervention with or without passive reinforcements

In two studies the intervention consisted of some type of educational meeting only; one half-day small group tutorial provided by an infection control liaison nurse in Ching 1990, and the delivery of a single 15 minute short lecture in Parra 2010.

In one study (Sannoh 2010) a 15 minute educational DVD delivered at a single in-service session was reinforced through checklists and CVC carts in the patient's room.

iii) Two active interventions (i.e. core educational intervention plus one other intervention e.g. audit and feedback), with or without passive reinforcements

In three of the included studies the core educational intervention was combined with one other active intervention. In Beathard 2003, a nurse educator gave instructions at educational meetings (of unknown duration and frequency), and performed spot checks (frequency not reported) of the adherence to guidelines. The instructions as well as the spot checks were repeated throughout the study period. In Salahuddin 2004, weekly lectures and departmental presentations were reinforced at the bedside and visual aids posted in the ICU. In the study by Sona 2009, educational meetings (of unknown frequency), with additional passive reinforcements, were combined with bi-weekly feedback on compliance with guidelines and monthly feedback on infection rates; the duration of education and training was not reported.

iii) More than two active interventions (i.e. at least two active interventions in addition to the core educational intervention) with passive reinforcements

In seven studies the core educational intervention was combined with at least two other active interventions, and with passive reinforcements. One-to-one bedside teaching and briefings (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4), lectures for attending physicians, fellows and residents (Coopersmith 2002), formal didactic lectures (Zack 2002), 45 to 60 minutes in-service lectures (Cocanour 2006; Coopersmith 2002; Kaye 2000; Warren 2004; Zack 2002), four face-to-face learning workshops and monthly telephone conferences (Miller 2010), were combined with audit and feedback (quarterly feedback in Abbott 2006 dataset 1, Abbott 2006 dataset 2, Abbott 2006 dataset 3 and Abbott 2006 dataset 4; monthly in Cocanour 2006, Coopersmith 2002, Warren 2004 and Zack 2002; and weekly in Kaye 2000), with champion leaders (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Miller 2010) and with the efforts of multidisciplinary teams (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Cocanour 2006; Coopersmith 2002; Kaye 2000; Miller 2010; Warren 2006; Zack 2002). It should however be noted that, while not stated in the other studies, audit and feedback was used during both the pre- and post-intervention period in Coopersmith 2002, Warren 2004 and Zack 2002. These multiple active interventions were reinforced also by passive interventions such as story boards, verbal and non-verbal reminders (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4), self-study modules, fact sheets and posters (Coopersmith 2002; Warren 2004; Zack 2002), newsletters with educational material (Kaye 2000), and guidelines in paper format (Cocanour 2006).

 
Barriers to change and organisational support

Five studies described the assessment of barriers to change. In the four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4), a multi-disciplinary team evaluated predisposing barriers to change and considered how this would impact on implementation. Strategies for identifying and coping with the barriers to guidelines/bundle implementation included assessment of factors facilitating or hindering the adoption of guideline related knowledge, attitudes, behaviour, policy and the healthcare system. Factors considered relevant to innovation included the incremental complexity of behaviour change, supporting systems, trialability and benefits to patients and units. Another study described quality improvements which included small tests of change, based on the 'Plan Do Study Act' (PDSA) quality and service improvement tool http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.html (Miller 2010). A third study described the definition of the feedback mechanism for problems encountered during the implementation phase of the study (Warren 2004). In Coopersmith 2002, a multidisciplinary task force evaluated practices and adopted the educational programme to address these, and lastly in Kaye 2000, a multidisciplinary team identified issues, evaluated infection control processes and implemented interventions to improve practice. In Ching 1990, the intervention had full approval and support by the nursing administration and in Kaye 2000, the multidisciplinary team had clear access to hospital management and full administrative support.

 
Format of intervention

The educational material delivered to the healthcare providers was printed in five studies (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Coopersmith 2002; Kaye 2000; Warren 2004; Zack 2002) and in one study the material was printed and in audio-visual format (Sannoh 2010). All educational interventions in the included studies involved interpersonal contact to convey the educational message to the healthcare professionals, for example during educational meetings, in-service training, lectures, one-to-one teaching, workshops and conference calls. In one study the format of the quality improvement intervention used was not clear (Cocanour 2006). Reminders were mostly printed, in one study they were delivered by email (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) and in another by audio-visual (DVD) means (Sannoh 2010).

 

Outcomes

 
Primary outcomes

The four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) and five other studies (Beathard 2003; Ching 1990; Miller 2010; Sannoh 2010; Sona 2009) reported measures of compliance with their different infection control recommendations. In three of the six studies pre-intervention as well as post-intervention adherence scores were presented (see  Table 7). The manner in which adherence had been assessed and judged varied greatly across studies (see  Table 7 for details).

Thirteen studies reported the rate of invasive device-related infections: the four datasets and five other studies reported the VAP rate (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Cocanour 2006; Kaye 2000; Salahuddin 2004; Sona 2009; Zack 2002); six studies reported the CLABSI rate (Beathard 2003; Coopersmith 2002; Miller 2010; Parra 2010; Sannoh 2010; Warren 2004); and in one study the primary outcome was incorrect urinary catheter practices (Ching 1990). The four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4); and eight other studies (Cocanour 2006; Coopersmith 2002; Kaye 2000; Miller 2010; Salahuddin 2004; Sannoh 2010; Sona 2009; Warren 2004) based the definition of device-related infections on the CDC or NNIS criteria (http://www.cdc.gov/nhsn/dataStat.html). One study considered a CVC-related blood stream infection to be device-related if it occurred at least 48 hours after admission or up to 48 hours after discharge from the ICU (Parra 2010); another study considered a CLABSI infection as bacteraemia in a patient with tunnelled dialysis catheters (TDCs) with no other etiologic explanation (Beathard 2003); and in a third study the definition used included a modification of CDC criteria for VAP (absence of additional criteria based on serologic testing, viral antigen identification and isolation of etiological organisms by transtracheal aspirate, bronchial brushing, or biopsy) (Zack 2002).

 
Secondary outcomes

The device utilisation rate (the percentage of patients in which the device was inserted) was presented graphically in one study (Sannoh 2010) in a manner that allowed reanalysis. The four datasets and seven other studies reported data on the duration of invasive device use (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Coopersmith 2002; Parra 2010; Salahuddin 2004; Sannoh 2010; Sona 2009; Warren 2004; Zack 2002). We could not reanalyse any of the other secondary outcomes listed in the protocol of this review (length of hospital stay, mortality and costs) and presented in the original papers (uncontrolled data), because this data was only reported as a mean before and a mean after the intervention (and with no graphs depicting the monthly or quarterly duration).

The four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) and three other studies (Coopersmith 2002; Sannoh 2010; Zack 2002) reported on cost savings secondary to the (inappropriately analysed) decreased infection rate; therefore we did not include these results in the review.

 

Excluded studies

See Characteristics of excluded studies and the PRISMA study flow chart Figure 1.

Of the 185 possible eligible studies identified, we excluded 155 studies after reading the full-texts. The major reasons for exclusion of studies were: (i) uncontrolled before-after studies that could not be reanalysed as ITS studies (111 studies); (ii) CBA studies with less than two control groups or less than two intervention groups (seven studies); (iii) surveillance studies (14 studies); (iv) controlled clinical trials (CCTs) and RCTs which did not target the health professional or reported outcomes that are not relevant for this review (seven studies); and (v) other ineligible study design such as protocols, review papers, qualitative studies or observational studies (16 studies).

 

Risk of bias in included studies

The risk of bias of included studies is summarised in the 'Risk of bias' tables within the Characteristics of included studies table and in Figure 2.

 FigureFigure 2. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

 
'Risk of bias' assessment of the cluster RCT study

The risk of bias for the generation of a random sequence as well as the concealment of allocation were assessed as unclear in Ching 1990 as too little information on the random draw was provided by the authors, and it was not certain that it was unpredictable (three wards were randomly selected as sites for the control group, and the remaining 24 wards formed the intervention sites). The protection against contamination were judged as adequate and at low risk of bias. The baseline characteristics of health professionals as well as the baseline outcome measures were similar in intervention and control groups, and therefore at low risk of bias. It was unclear if the outcome assessors were blinded, and we therefore considered the risk of bias for this item as unclear. There were no incomplete outcome data and the study was free from selective outcome reporting, and thus low risk of bias for both items. The unit of allocation was by ward, and the data were analysed by nurse, but the authors did not account for clustering in the analysis.

 
'Risk of bias' assessment of included ITS studies
 
Was the intervention independent of other changes?

Three of the twelve included ITS studies reported other changes that may have impacted on the effects of interventions (Cocanour 2006; Sannoh 2010; Warren 2004). In three studies the authors explicitly stated that no other changes occurred and the conditions were the same before and after the intervention (Beathard 2003; Parra 2010; Sona 2009), and in the four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) and five other studies (Coopersmith 2002; Kaye 2000; Miller 2010; Salahuddin 2004; Zack 2002) it was unclear whether the conditions before and after the intervention were the same.

Was the shape of the intervention effect prespecified?

All studies described the intended direction of effect of the intervention.

 
Was the intervention unlikely to affect data collection?

In two studies (Beathard 2003; Miller 2010) the data collection in the pre-intervention period was retrospective and based on records; data were prospectively collected in the post-intervention period. However, in Beathard 2003 the authors stated that the conditions under which data were collected were the same, and thus we judged the study at low risk of bias for this criteria, while in Miller 2010 we judged this item as unclear. The remaining studies were at low risk of bias for this criteria.

 
Was knowledge of the allocated interventions adequately prevented during the study?

All studies were judged to be at low risk of detection bias since the main outcome in all included studies (i.e. device-related infection rate) was based on predefined standard definitions and the outcome was considered objective.

 
Were incomplete outcome data adequately addressed?

In Abbott 2006 dataset 1, Abbott 2006 dataset 2, Abbott 2006 dataset 3 and Abbott 2006 dataset 4, the authors did not describe how they addressed the missing data in two of the included ICUs, and therefore this item was at high risk of bias. In Miller 2010 the incomplete outcome data in the pre-intervention period was adequately addressed, and the item judged at low risk of bias. In ten of the included studies the authors did not describe if incomplete outcome data were present, or, if so, how this was addressed, and the risk of bias was judged as being unclear for this item (Beathard 2003; Cocanour 2006; Coopersmith 2002; Kaye 2000; Parra 2010; Salahuddin 2004; Sannoh 2010; Sona 2009; Warren 2004; Zack 2002).

 
Was the study free from selective outcome reporting?

None of the ITS studies described protocols with predetermined outcomes; it was therefore unclear if selective outcome reporting occurred.

 
Was the study free from other risks of bias?

Two studies suffered from high risk of other bias (Cocanour 2006; Coopersmith 2002), and one study was judged as unclear risk of other bias (Salahuddin 2004). There were differences between pre- and post-intervention periods in terms of staffing (performance bias) (Cocanour 2006), type of catheters used (Coopersmith 2002) and possibly in populations (Salahuddin 2004).

 

Effects of interventions

See:  Summary of findings for the main comparison

The results of the reanalyses of VAP and CLABSI studies, which are reported for two effect sizes, a change in level and the difference in the slope of the regression (trend) line, are presented in  Table 1 and  Table 2. The median effect sizes for the change in level (with IQR) and for the change in the slope of the regression line (with IQR) are presented in the text below. The time interval for each data point is quarterly (i.e. three-month time intervals). All results are reported as the case infection rate per 1000 device days.

As we could not pool the data (I2 up to 97%), we have presented standardised effect sizes for each outcome as forest plots (without totals) in the Data and analyses section, to give the reader a visual overview of the results ( Analysis 1.1;  Analysis 1.2;  Analysis 1.3;  Analysis 1.4;  Analysis 1.5;  Analysis 2.1;  Analysis 2.2;  Analysis 2.3;  Analysis 2.4;  Analysis 2.5;  Analysis 2.6;  Analysis 2.7).

Ventilator-associated pneumonia (VAP)

Six of the 13 studies included in this review investigated the effects of different interventions to improve professional adherence to infection prevention guidelines on VAP infection rates; the four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) and five other studies (Cocanour 2006; Kaye 2000; Salahuddin 2004; Sona 2009; Zack 2002). We excluded data from Cocanour 2006 from the attempted meta-analysis, and from the forest plot, as the results were reported for monthly intervals (five months before the intervention and four months after); we only included these data in the narrative summary. The four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) presented the results separately for the four included ICUs.

There was a statistically significant pre-intervention trend (P = 0.048 to 0.001) in one study and in two of four sites from one study (Abbott 2006 dataset 2; Abbott 2006 dataset 4; Sona 2009) indicating a decreased infection rate before the start of the intervention in one study and one of the two study sites (Abbott 2006 dataset 4; Sona 2009) and an increased infection rate in the other study site (Abbott 2006 dataset 2). The median pre-intervention trend (IQR) was 0.35 (-1.31 to 0.62) cases per 1000 ventilator days .

Three studies (with an unknown number of educational events in Cocanour 2006; with core educational interventions weekly repeated in Salahuddin 2004; and with at least two active educational events in Zack 2002), based in seven sites and one of the ICUs in the (unknown number of educational events, but with the addition of dentists and dental hygienists performing oral care in Abbott 2006 dataset 2) showed a beneficial effect of the intervention at up to three months (Cocanour 2006), nine months (Salahuddin 2004), and 12 months (Abbott 2006 dataset 2; Zack 2002) (a decreased VAP rate of between 5 and 23 cases per 1000 ventilator days). One study based in four sites (unknown number of educational events in Kaye 2000) and three of the ICUs in the four datasets (unknown number of educational events in Abbott 2006 dataset 1; Abbott 2006 dataset 3; Abbott 2006 dataset 4) reported no statistically significant beneficial effects of the interventions. One study, in which the intervention was limited to involving training and feedback concerning oral care only, reported a statistically significant increase in VAP rate up to 12 months after the intervention (Sona 2009). The median effect sizes (IQR) for the change in level were -2.6 (-4.92 to 0.82) cases per 1000 ventilator days at three months (five studies and 15 sites); -5.0 (-9.33 to 1.38) cases per 1000 ventilator days at six months (five studies and 15 sites); -7.4 (-10.82 to 3.14) cases per 1000 ventilator days at nine months (five studies and 15 sites); and -5.2 (-14.21 to 4.62) cases per 1000 ventilator days at 12 months (three studies and nine sites).

Only two of the nine VAP study sites showed a change in the slope of the regression line which was indicative of a statistically significantly decreased VAP rate (-6.45 (SE 1.42), P = 0.002) in one study (Abbott 2006 dataset 2) and a statistically increased infection rate after the intervention (1.51 (SE 0.07), P = 0.003) in the other (Sona 2009). The median effect size for the change in slope of the regression line for the nine VAP studies was -0.14 (-4.81 to 1.02) cases per 1000 ventilator days. The follow-up time for the VAP studies ranged from three to 12 months.

Central line-associated blood stream infections (CLABSIs)

Improving professional compliance with guidelines

Six of the 13 included studies investigated the effectiveness of interventions to improve professional compliance with guidelines to prevent CLABSIs (Beathard 2003; Coopersmith 2002; Miller 2010; Parra 2010; Sannoh 2010; Warren 2004). The results for all six CLABSI studies showed statistically significant pre-intervention trends (P = 0.05 to 0.001) indicating a significantly decreased CLABSI rate before the intervention started. The median pre-intervention trend (IQR) was -0.6 (-0.69 to -0.59) cases per 1000 central line days.

The effects of the interventions varied across studies: three studies based in 31 sites, in which the core education intervention consisted of at least two active interventions, which in some studies was performed more than once (Beathard 2003; Coopersmith 2002; Miller 2010) showed a statistically significant beneficial change in the level effect of the intervention; two studies at up to six months (Beathard 2003; Miller 2010); and one study at up to nine months (Coopersmith 2002) (a decrease in the CLABSI rate by between 1 to 3.5 cases per 1000 central line days). The results for Beathard 2003 and Miller 2010 showed a strong tendency for a significant decrease also at nine months. Three CLABSI studies involving a single core educational event of short duration (15 to 45 minutes) did not show any beneficial effect of the intervention: one study (Warren 2004), based in one site, showed no statistically significant effect (step change). Two studies (based in four sites) reported a statistically significant increase in infection rate: Sannoh 2010 showed a significant increase in infection rate immediately after the intervention, and thereafter no effect, while Parra 2010 showed no effect up to 12 months after the intervention, and after that a significantly increased infection rate.

The median effect size for the change in level (IQR) was -0.6 (-2.74 to 0.28) cases per 1000 central line days at three months (six studies and 36 sites), -0.3 (-2.24 to 0.73) cases per 1000 central line days at six months (six studies and 36 sites), -0.16 (-1.73 to 1.08) cases per 1000 central line days at nine months (six studies and 36 sites), 0.06 (-1.3 to 0.93) cases per 1000 central line days (five studies and seven sites) at 12 months, 0.65 (-0.60 to 1.93) cases per 1000 central line days (four studies and six sites) at 18 months and 2.6 (1.61 to 3.57) cases per 1000 central line days (two studies and four sites) at 21 months.

Two of the six studies showed a statistically significant change in slope (Beathard 2003; Parra 2010) which was indicative of an increased infection rate after the intervention. The median effects size for the change in the slope of the regression line for the six CLABSI studies was +0.2 (0.11 to 0.54) CLABSI cases per 1000 central line days. The follow-up time for the CLABSI studies ranged from nine to 21 months.

Use of central line catheters

One ITS study reported data on the use of central line catheters (Sannoh 2010), and showed a small statistically significant decrease of -0.05 catheter days per 1000 patient days at three months (P = 0.03; 95% CI -0.09 to -0.01), no statistically significant effect at six months (0.03; P = 0.12; 95% CI -0.02 to 0.08), and a statistically significant increase at nine months (0.11; P = 0.02; 95% CI 0.05 to 0.17) and at 12 months (0.19; P = 0.01; 95% CI 0.12 to 0.27). There was a small but statistically significant change in slope (0.08 catheter days per 1000 patient days: P = 0.002; 95% CI 0.07 to 0.10), and a small but statistically significant pre-intervention trend (-0.03 catheter days per 1000 patient days; P = 0.01; 95% CI -0.05 to -0.02).

Improving professional compliance with infection control guidelines on urinary catheter practices

One RCT (Ching 1990) observed a beneficial effect of a short educational intervention on the percentage of incorrect urinary catheter practices; this decreased by 27.1 percentage points (from 63.1% before the intervention to 36.0% after the intervention) for the intervention group and by 19.6 percentage points (from 67.8% before the intervention to 48.2 % after the intervention) for the control group. The absolute difference was 12.2 percentage points. There was no statistically significant difference between groups in the percentage of incorrect urinary catheter practices before the intervention. The follow-up time was five weeks.

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Summary of main results

See  Summary of findings for the main comparison for the main results.

We included 13 studies in this review (one RCT and 12 ITS studies) investigating the effects of interventions to improve professional adherence to guidelines for the prevention of device-related infections: central line-associated blood stream infections (CLABSIs) (six studies); ventilator-associated pneumonia (VAP) (six studies); and catheter-associated urinary tract infections (CAUTIs) (one study). The studies, which were of low to very low quality, following an assessment with the GRADE criteria, involved 40 hospitals, 51 ICUs, 27 wards, more than 3504 patients and more than 1406 health professionals.

The results for both CLABSI and VAP studies were mixed, with half of the studies showing a beneficial effect of the intervention, and the other half showing no effect or an increased infection rate. 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 or VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among the included studies (I2 up to 97%), we did not retain these combined results. The effect sizes were small with the largest median effect for the change in level (IQR) for the six CLABSI studies being observed at three months follow-up with 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. The largest median effect for the VAP studies was found at nine months follow-up: -7.4 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). It is worth noting that N = 6 of the interventions that showed significantly decreased infection rates involved more than one active intervention, which in some of the studies, were repeatedly administered over time. Further, that the only intervention that involved specialised oral care personnel showed the largest step change (-22.9 (SE 4.0) cases per 1000 ventilator days), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002) at the longest follow-up among all included studies (Abbott 2006 dataset 2). The one included RCT observed improved urinary catheter practices after the intervention (absolute difference 12.2 percentage points). However the statistical significance of this is unknown given the unit of analysis error.

Possible sources of heterogeneity are related to: i) the interventions (e.g. the duration and intensity of the core educational intervention); ii) the population under investigation (e.g. patient's age, diagnosis and severity of condition; iii) the organisation of care (e.g. staffing, leadership, nurse-to-patient ratio; iv) the healthcare professional (e.g. level of experience, time since graduation, attitudes and acceptability of the intervention); v) and the healthcare environment, in terms of the baseline infection rate. Other factors, specific to the different medical devices, which may have contributed to the heterogeneity are: type of ventilator equipment used, type of catheter and insertion site, antibiotic use, and weaning protocols. In our review, none of the VAP studies reported on weaning protocols, and while the type of central lines used varied across CLABSI studies, only one study provided information on the insertion site (Warren 2004). It has been suggested that weaning protocols may decrease the number of ventilator days and therefore also the VAP rate (Blackwood 2011). The population, the organisation of care and the characteristics of the healthcare professionals targeted by the intervention were generally poorly described in the included studies.

While the low to very low quality of included studies prevents us from determining with certainty which interventions are most effective in changing professional behaviour and in what contexts, we have, when looking at the individual studies been able to identify some interventions which may be worth further study. Firstly, interventions including more than one active educational element, in some cases repeatedly administered over time, show promise in preventing both CLABSIs (Beathard 2003; Coopersmith 2002; Miller 2010) and VAP (Abbott 2006 dataset 2; Salahuddin 2004; Zack 2002), while for single active educational interventions of short duration (15 to 60 minutes) not repeated over time (Parra 2010; Sannoh 2010; Sona 2009; Warren 2004), no beneficial intervention effect was found. Secondly, the involvement of dedicated specialised personnel for VAP prevention may be worth further study, e.g. only in the ICU in Abbott 2006 dataset 2, in which special oral care equipment was purchased and dentists/dental auxiliaries were employed to provide oral care for patients with mechanical ventilation, was a significant decrease in the VAP rate found, while no significant intervention effect was found in the other ICUs from the same study. While there is evidence for the effectiveness of oral care in VAP prevention (Snyders 2011), results from an intensive care survey suggest that nurses perceive oral care as a difficult and unpleasant task, and that they are anxious of dislodging endotracheal tubes (Binkley 2004).

The content of the clinical practice guidelines varied greatly across the included studies, and none of the VAP or CLABSI studies actually implemented the same guidance. In this review therefore, we could not study the relative importance of the guidance on the intervention effect. It was clear, however, that not all the recommendations actually targeted the risk factors specific to each medical device. Targetting risk factors has been suggested as important for the prevention of device-related infections, by expert panels and national infection control guidelines (see  Table 5 and  Table 6). It was also unclear if some of the recommendations were evidence based.

In Beathard 2003 the preventive recommendations were specific to the dialysis context and population. In some CLABSI studies the guidance included only insertion practices, others only maintenance guidance and some clinical practice guidelines included both (see  Table 6). In Kaye 2000 only one of the preventive recommendations listed as important for VAP prevention was included in the clinical practice guideline. Five studies (the four datasets and four others) of six VAP studies (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Cocanour 2006; Salahuddin 2004; Sona 2009; Zack 2002) included recommendations on oral care, which (especially when Chlorhexidine is used for daily rinsing of the mouth) has been suggested effective in decreasing the VAP rate (Snyders 2011). Three of these studies (Cocanour 2006; Salahuddin 2004; Zack 2002) and one ICU site (Abbott 2006 dataset 2) showed a significant decrease in infection rate resulting from implementing oral care. One study, in which the recommendations were restricted to oral care only (see  Table 5), and previously implemented comprehensive interventions were in use, reported no beneficial effect (Sona 2009).

The degree of administrative and organisational support may impact on the effectiveness of an intervention (Griffiths 2009). However, this was only described in two of the included studies (Ching 1990; Kaye 2000). Since the aetiology of device-related infections is multifactorial and involves factors related to the patient (e.g. age, underlying disease, severity of condition), the organisation (e.g. bed occupancy, number of staff, workload), and the diagnostic and therapeutic procedures (type of invasive device), it can be assumed that hospital infection prevention programmes should be multidisciplinary and multifactorial (Griffiths 2009). Any infection control intervention, requires commitment from all involved parties for success, e.g. support by staff who are charged with implementing the intervention. Positive leadership and organisational changes are also needed to support and maximise these preventive interventions.

Factors related to the healthcare professional's attitude, willingness to change and satisfaction with the intervention may determine the behavioural response to a behavioural change intervention (Mitchie 2011). The prospective assessment of barriers to change, and the subsequent targeting of the intervention to the type of healthcare professionals and the organisational context, may impact on the effectiveness of the interventions (Baker 2010). Five (the four datasets and four other studies) of the 13 included studies (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Coopersmith 2002; Kaye 2000; Miller 2010; Warren 2004) assessed barriers to change, and used this knowledge when implementing the interventions, while in the remaining eight studies the interventions were not tailored to address specific barriers but only the more generic issue of a lack of adherence to guidelines. Not assessing barriers to change is not unusual in evaluations of quality improvement strategies (Grimshaw 2004; Ranji 2007).

Further, there are other non-modifiable factors that may have affected the intervention effect. One factor is whether or not guidelines/protocols for healthcare-associated infection (HAI) prevention existed before the intervention, since hypothetically the room for improvement is greater where no previous recommendations are in place. This was the case in two of the included studies that showed a beneficial intervention effect (Beathard 2003; Ching 1990). These results may be contrasted by the results of no effect or non-beneficial effect found in three of the included studies (Sannoh 2010; Sona 2009; Warren 2004), in which previously implemented interventions were on-going or reinforced, or new interventions introduced during the study period. Another factor is related to the baseline infection rate; also here the room for improvement is greater if the baseline infection rate is high. The comparatively lower infection rate in two studies (4.0 cases per 1000 device day in Parra 2010; 5.3 cases per 1000 device days in Sona 2009) may have reduced the potential to detect an intervention effect, requiring longer observation periods or larger sample sizes. However, not all studies with a high infection rate did show a beneficial effect of the intervention. For example in the four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) in the four ICUs with less than 106 patients, the ICUs with the highest baseline level did not show a significant effect of the intervention (Abbott 2006 dataset 4), while one of the ICUs with a (relatively) lower rate did (Abbott 2006 dataset 2). Five VAP studies (the four datasets and four other studies) reported high baseline rates or even outbreak situations (between 12.1 to 29.6 cases per 1000 ventilator days (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Cocanour 2006; Kaye 2000; Salahuddin 2004; Zack 2002). Four CLABSI studies also exhibited high infection rates (between 6.2 per ward and 14.8 cases per 1000 central line days) (Beathard 2003; Coopersmith 2002; Sannoh 2010; Warren 2004). These figures may be compared with the World Health Organization (WHO) statistics from 2011 in which a pooled cumulative incidence of VAP and CLABSIs among adult ICU patients of 7.9 and 3.5 per 1000 device-days was reported in high-income countries (WHO 2011). Baseline differences depend in part on the location of care, i.e. with lower rates for wards and higher rates for ICUs, but variations exist also between different types of ICUs (Dudeck 2011; WHO 2011), which, since the location varied greatly across the included studies, may explain some of these baseline differences.

 

Overall completeness and applicability of evidence

A majority of the included studies were conducted in high-income countries (10/13 in the United States), and only one study was performed in a lower-middle-income country (Pakistan) (Salahuddin 2004).

While the focus of approximately half of the 13 included studies was VAP prevention and the other half CLABSI prevention, only one study (Ching 1990) evaluated the effects of an educational intervention on improving urinary catheter care practices. However, the authors did not assess the effects of the intervention on the CAUTI rate, this despite the known potential for simple interventions to decrease the incidence of CAUTIs (Bernard 2012; Ranji 2007; Tambyah 2012).

The main aim for all studies included in this review was to evaluate interventions to improve the adoption of adequate procedures for insertion, and maintenance of invasive medical devices. None of the studies specifically evaluated the effectiveness of interventions to persuade health professionals to avoid the use of invasive medical devices (e.g. decision support systems giving stop orders or asking for reassessment of decisions to use invasive devices), or to reduce the duration of device use, which must be considered a central part of any programme to prevent device-related infections (O'Grady 2011; Saint 2009 ). This is important as it has been suggested that the insertion of indwelling medical devices may not be appropriate and may be overused (Conterno 2011; Gowardman 1998; Saint 2000). Furthermore, interventions that have previously been shown to be effective in changing professional practice e.g. on-screen point of care computer reminders (Shojania 2009) and other computerised decision support systems (Garg 2005) were not considered in any of the studies included in this review.

 

Quality of the evidence

Most of the evidence in this review comes from non-randomised low quality studies with no control groups, and five of the 12 studies involved only one intervention site. We reanalysed these studies as ITS studies to remove the risk of bias due to secular trends in uncontrolled data. However they were downgraded, using the GRADE criteria, from low to very low quality due to inconsistency (unexplained heterogeneity) among VAP studies, and imprecision of the effect among both VAP and CLABSI studies. In addition, in nine out of 13 studies the intervention was not independent of other changes, or this was not reported. The only included RCT study was judged to be of low quality due to inadequate sequence generation, the unclear blinding of assessors and the very short follow-up time.

A vast majority of studies that we found from the electronic searches were uncontrolled before-after studies, and that due to an insufficient number of data points before and after the implementation of one or more intervention(s), we could not reanalyse such studies using time regression techniques. Because of this, we had to exclude 91% of all seemingly relevant studies scrutinised for eligibility, since they did not comply with the EPOC quality criteria for study design (Ballini 2010), leaving only 9% of studies included in this review.

 

Potential biases in the review process

The search strategy was carefully scrutinised and adapted to existing terminology by experienced information technologists and a large number of databases were searched. One (or two) review authors sifted all references identified by the electronic searches, excluding papers that clearly were not eligible. Two review authors independently assessed all potentially eligible titles and abstracts against the eligibility criteria to ensure that no important references were missed. We searched reference lists of included studies and contacted authors about other published or unpublished studies. We did not, however, search any sources of grey literature.

 

Agreements and disagreements with other studies or reviews

We identified three systematic reviews specifically evaluating interventions to improve adherence to infection control guidelines to prevent device-related infections (Aboelela 2007; Ranji 2007; Safdar 2008). These reviews had wider inclusion criteria, in terms of study design, compared to this review and consisted primarily of simple before-after studies with inadequate analyses and controlled before-after (CBA) studies with only one control and one intervention group. The studies included in these reviews were also heterogenous and differed in terms of populations and educational approaches, similar to the studies included in this review, and were often combined with other strategies to prevent HAIs.

Ranji 2007 evaluated the effects of quality improvement strategies on promoting adherence to interventions for prevention of HAIs. The review included 64 studies (19 studies addressed CLABSI prevention, 12 VAP prevention, 10 CAUTI prevention, and the remaining studies, surgical site infections). The evidence was of low quality, and no firm conclusions could be drawn about which interventions were the most effective in improving practice. Aboelela 2007 included a total of 33 studies evaluating the effectiveness of interventions to change healthcare workers’ behaviour in reducing HAIs. The authors suggested that educational programmes and multi-disciplinary teams may be effective strategies to reduce HAI rates. Finally, the review by Safdar 2008 evaluated the effect of educational strategies targeted at health professionals to reduce the HAI rate. Twenty of the 26 included studies evaluated the impact on infections related to indwelling devices. The authors suggested that the systematic application of educational interventions may reduce the HAI rate, but they could not determine which particular educational intervention was the most effective.

As in our review, the included studies used a variety of approaches, and many in combination with other strategies to prevent HAIs. Unlike a systematic review on the effectiveness of guideline strategies to change practice in general (Grimshaw 2004) in which mostly process outcomes were reported, the main outcome for a majority of the studies included in this review was a patient outcome (infection rate) and only one study (Ching 1990) reported on a professional outcome.

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

 

Implications for practice

The low to very low quality of the included evidence along with the mixed results of this review provide insufficient evidence to draw any firm conclusions about which type of intervention is effective in changing professional behaviour, and in what context. However, interventions that may be worth further study are educational interventions involving more than one active element, in some cases repeatedly administered over time, and interventions employing specialised personnel, who are focused on a certain aspect of care that is supported by evidence e.g. dentists/dental auxiliaries performing oral care to prevent VAP. The core intervention of all included studies consisted of some type of educational strategy. Even if education is a necessary factor in the knowledge translation process, successful behaviour change also requires the targeting of interventions through an assessment of the current practice gap and barriers to change. In addition, a behaviour change model may help guide the design of the intervention. If possible, healthcare organisations should avoid implementing more than one intervention simultaneously, since this makes it difficult to disentangle the effects of the different interventions. For effective prevention of device-related hospital infections, it is also of great importance to ensure that the clinical practice guidelines/protocols/bundles that are implemented are evidence based and target important risk factors for the specific indwelling medical devices in question.

 
Implications for research

There is a great need to undertake further rigorous research (ideally cluster RCTs) to evaluate interventions to reduce HAIs. However, If randomised studies are not feasible, other robust study designs should be used, for example ITS studies with more than three data points both before and after the intervention, that take into account secular trends and cointerventions. More than one intervention site should also be considered.

Since many of the studies found by the electronic searches involved care bundle interventions that could not be reanalysed, care should be taken to ensure that future interventions are designed in a way that makes appropriate analysis possible. This may be done either by implementing all parts of the bundle simultaneously, or if implemented consecutively, ensure a sufficient number of data points before and after each part of the bundle, and ensure that these are reported.

Future studies should also consider evaluating the effectiveness of interventions aimed explicitly at reducing the use of indwelling medical devices, or to prompt reassessment and discontinuation of device use, for example through the use of on-screen point of care computer reminders (Shojania 2009) and other computerised decision support systems (Garg 2005). It is strongly recommended to include both infection rate and adherence outcomes, as well as the resources required to implement the intervention and the cost (length of hospital stay, laboratory tests, and antimicrobial treatments), to get a fuller picture of the effectiveness and cost-effectiveness of implementing interventions to improve professionals' adherence to guidelines for the prevention of device-related infections.

All future studies should aim to provide information on:

  • relevant patient characteristics for control and intervention conditions;
  • relevant characteristics of healthcare professionals for control and intervention conditions;
  • the type of indwelling devices, number of device days;
  • details on the intervention duration, intensity and the extent to which those targeted by the intervention actually received the intervention;
  • details of any cointerventions;
  • details of the evidence supporting the guideline recommendation;
  • the effect of the intervention on adherence to recommended preventive interventions;
  • the effect of the intervention on length of hospital stay, mortality, and costs (besides the infection rates); and
  • the theory base supporting the behavioural change intervention (i.e. behaviour change model).

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

We wish to acknowledge information technologist Douglas Salzwedel for developing and running the search strategy, and information technologist Michelle Fiander for further refining and re-running it. We would like to thank Craig Ramsay, Luke Vale, Jeremy Grimshaw, Russell Gruen, Marlene Miller and E. Andrea Nelson for their helpful comments. We would like to thank Emma Tavender and Clare Dooley for their editorial assistance in publishing this review.

We also wish to acknowledge the generous funding received from a NIHR Cochrane Programme Grant and FAPESP that have enabled us to conduct this review.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
Download statistical data

 
Comparison 1. Ventilator-associated pneumonia (VAP) analysis

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 VAP change in pre- and post-intervention slope at 3 to 6 months8Effect Size (Random, 95% CI)Totals not selected

 2 VAP 3 months level8Effect size (Random, 95% CI)Totals not selected

 3 VAP 6 months level8Effect size (Random, 95% CI)Totals not selected

 4 VAP 9 months level8Effect size (Random, 95% CI)Totals not selected

 5 VAP 12 months level5Effect size (Random, 95% CI)Totals not selected

 
Comparison 2. Central line-associated blood stream infections (CLABSIs) analysis

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 CLABSI change in pre- and post-intervention slope at 4 to 8 months6Effect size (Random, 95% CI)Totals not selected

 2 CLABSI 3 months level6Effect size (Random, 95% CI)Totals not selected

 3 CLABSI 6 months level6Effect size (Random, 95% CI)Totals not selected

 4 CLABSI 9 months level6Effect size (Random, 95% CI)Totals not selected

 5 CLABSI 12 months level5Effect size (Random, 95% CI)Totals not selected

 6 CLABSI 18 months level4Effect size (Random, 95% CI)Totals not selected

 7 CLABSI 21 months level2Effect size (Random, 95% CI)Totals not selected

 

Appendices

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Appendix 1. MEDLINE strategy 2012

Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) <1946 to June 18, 2012>

1 Prosthesis-Related Infections/ or Pneumonia, Ventilator-Associated/ (7997)
2 exp Catheterization/ or Intubation, Intratracheal/ or Ventilators, Mechanical/ or Respiration, Artificial/ or Device Removal/ or Ventilator Weaning/ or Catheters, Indwelling/ (249901)
3 (((mechanical or device or artificial or assist$ or wean$) adj2 ventilat$) or (artificial adj respirat$) or catheter$).ti,ab. (168505)
4 indwelling device?.ti,ab. (134)
5 exp "Prostheses and Implants"/ (342700)
6 or/2-5 [Indwelling devices] (645252)

7 exp Sepsis/ or exp Urinary Tract Infections/ or Respiratory Tract Infections/ or Prosthesis-Related Infections/ or exp Pneumonia/ or Equipment Contamination/ (219377)
8 exp Cross Infection/ or exp Infection Control/ or Infection Control Practitioners/ (80299)
9 sepsi?.tw. or Septicaemi$.ti,ab. or ventilator-associated pneumonia.tw. or (bacteremia or fungemia).tw. or nosocomial$.ti,ab. or infection?.ti,ab,hw. (1260719)
10 or/7-9 [Infection] (1344593)

11 6 and 10 [Devices & INfection] (60636)

12 guidelines as topic/ or practice guidelines as topic/ (95299)
13 Guideline Adherence/ (16335)
14 exp Critical Pathways/ (3940)
15 (guideline? not (guideline? adj2 author?)).ti,ab. (152274)
16 ((pathway? or protocol? or algorithm?) adj2 (clinical or treatment? or diagnos$ or management or infection? or infectious? or antibiotic?)).ti,ab. (31515)
17 critical pathway?.ti,ab. (1000)
18 guidance.ti,ab. (48961)
19 (quality adj2 (improv$ or manag$ or care or healthcare)).ti,ab. (79532)
20 (guideline? adj2 (impact or effect$)).ti,ab. (1090)
21 or/12-20 [Guideline Adherence etc] (359808)

22 intervention?.ti. or (intervention? adj6 (clinician? or collaborat$ or community or complex or DESIGN$ or doctor? or educational or family doctor? or family physician? or family practitioner? or financial or GP or general practice? or hospital? or impact? or improv$ or individuali?e? or individuali?ing or interdisciplin$ or multicomponent or multi-component or multidisciplin$ or multi-disciplin$ or multifacet$ or multi-facet$ or multimodal$ or multi-modal$ or personali?e? or personali?ing or pharmacies or pharmacist? or pharmacy or physician? or practitioner? or prescrib$ or prescription? or primary care or professional$ or provider? or regulatory or regulatory or tailor$ or target$ or team$ or usual care)).ab. (127021)
23 (pre-intervention? or preintervention? or "pre intervention?" or post-intervention? or postintervention? or "post intervention?").ti,ab. [added 2.4] (7278)
24 (hospital$ or patient?).hw. and (study or studies or care or health$ or practitioner? or provider? or physician? or nurse? or nursing or doctor?).ti,hw. (646037)
25 demonstration project?.ti,ab. (1750)
26 (pre-post or "pre test$" or pretest$ or posttest$ or "post test$" or (pre adj5 post)).ti,ab. (52486)
27 (pre-workshop or post-workshop or (before adj3 workshop) or (after adj3 workshop)).ti,ab. (468)
28 trial.ti. or ((study adj3 aim?) or "our study").ab. (494529)
29 (before adj10 (after or during)).ti,ab. (314647)
30 ("quasi-experiment$" or quasiexperiment$ or "quasi random$" or quasirandom$ or "quasi control$" or quasicontrol$ or ((quasi$ or experimental) adj3 (method$ or study or trial or design$))).ti,ab,hw. [ML] (87590)
31 ("time series" adj2 interrupt$).ti,ab,hw. [ML] (707)
32 (time points adj3 (over or multiple or three or four or five or six or seven or eight or nine or ten or eleven or twelve or month$ or hour? or day? or "more than")).ab. (6857)
33 pilot.ti. (32046)
34 Pilot projects/ [ML] (70498)
35 (clinical trial or controlled clinical trial or multicenter study).pt. [ML] (577853)
36 (multicentre or multicenter or multi-centre or multi-center).ti. (23887)
37 random$.ti,ab. or controlled.ti. (634227)
38 (control adj3 (area or cohort? or compare? or condition or design or group? or intervention? or participant? or study)).ab. not (controlled clinical trial or randomized controlled trial).pt. [ML] (344998)
39 "comment on".cm. or review.ti,pt. or randomized controlled trial.pt. [ML] (2590340)
40 review.ti. [EM] (216723)
41 (rat or rats or cow or cows or chicken? or horse or horses or mice or mouse or bovine or animal?).ti. (1256436)
42 exp animals/ not humans.sh. [ML] (3710539)
43 (animal$ not human$).sh,hw. [EM] (3616759)
44 *experimental design/ or *pilot study/ or quasi experimental study/ [EM] (17908)
45 ("quasi-experiment$" or quasiexperiment$ or "quasi random$" or quasirandom$ or "quasi control$" or quasicontrol$ or ((quasi$ or experimental) adj3 (method$ or study or trial or design$))).ti,ab. [EM] (87590)
46 ("time series" adj2 interrupt$).ti,ab. [EM] (707)
47 (or/22-38) not (or/39,41-42) [EPOC Methods Filter ML 2.4] (1827470)

48 (or/22-29,32-33,36-37,44-46) not (or/40,43) [EPOC Methods Filter EM 1.9-2.4] (1848292)

49 (randomized controlled trial or controlled clinical trial).pt. or randomized.ab. or placebo.ab. or clinical trials as topic.sh. or randomly.ab. or trial.ti. (782977)
50 exp animals/ not humans.sh. (3710539)
51 49 not 50 [Cochrane RCT Filter 6.4.d Sens/Precision Maximizing] (724020)

52 (or/1,11) and 21 [Results before filters] (3296)

53 52 and 51 [RCT Results] (251)
54 (52 and 47) not 53 [EPOC FIlter Results] (768)

 

 

 

Appendix 2. EMBASE strategy 2012

Embase Classic + Embase <1947 to 2012 May 04> OvidSP

1     ventilator associated pneumonia/ or device infection/ or catheter infection/ or prosthesis infection/ or shunt infection/ (18241)

2     ((ventilator? adj2 (infection? or pneumonia)) or (cather$ adj3 infection?)).ti,ab. (3731)

3     or/1-2 [Device infections] (19565)

4     Indwelling Catheter/ or *Endotracheal Intubation/ or *Ventilator/ or *Artificial Ventilation/ or exp *Device Removal/ or (((mechanical or device or artificial or assist$ or wean$) adj2 ventilat$) or (artificial adj respirat$) or catheter$).ti,ab. or indwelling device?.ti,ab. [Indwelling Devices] (274585)

5     exp Urinary Tract Infection/ or Sepsis/ or exp Respiratory Tract Infection/ or Septicemia/ or bacteremia/ or exp Fungemia/ or exp Pneumonia/ or Equipment Contamination/ or hospital infection/ (646745)

6     exp *infection/ (1845246)

7     (sepsis or septic?emi$ or ventilator-associated pneumonia or (bacteremia or fungemia) or nosocomial$).ti,ab. or infection?.ti,ab,hw. (1739175)

8     or/5-7 [Infection] (2760649)

9     (guideline? adj4 (adher$ or antibiotic? or applicat$ or apply$ or clinical or complian$ or concord$ or deploy$ or diagnos$ or effect$ or efficacy or evidence or experiment$ or impact or implement$ or infectious? or infection? or introduc$ or management or pilot$ or study or treatment? or trial? or utili?ation or utili?ing or utili?e?)).ti,ab. (76667)

10     (protocol? adj3 (adher$ or antibiotic? or applicat$ or apply$ or clinical or complian$ or concord$ or deploy$ or diagnos$ or effect$ or efficacy or evidence or experiment$ or impact or implement$ or infectious? or infection? or introduc$ or management or pilot$ or study or treatment? or trial? or utili?ation or utili?ing or utili?e?)).ti,ab. (58463)

11     practice guideline/ and (adher$ or antibiotic? or applicat$ or apply$ or clinical or complian$ or concord$ or deploy$ or diagnos$ or effect$ or efficacy or evidence or experiment$ or impact or implement$ or infectious? or infection? or introduc$ or management or pilot$ or study or treatment? or trial? or utili?ation or utili?ing or utili?e?).ti,ab. (126210)

12     (pathway? or guidance or algorithm? or (quality adj2 (improv$ or manag$ or care or healthcare))).ti,ab. (955438)

13     or/9-12 [GL/Protocol adherence implementation] (1153989)

14     secondary prevention/ or prevention/ or infection prevention/ or primary prevention/ or "prevention and control"/ (234982)

15     (prevention adj2 (primary or secondary or infection or control)).ti,ab. (50736)

16     or/14-15 [prevention] (268125)

17     controlled clinical trial/ or controlled study/ or randomized controlled trial/ [EM] (3840771)

18     (book or conference paper or editorial or letter or review).pt. not randomized controlled trial/ [Per BMJ Clinical Evidence filter] (3736305)

19     (random sampl$ or random digit$ or random effect$ or random survey or random regression).ti,ab. not randomized controlled trial/ [Per BMJ Clinical Evidence filter] (44243)

20     (animal$ not human$).sh,hw. (3704209)

21     17 not (or/18-20) [Trial filter per BMJ CLinical Evidence] (2513402)

22     intervention?.ti. or (intervention? adj6 (clinician? or collaborat$ or community or complex or DESIGN$ or doctor? or educational or family doctor? or family physician? or family practitioner? or financial or GP or general practice? or hospital? or impact? or improv$ or individuali?e? or individuali?ing or interdisciplin$ or multicomponent or multi-component or multidisciplin$ or multi-disciplin$ or multifacet$ or multi-facet$ or multimodal$ or multi-modal$ or personali?e? or personali?ing or pharmacies or pharmacist? or pharmacy or physician? or practitioner? or prescrib$ or prescription? or primary care or professional$ or provider? or regulatory or regulatory or tailor$ or target$ or team$ or usual care)).ab. (163414)

23     (pre-intervention? or preintervention? or "pre intervention?" or post-intervention? or postintervention? or "post intervention?").ti,ab. [added 2.4] (9234)

24     (hospital$ or patient?).hw. and (study or studies or care or health$ or practitioner? or provider? or physician? or nurse? or nursing or doctor?).ti,hw. (1355594)

25     demonstration project?.ti,ab. (2173)

26     (pre-post or "pre test$" or pretest$ or posttest$ or "post test$" or (pre adj5 post)).ti,ab. (73862)

27     (pre-workshop or post-workshop or (before adj3 workshop) or (after adj3 workshop)).ti,ab. (620)

28     trial.ti. or ((study adj3 aim?) or "our study").ab. (670264)

29     (before adj10 (after or during)).ti,ab. (420683)

30     ("quasi-experiment$" or quasiexperiment$ or "quasi random$" or quasirandom$ or "quasi control$" or quasicontrol$ or ((quasi$ or experimental) adj3 (method$ or study or trial or design$))).ti,ab,hw. [ML] (202537)

31     ("time series" adj2 interrupt$).ti,ab,hw. [ML] (836)

32     (time points adj3 (over or multiple or three or four or five or six or seven or eight or nine or ten or eleven or twelve or month$ or hour? or day? or "more than")).ab. (8961)

33     pilot.ti. (41495)

34     Pilot projects/ [ML] (55857)

35     (clinical trial or controlled clinical trial or multicenter study).pt. [ML] (0)

36     (multicentre or multicenter or multi-centre or multi-center).ti. (32227)

37     random$.ti,ab. or controlled.ti. (796262)

38     (control adj3 (area or cohort? or compare? or condition or design or group? or intervention? or participant? or study)).ab. not (controlled clinical trial or randomized controlled trial).pt. [ML] (524066)

39     "comment on".cm. or review.ti,pt. or randomized controlled trial.pt. [ML] (2008120)

40     review.ti. [EM] (274694)

41     (rat or rats or cow or cows or chicken? or horse or horses or mice or mouse or bovine or animal?).ti. (1560050)

42     exp animals/ not humans.sh. [ML] (1778563)

43     (animal$ not human$).sh,hw. [EM] (3704209)

44     *experimental design/ or *pilot study/ or quasi experimental study/ [EM] (4494)

45     ("quasi-experiment$" or quasiexperiment$ or "quasi random$" or quasirandom$ or "quasi control$" or quasicontrol$ or ((quasi$ or experimental) adj3 (method$ or study or trial or design$))).ti,ab. [EM] (115657)

46     ("time series" adj2 interrupt$).ti,ab. [EM] (836)

47     (or/22-38) not (or/39,41-42) [EPOC Methods Filter ML 2.4] (3034482)

48     (or/22-29,32-33,36-37,44-46) not (or/40,43) [EPOC Methods Filter EM 1.9-2.4] (2810625)

49     3 and 13 [Indwelling Device Infections & GL] (2086)

50     (3 and 16) not 49 [Indwelling device Infections & Prev Control] (1355)

51     (4 and 8 and 9) not (or/49-50) [Devices & Infection & GL] (489)

52     (4 and 8 and 16) not (or/49-51) [Device & Infection & Prevention] (1436)

53     (or/49-52) and 21 [RCT Results] (771)

54     ((or/49-52) and 47) not 53 [EPOC Filter Results] (1656)

 

Appendix 3. CENTRAL strategy 2012

EBM Reviews - Cochrane Central Register of Controlled Trials <April 2012> OvidSP

1 ((prosthes$ or ventilat$ or device or catheter?) adj3 infection?).ti,ab,tw,kw. (585)
2 (Catheteri?ation or (Intubation adj Intratracheal) or (Ventilator? adj2 Mechanical) or (Device? adj2 Remov$) or (ventilator? adj2 Wean$) or Catheter?).ti,ab,tw,kw. (8662)
3 (((mechanical or device or artificial or assist$ or wean$) adj2 ventilat$) or (artificial adj respirat$)).ti,ab,tw,kw. (3106)
4 indwelling device?.ti,ab,tw,kw. (3)
5 or/2-4 [Devices] (11457)
6 (sepsis or septic?em$ or bacteremia or fungemia or nosocomial$ or Hospital acquired or (equipment adj2 contamination) or infection? or (ventilator? adj2 pneumonia)).ti,ab,tw,kw. (31098)
7 ((pathway? or protocol? or algorithm?) adj2 (clinical or treatment? or diagnos$ or management or infection? or infectious? or antibiotic?)).ti,ab,tw,kw. (3234)
8 critical pathway?.ti,ab. (22)
9 guidance.ti,ab. (1327)
10 (quality adj2 (improv$ or manag$ or care or healthcare)).ti,ab. (6101)
11 (guideline? adj4 (adher$ or antibiotic? or applicat$ or apply$ or clinical or complian$ or concord$ or deploy$ or diagnos$ or effect$ or efficacy or evidence or experiment$ or impact or implement$ or infectious? or infection? or introduc$ or management or pilot$ or study or treatment? or trial? or utili?ation or utili?ing or utili?e?)).ti,ab,kw,tw. (2553)
12 (protocol? adj3 (adher$ or antibiotic? or applicat$ or apply$ or clinical or complian$ or concord$ or deploy$ or diagnos$ or effect$ or efficacy or evidence or experiment$ or impact or implement$ or infectious? or infection? or introduc$ or management or pilot$ or study or treatment? or trial? or utili?ation or utili?ing or utili?e?)).ti,ab,tw,hw. (8955)
13 (pathway? or guidance or algorithm? or (quality adj2 (improv$ or manag$ or care or healthcare))).ti,ab,tw,kw. (12635)
14 or/7-13 [GL] (23241)
15 and/5-6,14 (124)
16 1 or 15 (665)
17 exp Catheter-Related Infections/ (51)
18 Prosthesis-Related Infections/ or Pneumonia, Ventilator-Associated/ (188)
19 exp Catheterization/ or Intubation, Intratracheal/ or Ventilators, Mechanical/ or Respiration, Artificial/ or Device Removal/ or Ventilator Weaning/ or Catheters, Indwelling/ (12546)
20 (((mechanical or device or artificial or assist$ or wean$) adj2 ventilat$) or (artificial adj respirat$) or catheter$).ti,ab. (11043)
21 indwelling device?.ti,ab. (3)
22 exp "Prostheses and Implants"/ (9839)
23 or/19-22 [Indwelling devices] (27481)
24 exp Sepsis/ or exp Urinary Tract Infections/ or Respiratory Tract Infections/ or Prosthesis-Related Infections/ or exp Pneumonia/ or Equipment Contamination/ (7213)
25 exp Cross Infection/ or exp Infection Control/ or Infection Control Practitioners/ (1515)
26 sepsi?.tw. or Septicaemi$.ti,ab. or ventilator-associated pneumonia.tw. or (bacteremia or fungemia).tw. or nosocomial$.ti,ab. or infection?.ti,ab,hw. (39376)
27 or/24-26 [Infection] (40954)
28 23 and 27 [Devices & INfection] (2935)
29 guidelines as topic/ or practice guidelines as topic/ (1001)
30 Guideline Adherence/ (420)
31 exp Critical Pathways/ (96)
32 (guideline? not (guideline? adj2 author?)).ti,ab. (4784)
33 ((pathway? or protocol? or algorithm?) adj2 (clinical or treatment? or diagnos$ or management or infection? or infectious? or antibiotic?)).ti,ab. (2904)
34 critical pathway?.ti,ab. (22)
35 guidance.ti,ab. (1327)
36 (quality adj2 (improv$ or manag$ or care or healthcare)).ti,ab. (6101)
37 (guideline? adj2 (impact or effect$)).ti,ab. (220)
38 or/29-37 [Guideline Adherence etc] (14875)
39 (or/18,28) and 38 [Results before filters] (115)
40 16 or 39 [Results] (698)
41 limit 40 to yr="2008 -Current" (132)
42 40 not 41 (566)

 

Appendix 4. CINAHL strategy 2012

 


#CINAHL EbscoHost, May 3, 2012Results

S58S57 NOT S56 [EPOC Filter Results]284

S57S55 AND S54408

S56S55 AND S29 [RCT Filter Results]151

S55S5 AND S13 AND S221049

S54S30 or S31 or S32 or S33 or S34 or S35 or S36 or S37 or S38 or S39 or S40 or S41 or S42 or S43 or S44 or S45 or S46 or S47 or S48 or S49 or S50 or S51 or S52 or S53360238

S53TI ( (time points n3 over) or (time points n3 multiple) or (time points n3 three) or (time points n3 four) or (time points n3 five) or (time points n3 six) or (time points n3 seven) or (time points n3 eight) or (time points n3 nine) or (time points n3 ten) or (time points n3 eleven) or (time points n3 twelve) or (time points n3 month*) or (time points n3 hour*) or (time points n3 day*) or (time points n3 "more than") ) or AB ( (time points n3 over) or (time points n3 multiple) or (time points n3 three) or (time points n3 four) or (time points n3 five) or (time points n3 six) or (time points n3 seven) or (time points n3 eight) or (time points n3 nine) or (time points n3 ten) or (time points n3 eleven) or (time points n3 twelve) or (time points n3 month*) or (time points n3 hour*) or (time points n3 day*) or (time points n3 "more than") )1265

S52TI ( (control w3 area) or (control w3 cohort*) or (control w3 compar*) or (control w3 condition) or (control w3 group*) or (control w3 intervention*) or (control w3 participant*) or (control w3 study) ) or AB ( (control w3 area) or (control w3 cohort*) or (control w3 compar*) or (control w3 condition) or (control w3 group*) or (control w3 intervention*) or (control w3 participant*) or (control w3 study) )39068

S51TI ( multicentre or multicenter or multi-centre or multi-center ) or AB random*83931

S50TI random* OR controlled28277

S49TI ( trial or (study n3 aim) or "our study" ) or AB ( (study n3 aim) or "our study" )68810

S48TI ( pre-workshop or preworkshop or post-workshop or postworkshop or (before n3 workshop) or (after n3 workshop) ) or AB ( pre-workshop or preworkshop or post-workshop or postworkshop or (before n3 workshop) or (after n3 workshop) )267

S47TI ( demonstration project OR demonstration projects OR preimplement* or pre-implement* or post-implement* or postimplement* ) or AB ( demonstration project OR demonstration projects OR preimplement* or pre-implement* or post-implement* or postimplement* )1153

S46(intervention n6 clinician*) or (intervention n6 community) or (intervention n6 complex) or (intervention n6 design*) or (intervention n6 doctor*) or (intervention n6 educational) or (intervention n6 family doctor*) or (intervention n6 family physician*) or (intervention n6 family practitioner*) or (intervention n6 financial) or (intervention n6 GP) or (intervention n6 general practice*) Or (intervention n6 hospital*) or (intervention n6 impact*) Or (intervention n6 improv*) or (intervention n6 individualize*) Or (intervention n6 individualise*) or (intervention n6 individualizing) or (intervention n6 individualising) or (intervention n6 interdisciplin*) or (intervention n6 multicomponent) or (intervention n6 multi-component) or (intervention n6 multidisciplin*) or (intervention n6 multi-disciplin*) or (intervention n6 multifacet*) or (intervention n6 multi-facet*) or (intervention n6 multimodal*) or (intervention n6 multi-modal*) or (intervention n6 personalize*) or(intervention n6 personalise*) or (intervention n6 personalizing) or (intervention n6 personalising) or (intervention n6 pharmaci*) or (intervention n6 pharmacist*) or (intervention n6 pharmacy) or (intervention n6 physician*) or (intervention n6 practitioner*) Or (intervention n6 prescrib*) or (intervention n6 prescription*) or (intervention n6 primary care) or (intervention n6 professional*) or (intervention* n6 provider*) or (intervention* n6 regulatory) or (intervention n6 regulatory) or (intervention n6 tailor*) or (intervention n6 target*) or (intervention n6 team*) or (intervention n6 usual care)34670

S45TI ( collaborativ* or collaboration* or tailored or personalised or personalized ) or AB ( collaborativ* or collaboration* or tailored or personalised or personalized )32003

S44TI pilot9671

S43(MH "Pilot Studies")25112

S42AB "before-and-after"14578

S41AB time series1486

S40TI time series205

S39AB ( before* n10 during or before n10 after ) or AU ( before* n10 during or before n10 after )27667

S38TI ( (time point*) or (period* n4 interrupted) or (period* n4 multiple) or (period* n4 time) or (period* n4 various) or (period* n4 varying) or (period* n4 week*) or (period* n4 month*) or (period* n4 year*) ) or AB ( (time point*) or (period* n4 interrupted) or (period* n4 multiple) or (period* n4 time) or (period* n4 various) or (period* n4 varying) or (period* n4 week*) or (period* n4 month*) or (period* n4 year*) )42246

S37TI ( ( quasi-experiment* or quasiexperiment* or quasi-random* or quasirandom* or quasi control* or quasicontrol* or quasi* W3 method* or quasi* W3 study or quasi* W3 studies or quasi* W3 trial or quasi* W3 design* or experimental W3 method* or experimental W3 study or experimental W3 studies or experimental W3 trial or experimental W3 design* ) ) or AB ( ( quasi-experiment* or quasiexperiment* or quasi-random* or quasirandom* or quasi control* or quasicontrol* or quasi* W3 method* or quasi* W3 study or quasi* W3 studies or quasi* W3 trial or quasi* W3 design* or experimental W3 method* or experimental W3 study or experimental W3 studies or experimental W3 trial or experimental W3 design* ) )10371

S36TI pre w7 post or AB pre w7 post7539

S35MH "Multiple Time Series" or MH "Time Series"1132

S34TI ( (comparative N2 study) or (comparative N2 studies) or evaluation study or evaluation studies ) or AB ( (comparative N2 study) or (comparative N2 studies) or evaluation study or evaluation studies )8942

S33MH Experimental Studies or Community Trials or Community Trials or Pretest-Posttest Design + or Quasi-Experimental Studies + Pilot Studies or Policy Studies + Multicenter Studies29222

S32TI ( pre-test* or pretest* or posttest* or post-test* ) or AB ( pre-test* or pretest* or posttest* or "post test* ) OR TI ( preimplement*" or pre-implement* ) or AB ( pre-implement* or preimplement* )5931

S31TI ( intervention* or multiintervention* or multi-intervention* or postintervention* or post-intervention* or preintervention* or pre-intervention* ) or AB ( intervention* or multiintervention* or multi-intervention* or postintervention* or post-intervention* or preintervention* or pre-intervention* )125184

S30(MH "Quasi-Experimental Studies")5005

S29S23 or S24 or S25 or S26 or S27 or S28157058

S28TI ( “control* N1 clinical” or “control* N1 group*” or “control* N1 trial*” or “control* N1 study” or “control* N1 studies” or “control* N1 design*” or “control* N1 method*” ) or AB ( “control* N1 clinical” or “control* N1 group*” or “control* N1 trial*” or “control* N1 study” or “control* N1 studies” or “control* N1 design*” or “control* N1 method*” )69400

S27TI controlled or AB controlled53215

S26TI random* or AB random*92562

S25TI ( “clinical study” or “clinical studies” ) or AB ( “clinical study” or “clinical studies” )21930

S24(MM "Clinical Trials+")7190

S23TI ( (multicent* n2 design*) or (multicent* n2 study) or (multicent* n2 studies) or (multicent* n2 trial*) ) or AB ( (multicent* n2 design*) or (multicent* n2 study) or (multicent* n2 studies) or (multicent* n2 trial*) )6596

S22S14 or S15 or S16 or S17 or S18 or S19 or S20 or S21124638

S21TI ( (guideline* N2 (impact or effect*)) ) OR AB ( (guideline* N2 (impact or effect*)) )611

S20TI ( (quality N2 (improv* or manag* or care or healthcare)) ) OR AB ( (quality N2 (improv* or manag* or care or healthcare)) )34858

S19TI guidance OR AB guidance11022

S18TI critical pathway* OR AB critical pathway*606

S17TI ( ((pathway* or protocol* or algorithm*) N2 (clinical or treatment* or diagnos* or management or infection* or infectious* or antibiotic*)) ) OR AB ( ((pathway* or protocol* or algorithm*) N2 (clinical or treatment* or diagnos* or management or infection* or infectious* or antibiotic*)) )6562

S16TI ( (guideline* not (guideline* N2 author*)) ) OR AB ( (guideline* not (guideline* N2 author*)) )42510

S15(MH "Critical Path")2747

S14(MH "Practice Guidelines") OR (MH "Guideline Adherence") OR (MH "Education, Continuing+") OR (MH "Education, Interdisciplinary")46728

S13S6 or S7 or S8 or S9 or S10 or S11 or S12286503

S12TI ( infection OR infections ) OR AB ( infection OR infections ) OR MW ( infection OR infections )125155

S11TI nosocomial* OR AB nosocomial*4000

S10TX (bacteremia or fungemia)3130

S9TX ventilator-associated pneumonia1633

S8TI Septicaemi* OR AB Septicaemi*240

S7TX sepsi*7853

S6(MH "Urinary Tract Infections+") OR (MH "Sepsis+") OR (MH "Respiratory Tract Infections+") OR (MH "Equipment Contamination") OR (MH "Prosthesis-Related Infections") OR (MH "Cross Infection") OR (MH "Infection Control+") OR (MH "Infection Control Practitioners") OR (MH "Intensive Care Units+") OR (MH "Critical Care") OR (MH "Preventive Health Care+")208416

S5S1 or S2 or S3 or S430461

S4TI indwelling device* OR AB indwelling device*68

S3TI ( (((mechanical or device or artificial or assist$ or wean$) N2 ventilat$) or (artificial adj respirat$) or catheter$) ) OR AB ( (((mechanical or device or artificial or assist$ or wean$) N2 ventilat$) or (artificial adj respirat$) or catheter$) )11137

S2(MH "Intubation, Intratracheal") OR (MH "Ventilators, Mechanical") OR (MH "Ventilator Weaning") OR (MH "Respiration, Artificial") OR (MH "Device Removal")14682

S1(MH "Catheters and Tubes+")8366



 

Appendix 5. Cochrane Library strategies

EBM Reviews - Cochrane Database of Systematic Reviews 2005 to May 2012, EBM Reviews - Database of Abstracts of Reviews of Effects 2nd Quarter 2012, EBM Reviews - Health Technology Assessment 2nd Quarter 2012, EBM Reviews - NHS Economic Evaluation Database 2nd Quarter 2012. OvidSP

Date: June 18, 2012


#SearchesResults

1((prosthes$ or device or catheter$ or ventilat$) adj5 (infection? or sepsis or nosocomial or HAI or hospital acquired)).ti,ab,kw.117

2(reduce? or reducing or prevent$).ti,ab,kw.8544

31 and 2 [reducing/prefeventing device infections]82

4catheter$.ti,kw. or catheteri$.ab. or ventilator?.ti,ab,kw. or ventilated.ti,ab,kw.707

5((Intubat$ adj2 Intratracheal) or (Device? adj2 Remov$)).ti,ab,kw.84

6(artificial$ adj2 respirat$).ti,ab,kw.152

7indwelling device?.ti,ab,tw,kw.4

8or/4-7 [Devices]840

9(sepsis or septic?em$ or bacteremia or fungemia or nosocomial$ or Hospital acquired or (equipment adj2 contamination) or infection? or (ventilator? adj2 pneumonia)).ti,ab,kw. [Infection]2726

10(prevent$ or reduc$).ti.4390

11((protocol? or algorithm?) adj2 (clinical or treatment? or diagnos$ or management or infection? or infectious? or antibiotic?)).ti,ab,kw.107

12(bundle? or pathway?).ti,ab,kw.139

13guidance.ti,ab.151

14(quality adj2 (improv$ or manag$ or care or healthcare)).ti,ab.320

15(guideline? adj2 (accord$ or adher$ or application? or apply$ or implement$ or enforc$ or comply or complian$ or concorda$ or impact or implement$ or introduc$ or pilot$ or utili?ation or utili?ing or utili?e?)).tw.1213

16(guideline? adj4 (accord$ or adher$ or antibiotic? or applicat$ or apply$ or clinical or complian$ or concord$ or enforc$ or deploy$ or diagnos$ or effect$ or efficacy or evidence or experiment$ or impact or implement$ or infectious? or infection? or introduc$ or management or pilot$ or study or treatment? or trial? or utili?ation or utili?ing or utili?e?)).ti,ab,kw.476

17(protocol? adj3 (adher$ or antibiotic? or applicat$ or apply$ or clinical or complian$ or concord$ or deploy$ or diagnos$ or effect$ or efficacy or evidence or experiment$ or impact or implement$ or infectious? or infection? or introduc$ or management or pilot$ or study or treatment? or trial? or utili?ation or utili?ing or utili?e?)).ti,ab,hw.206

18(pathway? or guidance or algorithm? or (quality adj2 (improv$ or manag$ or care or healthcare))).ti,ab,kw.802

19or/10-18 [Prevention or Guideline Adherence]6634

20and/8-9,19 [devices & infection & GL terms]115

213 not 2026

2220 or 21 [Results]141

23from 22 keep 1-52 [CDSR]52

24from 22 keep 53-105 [DARE]53

25from 22 keep 106-119 [HTA]14

26from 22 keep 120-141 [NHS Econ]22



 

Appendix 6. EPOC Register strategies

June 2012:  59 results all years.

 

ALL FIELDS: (cather* or ventilat* or device* or intubat*) AND infection* or bacterem* or bacterial* or nosocomial or hospital acquired

OR

ALL FIELDS: Ventilat* and pneumon* and reduc*

OR

ALL FIELDS:  Ventilat* and pneumon* and  prevent*

OR

TITLE: intravenous* and infect*

March 2007: 51 citations in Register; 41 results from 'pending' (e.g. unclassified) file

catheter*

 (intuba* or ventilator*)

 (device* and infection*)

 ("infection control*") and (device* or catheter*)

 

Appendix 7. MEDLINE strategy (2008)


MEDLINE 1950-week 1, May 2008, OvidSP

The strategy below shows results per line from the search in May 2008; this strategy was also run in June 2007, and December 2010

1     exp Catheterization/ (146741)

2     Intubation, Intratracheal/ (23022)

3     Ventilators, Mechanical/ (7038)

4     ((mechanical or device or artificial or assist$) adj ventilat$).tw. (20637)

5     Respiration, Artificial/ (29575)

6     ((mechanical or device or artificial or assist$) adj respirat$).tw. (1979)

7     Device Removal/ (3273)

8     Ventilator Weaning/ (1981)

9     ((ventilat$ or respirat$) adj wean$).tw. (248)

10     Catheters, Indwelling/ (12908)

11     catheter$.tw. (115877)

12     or/1-11 (278648)

13     exp Urinary Tract Infections/ (33272)

14     (urinary adj2 infection?).tw. (23103)

15     uti?.tw. (3557)

16     exp Sepsis/ (67938)

17     sepsis.tw. (41962)

18     Respiratory Tract Infections/ (25533)

19     (respiratory adj2 infection?).tw. (20398)

20     (bacter?emia or fung?emia or septic?emia).tw. (27955)

21     exp Pneumonia/ (58557)

22     ventilator-associated pneumonia.tw. (1322)

23     Equipment Contamination/ (7047)

24     (equipment adj contaminat$).tw. (19)

25     Prosthesis-Related Infections/ (4608)

26     ((prosthesis or prosthetic or device or shunt or catheter) adj infection?).tw. (1792)

27     exp Cross Infection/ (34977)

28     ((cross or nosocomial) adj infection?).tw. (8175)

29     exp Infection Control/ (40292)

30     Infection Control Practitioners/mt, st (52)

31     exp Intensive Care Units/mt, st (2170)

32     Intensive Care/mt, st (2710)

33     ((hospital or health or healthcare) adj (associated infection? or acquired infection?)).tw. (1440)

34     Primary Prevention/mt (3283)

35     (prevention adj control?).tw. (166)

36     or/13-35 (301298)

37     12 and 36 (22427)

38     exp *education, continuing/ (24929)

39     (education$ adj2 (program$ or intervention? or meeting? or session? or strateg$ or workshop? or visit?)).tw. (25994)

40     (behavio?r$ adj2 intervention?).tw. (3651)

41     *pamphlets/ (1097)

42     (leaflet? or booklet? or poster or posters).tw. (13491)

43     ((written or printed or oral) adj information).tw. (933)

44     (information$ adj2 campaign).tw. (228)

45     (education$ adj1 (method? or material?)).tw. (2983)

46     *advance directives/ (2306)

47     outreach.tw. (4346)

48     ((opinion or education$ or influential) adj1 leader?).tw. (478)

49     facilitator?.tw. (7388)

50     academic detailing.tw. (194)

51     consensus conference?.tw. (2770)

52     *guideline adherence/ (4659)

53     practice guideline?.tw. (7259)

54     (guideline? adj2 (introduc$ or issu$ or impact or effect? or disseminat$ or distribut$)).tw. (1866)

55     ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 training program$).tw. (326)

56     *reminder systems/ (667)

57     reminder?.tw. (3860)

58     (recall adj2 system$).tw. (268)

59     (prompter? or prompting).tw. (2527)

60     algorithm?.tw. (57512)

61     *feedback/ or feedback.tw. (48086)

62     chart review$.tw. (11686)

63     ((effect? or impact or records or chart?) adj2 audit).tw. (514)

64     compliance.tw. (52614)

65     marketing.tw. (10550)

66     or/38-65 (276296)

67     exp *reimbursement mechanisms/ (13279)

68     fee for service.tw. (2399)

69     *capitation fee/ (1921)

70     *"deductibles and coinsurance"/ (441)

71     cost shar$.tw. (698)

72     (copayment? or co payment?).tw. (705)

73     (prepay$ or prepaid or prospective payment?).tw. (3687)

74     *hospital charges/ (666)

75     formular?.tw. (2021)

76     fundhold?.tw. (1)

77     *medicaid/ (8042)

78     *medicare/ (14410)

79     blue cross.tw. (940)

80     or/67-79 (40409)

81     *nurse clinicians/ (4829)

82     *nurse midwives/ (4089)

83     *nurse practitioners/ (8520)

84     (nurse adj (rehabilitator? or clinician? or practitioner? or midwi$)).tw. (7204)

85     *pharmacists/ (4541)

86     clinical pharmacist?.tw. (760)

87     paramedic?.tw. (2114)

88     *patient care team/ (15600)

89     exp *patient care planning/ (18188)

90     (team? adj2 (care or treatment or assessment or consultation)).tw. (5850)

91     (integrat$ adj2 (care or service?)).tw. (3604)

92     (care adj2 (coordinat$ or program$ or continuity)).tw. (11457)

93     (case adj1 management).tw. (5252)

94     exp *ambulatory care facilities/ (19922)

95     *ambulatory care/ (12474)

96     or/81-95 (108522)

97     *home care services/ (16296)

98     *hospices/ (2826)

99     *nursing homes/ (16664)

100     *office visits/ (1535)

101     *house calls/ (984)

102     *day care/ (2631)

103     *aftercare/ (2317)

104     *community health nursing/ (13195)

105     (chang$ adj1 location?).tw. (196)

106     domiciliary.tw. (1813)

107     (home adj1 treat$).tw. (1022)

108     day surgery.tw. (1449)

109     *medical records/ (14449)

110     *medical records systems, computerized/ (9375)

111     (information adj2 (management or system?)).tw. (15836)

112     *peer review/ (2663)

113     *utilization review/ (2450)

114     exp *health services misuse/ (2243)

115     or/97-114 (101100)

116     *physician's practice patterns/ (14552)

117     Quality Assurance, Health Care/mt, st (4986)

118     Quality of Health Care/st (2421)

119     quality assurance.tw. (13405)

120     process assessment/ [health care] (2144)

121     *program evaluation/ (4568)

122     *length of stay/ (4985)

123     (early adj1 discharg$).tw. (1532)

124     discharge planning.tw. (1640)

125     offset.tw. (10923)

126     triage.tw. (4905)

127     exp *"Referral and Consultation"/ and "consultation"/ (14446)

128     *drug therapy, computer assisted/ (740)

129     near patient testing.tw. (145)

130     *medical history taking/ (3557)

131     *telephone/ (3335)

132     (physician patient adj (interaction? or relationship?)).tw. (1324)

133     *health maintenance organizations/ (9211)

134     managed care.tw. (14207)

135     (hospital? adj1 merg$).tw. (322)

136     or/116-133 (94857)

137     ((standard or usual or routine or regular or traditional or conventional or pattern) adj2 care).tw. (16715)

138     (program$ adj2 (reduc$ or increas$ or decreas$ or chang$ or improv$ or modify$ or monitor$ or care)).tw. (22667)

139     (program$ adj1 (health or care or intervention?)).tw. (18128)

140     ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 treatment program$).tw. (226)

141     ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 care program$).tw. (106)

142     ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 screening program$).tw. (342)

143     ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 prevent$ program$).tw. (269)

144     (computer$ adj2 (dosage or dosing or diagnosis or therapy or decision?)).tw. (2533)

145     ((introduc$ or impact or effect? or implement$ or computer$) adj2 protocol?).tw. (1294)

146     ((effect or impact or introduc$) adj2 (legislation or regulations or policy)).tw. (828)

147     clinical strateg$.tw. (854)

148     or/137-147 (56284)

149     66 or 80 or 96 or 115 or 136 or 148 (607925)

150     randomized controlled trial.pt. (256632)

151     random$.tw. (410722)

152     control$.tw. (1663443)

153     intervention$.tw. (289010)

154     evaluat$.tw. (1326665)

155     or/150-154 (3125018)

156     37 and 149 and 155 (775)

157     animal/ (4262655)

158     human/ (10397158)

159     157 not (157 and 158) (3213354)

160     156 not 159 (748) [Results 2008 Search]

Note: June 15, 2007 search of MEDLINE yielded 788 citations

Note: December 2010 search yielded 119 citations



 

Appendix 8. EMBASE strategy (2008)


EMBASE <1980 to 2008 Week 20>, Ovid

1     exp *Catheterization/ (13924)

2     exp *Catheter/ (11837)

3     Endotracheal Intubation/ (14953)

4     Ventilator/ (4648)

5     ((mechanical or device or artificial or assist$) adj ventilat$).tw. (18558)

6     Artificial Ventilation/ (33746)

7     ((mechanical or device or artificial or assist$) adj respirat$).tw. (732)

8     exp Device Removal/ (3859)

9     ((ventilat$ or respirat$) adj wean$).tw. (181)

10     Indwelling Catheter/ (2308)

11     catheter$.tw. (93621)

12     or/1-11 (154596)

13     exp Urinary Tract Infection/ (30417)

14     (urinary adj2 infection?).tw. (19088)

15     uti?.tw. (3625)

16     Sepsis/ (39055)

17     sepsis.tw. (36556)

18     exp Respiratory Tract Infection/ (101210)

19     (respiratory adj2 infection?).tw. (18771)

20     Septicemia/ (8533)

21     Bacteremia/ (13756)

22     exp Fungemia/ (1401)

23     (bacter?emia or fung?emia or septic?emia).tw. (21890)

24     exp Pneumonia/ (79311)

25     ventilator-associated pneumonia.tw. (1368)

26     Equipment Contamination/ (6442)

27     (equipment adj contaminat$).tw. (17)

28     exp Device Infection/ (8254)

29     ((prosthesis or prosthetic or device or shunt or catheter) adj2 infection?).tw. (3964)

30     Hospital Infection/ (21189)

31     ((cross or nosocomial or hospital) adj infection?).tw. (8406)

32     *Intensive Care Unit/ (5810)

33     *Intensive Care/ (10997)

34     ((hospital or health or healthcare or device) adj (associated infection? or acquired infection?)).tw. (1275)

35     (infection adj (prevention or control$)).tw. (5778)

36     Primary Prevention/ (9261)

37     (prevention adj control$).tw. (111)

38     or/13-37 (305098)

39     12 and 38 (23053)

40     (education$ adj2 (program$ or intervention? or meeting? or session? or strateg$ or workshop? or visit?)).tw. (17748)

41     (behavio?r$ adj2 intervention?).tw. (3482)

42     (leaflet? or booklet? or poster or posters).tw. (10663)

43     ((written or printed or oral) adj information).tw. (822)

44     (information$ adj2 campaign).tw. (194)

45     (education$ adj1 (method? or material?)).tw. (2087)

46     outreach.tw. (3060)

47     ((opinion or education$ or influential) adj1 leader?).tw. (373)

48     facilitator?.tw. (5879)

49     academic detailing.tw. (178)

50     consensus conference?.tw. (2609)

51     practice guideline?.tw. (5904)

52     (guideline? adj2 (introduc$ or issu$ or impact or effect? or disseminat$ or distribut$)).tw. (1669)

53     ((introduc$ or impact or effect? or implement$ or computer$ or compli$) adj2 protocol?).tw. (1396)

54     ((introduc$ or impact or effect? or implement$ or computer$ or compli$) adj2 algorithm?).tw. (2383)

55     clinical pathway?.tw. (792)

56     critical pathway?.tw. (506)

57     ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 training program$).tw. (265)

58     reminder?.tw. (2910)

59     (recall adj2 system$).tw. (132)

60     (prompter? or prompting).tw. (2112)

61     advance directive?.tw. (1068)

62     *feedback/ or feedback.tw. (39570)

63     chart review$.tw. (10632)

64     ((effect? or impact or records or chart?) adj2 audit).tw. (340)

65     compliance.tw. (47746)

66     marketing.tw. (7533)

67     ((cost or clinical or medical) adj information).tw. (8358)

68     *medical education/ (28293)

69     *medical audit/ (3189)

70     continuing education/ (15167)

71     postgraduate education/ (8158)

72     or/40-71 (217365)

73     fee for service.tw. (1583)

74     cost shar$.tw. (464)

75     (copayment? or co payment?).tw. (551)

76     (prepay$ or prepaid or prospective payment?).tw. (1838)

77     formular?.tw. (2026)

78     fundhold?.tw. (1)

79     blue cross.tw. (378)

80     voucher?.tw. (350)

81     (free adj2 care).tw. (338)

82     exp *health insurance/ (14417)

83     *health care costs/ (10170)

84     *health care financing/ (2642)

85     *medical fee/ (1154)

86     *prospective payment/ (886)

87     or/73-86 (31665)

88     (nurse adj (rehabilitator? or clinician? or practitioner? or midwi$)).tw. (2014)

89     ((nurse or midwi$ or practitioner) adj managed).tw. (110)

90     clinical pharmacist?.tw. (838)

91     paramedic?.tw. (1513)

92     exp *paramedical personnel/ (16498)

93     *general practitioner/ (5722)

94     *physician/ (7492)

95     (team? adj2 (care or treatment or assessment or consultation)).tw. (4001)

96     (integrat$ adj2 (care or service?)).tw. (2594)

97     (care adj2 (coordinat$ or program$ or continuity)).tw. (6813)

98     (case adj1 management).tw. (3152)

99     *patient care/ (10088)

100     (chang$ adj1 location?).tw. (164)

101     domiciliary.tw. (1169)

102     (home adj1 (treat$ or visit?)).tw. (2652)

103     day surgery.tw. (1155)

104     exp *primary health care/ (12562)

105     *ambulatory surgery/ (1993)

106     *nursing home/ (4739)

107     *day hospital/ (798)

108     *outpatient care/ (1861)

109     *terminal care/ (2291)

110     *group practice/ (628)

111     *general practice/ (9798)

112     *rural health care/ (1962)

113     *community mental health center/ (212)

114     information system/ (11104)

115     *medical record/ (4163)

116     (information adj2 (management or system?)).tw. (10167)

117     *peer review/ (1193)

118     *professional standards review organization/ (108)

119     exp *clinical practice/ (8582)

120     quality assurance.tw. (10181)

121     exp *health care delivery/ (120061)

122     *health care quality/ (11229)

123     *professional practice/ (5108)

124     (early adj1 discharg$).tw. (1167)

125     discharge planning.tw. (614)

126     offset.tw. (9499)

127     triage.tw. (3803)

128     near patient testing.tw. (149)

129     *patient referral/ (2337)

130     (physician patient adj (interaction? or relationship?)).tw. (928)

131     managed care.tw. (7643)

132     *health care organization/ (8506)

133     *health maintenance organization/ (1635)

134     *health care system/ (7777)

135     *health care access/ (2904)

136     (hospital? adj1 merg$).tw. (92)

137     (computer$ adj2 (dosage or dosing or diagnosis therapy or decision?)).tw. (586)

138     (computer$ adj2 (diagnosis or therapy)).tw. (1164)

139     gatekeep$.tw. (1224)

140     or/88-139 (281781)

141     ((standard or usual or routine or regular or traditional or conventional or pattern) adj2 care).tw. (14093)

142     (program$ adj2 (reduc$ or increas$ or decreas$ or chang$ or improv$ or modify$ or monitor$ or care)).tw. (17346)

143     (program$ adj1 (health or care or intervention?)).tw. (11327)

144     ((effect or impact or introduc$) adj2 (legislation or regulations or policy)).tw. (660)

145     ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 treatment program$).tw. (216)

146     ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 care program$).tw. (58)

147     ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 screening program$).tw. (285)

148     ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 prevent$ program$).tw. (201)

149     or/141-148 (39344)

150     72 or 87 or 140 or 149 (518522)

151     Randomized controlled trial/ (157553)

152     random$.tw. (369378)

153     control$.tw. (1411518)

154     intervention$.tw. (253334)

155     (time adj series).tw. (6502)

156     (pre test or pretest or posttest or post test).tw. (7004)

157     evaluat$.tw. (1130889)

158     effect$.tw. (2578193)

159     compar$.tw. (1913563)

160     or/151-159 (4958905)

161     39 and 150 and 160 (3058)

162     Nonhuman/ (3062352)

163     161 not 162 (2802)



 

Appendix 9. CINAHL strategy (2008-2010)



CINAHL, 1982- , Ovid (Search date May 2008, Week 3). This strategy was used in 2010

1     exp Catheterization/ (11920)

2     Intubation, Intratracheal/ (2653)

3     Ventilators, Mechanical/ (756)

4     Respiration, Artificial/ (4898)

5     ((mechanical or device or artificial or assist$) adj (ventilat$ or respirat$)).tw. (3271)

6     Device Removal/ (230)

7     Ventilator Weaning/ (938)

8     ((ventilat$ or respirat$) adj (remov$ or wean$)).tw. (143)

9     Catheters, Indwelling/ (730)

10     catheter$.tw. (8454)

11     or/1-10 (26367)

12     exp Urinary Tract Infections/ (2587)

13     (urinary adj2 infection?).tw. (1777)

14     uti?.tw. (616)

15     exp Sepsis/ (4837)

16     sepsis.tw. (2952)

17     exp Respiratory Tract Infections/ (18383)

18     (respiratory adj2 infection?).tw. (1737)

19     (bacter?emia or fung?emia or septic?emia).tw. (1453)

20     ventilator-associated pneumonia.tw. (536)

21     Equipment Contamination/ (1371)

22     (equipment adj2 contaminat$).tw. (24)

23     Prosthesis-Related Infections/ (247)

24     ((prosthesis or prosthetic or device or shunt or catheter) adj2 infection?).tw. (518)

25     Cross Infection/ (9054)

26     ((cross or nosocomial) adj infection?).tw. (1652)

27     exp Infection Control/mt, st (5577)

28     Infection Control Practitioners/mt, st (29)

29     exp Intensive Care Units/mt, st (247)

30     Intensive Care/mt, st (512)

31     ((hospital or health or healthcare) adj (associated infection? or acquired infection?)).tw. (587)

32     exp Preventive Health Care/ (81492)

33     (prevention adj control?).tw. (33)

34     or/12-33 (118362)

35     11 and 34 (4032)

36     exp *education,continuing/ or *education,interdisciplinary/ (7156)

37     (education$ adj2 (program$ or intervention? or meeting? or session? or strateg$ or workshop? or visit?)).tw. (12613)

38     (behavio?r$ adj2 intervention?).tw. (1459)

39     *pamphlets/ (489)

40     (leaflet? or booklet? or poster or posters).tw. (2985)

41     ((written or printed or oral) adj information).tw. (346)

42     (information$ adj2 campaign).tw. (39)

43     (education$ adj1 (method? or material?)).tw. (1337)

44     *advance directives/ or *living wills/ (1597)

45     outreach.tw. (2220)

46     ((opinion or education$ or influential) adj1 leader?).tw. (158)

47     facilitator?.tw. (1710)

48     academic detailing.tw. (61)

49     consensus conference?.tw. (487)

50     practice guideline?.tw. (3156)

51     (guideline? adj2 (introduc$ or issu$ or impact or effect? or disseminat$ or distribut$)).tw. (540)

52     ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 training program$).tw. (103)

53     *reminder systems/ (323)

54     reminder?.tw. (1147)

55     (recall adj2 system$).tw. (42)

56     (prompter? or prompting).tw. (360)

57     algorithm?.tw. (3060)

58     *feedback/ or feedback.tw. (5011)

59     chart review$.tw. (2368)

60     ((effect? or impact or records or chart?) adj2 audit).tw. (223)

61     compliance.tw. (9179)

62     marketing.tw. (2896)

63     or/36-62 (56142)

64     exp *reimbursement mechanisms/ (2794)

65     fee for service.tw. (539)

66     exp *"fees and charges"/ (2277)

67     cost shar$.tw. (152)

68     (copayment? or co payment?).tw. (167)

69     (prepay$ or prepaid or prospective payment?).tw. (809)

70     exp *managed care programs/ (7198)

71     formular?.tw. (548)

72     fundhold?.tw. (0)

73     *medicaid/ (2317)

74     *medicare/ (6243)

75     blue cross.tw. (138)

76     or/64-75 (19538)

77     exp *advanced practice nurses/ (10832)

78     *nurse consultants/ (644)

79     (nurse adj (rehabilitator? or clinician? or practitioner? or midwi$)).tw. (7199)

80     *pharmacists/ (1098)

81     clinical pharmacist?.tw. (111)

82     paramedic?.tw. (1178)

83     *multidisciplinary care team/ (3740)

84     exp *protocols/ (4314)

85     (team? adj2 (care or treatment or assessment or consultation)).tw. (2920)

86     (integrat$ adj2 (care or service?)).tw. (1874)

87     *health care delivery, integrated/ (1227)

88     (care adj2 (coordinat$ or program$ or continuity)).tw. (4756)

89     exp *continuity of patient care/ (2553)

90     *case managers/ (616)

91     (case adj1 management).tw. (4069)

92     or/77-91 (39592)

93     exp *ambulatory care facilities/ (3294)

94     *ambulatory care/ (2219)

95     exp *home health care/ (15754)

96     *hospices/ (651)

97     exp *nursing homes/ (5396)

98     *office visits/ (437)

99     *office nursing/ (1760)

100     *home visits/ (766)

101     *day care/ (697)

102     *after care/ (1125)

103     exp *community health nursing/ (10668)

104     (chang$ adj1 location?).tw. (19)

105     domiciliary.tw. (278)

106     (home adj1 treat$).tw. (179)

107     day surgery.tw. (757)

108     or/93-107 (41445)

109     *medical records/ (2311)

110     exp *decision making, computer assisted/ (2098)

111     *computerized patient record/ (2135)

112     *nursing records/ (1278)

113     *problem oriented records/ (18)

114     (information adj2 (management or system?)).tw. (4357)

115     *health service misuse/ (203)

116     exp *quality assessment/ (10454)

117     quality assurance.tw. (2411)

118     *length of stay/ (1220)

119     (early adj1 discharg$).tw. (496)

120     discharge planning.tw. (1159)

121     offset.tw. (847)

122     triage.tw. (2314)

123     exp *"Referral and Consultation"/ (3182)

124     gatekeep$.tw. (401)

125     *drug therapy, computer assisted/ (108)

126     near patient test$.tw. (39)

127     exp *patient history taking/ (1281)

128     *telephone/ (1148)

129     exp *telehealth/ (2947)

130     (physician patient adj (interaction? or relationship?)).tw. (226)

131     *health maintenance organizations/ (1721)

132     managed care.tw. (6246)

133     (hospital? adj1 merg$).tw. (88)

134     or/109-133 (45787)

135     ((standard or usual or routine or regular or traditional or conventional or pattern) adj2 care).tw. (5653)

136     (program$ adj2 (reduc$ or increas$ or decreas$ or chang$ or improv$ or modify$ or monitor$ or care)).tw. (7019)

137     (program$ adj1 (health or care or intervention?)).tw. (5755)

138     ((effect or impact or introduc$) adj2 (legislation or regulations or policy)).tw. (331)

139     ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 treatment program$).tw. (40)

140     ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 care program$).tw. (32)

141     ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 screening program$).tw. (38)

142     ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 prevent$ program$).tw. (63)

143     (computer$ adj2 (dosage or dosing or diagnosis or therapy or decision?)).tw. (278)

144     ((introduc$ or impact or effect? or implement$ or computer$) adj2 protocol?).tw. (325)

145     or/135-144 (17011)

146     63 or 76 or 92 or 108 or 134 or 145 (187097)

147     clinical trials/ (47777)

148     control$.tw. (108869)

149     random$.tw. (54495)

150     comparative studies/ (44393)

151     experiment$.tw. (19102)

152     (time adj series).tw. (729)

153     impact.tw. (44419)

154     intervention$.tw. (75152)

155     evaluat$.tw. (109418)

156     effect?.tw. (116001)

157     exp pretest-posttest design/ (11525)

158     exp quasi-experimental studies/ (4066)

159     or/147-158 (382805)

160     35 and 146 and 159 (364)



 

What's new

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Last assessed as up-to-date: 16 July 2012.


DateEventDescription

12 March 2013AmendedPunctuation corrected



 

History

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Protocol first published: Issue 2, 2007
Review first published: Issue 3, 2013


DateEventDescription

25 August 2008AmendedConverted to new review format



 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Lucieni O Conterno (LOC), Alain Mayhew (AM) and Cresio Romeu Pereira (CRP) sifted the search results; LOC, AM, Gerd Flodgren (GF) and CRP applied eligibility criteria, extracted data and assessed the risk of bias; and Omar Omar (OO) conducted the data analysis. GF led the writing of the review, and all authors (AM, CRP, GF, LOC, OO and Sasha Shepperd (SS)) interpreted the results, read and commented on drafts and approved the final version of the review.

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Alain Mayhew is the Managing Editor of the Cochrane Effective Practice and Organisation of Care Group (EPOC). Sasha Shepperd is a Co-ordinating Editor of EPOC. None of the other authors have any competing interests to declare.

 

Sources of support

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Internal sources

  • Ottawa Hospital Research Institute, Ottawa Hospital, Canada.
  • Marilia Medical School, Brazil.

 

External sources

  • NIHR Cochrane EPOC Programme Grant, UK.
  • FAPESP Fundação de Amparo a Pesquisa do Estado de São Paulo, Brazil.
    Grant N° 2006/07217-1
  • Canadian Institutes of Health Research, Canada.
    CON-105529
  • Ontario Ministry of Health and Long-Term Care, Canada.

 

Differences between protocol and review

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

We had planned to handsearch high yield journals in the field, but in the end it was not necessary since they are all indexed in the databases searched.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. Additional references
Abbott 2006 dataset 1 {published data only}
Abbott 2006 dataset 2 {published data only}
Abbott 2006 dataset 3 {published data only}
Abbott 2006 dataset 4 {published data only}
Beathard 2003 {published data only}
Ching 1990 {published data only}
Cocanour 2006 {published data only}
Coopersmith 2002 {published data only}
  • Coopersmith CM, Rebmann TL, Zack JE, Ward MR, Corcoran RM, Schallom ME, et al. Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit. Critical Care Medicine 2002;30(1):59-64.
Kaye 2000 {published data only}
  • Kaye J, Ashline V, Erickson D, Zeiler K, Gavigan D, Gannon L, et al. Critical care bug team: a multidisciplinary team approach to reducing ventilator-associated pneumonia. American Journal of Infection Control 2000;28:197-201.
Miller 2010 {published data only}
  • Miller MR, Griswold M, Harris JM, Yenokyan G, Huskins WC,  Moss M, et al. Decreasing PICU catheter-associated bloodstream infections: NACHRI's quality transformation efforts. Pediatrics 2010;125:206-13.
Parra 2010 {published data only}
  • Parra AP, Menárguez MC, Granda MJP, Tomey MJ, Padilla B, Bouza E. A simple educational intervention to decrease incidence of central line–associated bloodstream infection (CLABSI) in intensive care units with low baseline incidence of CLABSI. Infection Control and Hospital Epidemiology 2010;31(9):964-7.
Salahuddin 2004 {published data only}
  • Salahuddin N, Zafar A, Sukhyani L, Rahim S, Noor KH, Hussain K, et al. Reducing ventilator-associated pneumonia rates through a staff eduction programme. The Journal of Hospital Infection 2004;57:223-7.
Sannoh 2010 {published data only}
  • Sannoh S, Clones B, Munoz J, Montecalvo M, Parvez B. A multimodal approach to central venous catheter hub care can decrease catheter-related bloodstream infection. American Journal of Infection Control 2010;38:424-9.
Sona 2009 {published data only}
  • Sona CS, Zack JE, Schallon ME, McSweeney M, McMullen K, Thomas J, et al. The impact of a simple, low-cost oral care protocol on ventilator-associated pneumonia rates in a surgical intensive care unit. Journal of Intensive Care Medicine 2009;24(1):54-62.
Warren 2004 {published data only}
  • Warren DK, Zack JE, Mayfield JL, Chen A, Prentice D, Fraser VJ, et al. The effect of an educational program on the incidence of central venous catheter-associated bloodstream infection in a Medical ICU. Chest 2004;126:1612-18.
Zack 2002 {published data only}
  • Zack JE, Garrison T, Trovillion E, Clinkscale D, Coopersmith CM, Frase VJ, et al. Effect of an educational program aimed at reducing the occurrence of ventilator-associated pneumonia. Critical Care Medicine 2002;30:2407-12.

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. Additional references
Abramczyk 2011 {published data only}
  • Abramczyk ML, Carvalho WB, Medeiros E. Preventing catheter-associated infections in the paediatric intensive care unit: impact of an educational program surveying policies for insertion and care of central venous catheters in a Brazilian teaching hospital. Brazilian Journal of Infectious Diseases 2011;15(6):573-7.
Apisarnthanarak 2007 {published data only}
  • Apisarnthanarak A, Pinitchai U, Thongphubeth K, Yuekyen C, Warren DK, Zack JE, et al. Effectiveness of an educational program to reduce ventilator-associated pneumonia in a tertiary care center in Thailand: a 4-year study. Clinical Infectious Disease 2007;45(6):704-11.
Apisarnthanarak 2008 {published data only}
  • Apisarnthanarak A, Suwannakin A, Maungboon P, Warren DK, Fraser VJ. Long-term outcome of an intervention to remove unnecessary urinary catheters, with and without a quality improvement team, in a Thai tertiary care center. Infection Control Hospital Epidemiology 2008;29:1094-5.
  • Apisarnthanarak A, Thongphubeth K, Sirinvaravong S, Kitkangvan D, Yuekyen C, Warachan B, et al. Effectiveness of multifaceted hospital wide quality improvement programs featuring an intervention to remove unnecessary urinary catheters at a tertiary care center in Thailand. Infection Control Hospital Epidemiology 2007;28(7):791-8.
Babcock 2004 {published data only}
  • Babcock HM, Zack JE, Garrison T, Trovillion E, Jones M, Fraser VJ, et al. An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects. Chest 2004;125(6):2224-31.
Barsuk 2009 {published data only}
  • Barsuk JH, Cohen ER, Feiglass J, McGahie WC, Wayne DB. Use of simulation-based education to reduce catheter-related bloodstream infections. Archives of Internal Medicine 2009;169(15):1420-3.
Baxter 2005 {published data only}
  • Baxter AD, Allan J, Bedard J, Malone-Tucker S, Slivar S, Langill M, et al. Adherence to simple and effective measures reduces the incidence of ventilator-associated pneumonia. Canadian Journal of Anaesthesia 2005;52(5):535-41.
Berenholtz 2004a {published data only}
  • Berenholtz SM, Milanovich S, Faircloth A, Prow TD, Earsing K, Lipsett P, et al. Improving care for the ventilated patient. Joint Commission Journal on Quality and Safety 2004;30(4):195-204.
Berenholtz 2004b {published data only}
  • Berenholtz SM, Provonost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Critical Care Medicine 2004;32(10):2014-20.
Berg 1995 {published data only}
  • Berg DE, Hershow RC, Ramirez CA, Weinstein RA. Control of nosocomial infections in an intensive care unit in Guatemala city. Clinical Infectious Diseases 1995;21:588-93.
Berhe 2006 {published data only}
  • Berhe M, Edmond MB, Bearman G. Measurement and feedback of infection control process measures in the intensive care unit: Impact on compliance. American Journal of Infection Control 2006;34(8):537-9.
Bird 2010 {published data only}
  • Bird D, Zambuto A, O’Donnell C, Silva J, Korn C, Burke R, et al. Adherence to ventilator-associated pneumonia bundle and incidence of ventilator-associated pneumonia in the surgical intensive care unit. Archives of Surgery 2010;145(5):465-70.
Bizarro 2010 {published data only}
  • Bizzarro MJ, Sabo B, Noonan M, Bonfiglio M, Northrup V, Diefenbach K, Central Venous Catheter Initiative Committee. A quality improvement initiative to reduce central line–associated bloodstream infections in a neonatal intensive care unit. Infection Control and Hospital Epidemiology 2010;31(3):241-8.
Björnestam 2000 {published data only}
  • Björnestam B, Hedborg K, Ulrika R, Yigael F. The effect of a 1-hour nurse training program on the frequency of bacteremia in patients receiving parenteral nutrition. Journal of Intravenous Nursing 2000;23:154-7.
Bruminhent 2010 {published data only}
  • Bruminhent J, Keegan M, Lakhani A, Roberts IM, Passalacqua J. Effectiveness of a simple intervention for prevention of catheter-associated urinary tract infections in a community teaching hospital. American Journal of Infection Control 2010;38:689-93.
Brunelle 2003 {published data only}
  • Brunelle D. Impact of a dedicated infusion therapy team on the reduction of catheter-related nosocomial infections. Journal of Intravenous Nursing 2003;26(6):362-6.
Burns 2003 {published data only}
  • Burns SM, Earven S, Fisher C, Lewis R, Merrell P, Schubart JR, et al. Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: One-year outcomes and lessons learned. Critical Care Medicine 2003;31:2752-63.
Camp 2009 {published data only}
Casey 2003 {published data only}
  • Casey J, Davies J. A nurse led central line insertion service. EDTNA/ERCA Journal 2003;29(4):203-5.
Castello 2011 {published data only}
  • Castello FV, Maher A, Cable G. Reducing bloodstream infections in pediatric rehabilitation patients receiving parenteral nutrition. Pediatrics 2011;128(5):e1273-8.
Cherry-Bukowiec 2011 {published data only}
  • Cherry-Bukowiec JR, Denchev K, Dickinson S, Chenoweth CE, Zalewski C, Meldrum C, et al. Prevention of catheter-related blood stream infection: Back to basics?. Surgical Infections 2011;12:27-32.
Chrdle 2012 {published data only}
  • Chrdle A, Stropková R, Smítková S, Řehořová I, Chmelík V. [Katétrové infekce krevního řečiště – prevalence a intervence]. Čas Lék čes 2012;151:13-16.
Christenson 2006 {published data only}
  • Christenson M, Hitt JA, Abbott G, Septimus EJ, Iversen N. Improving patient safety: Resource availability and application for reducing the incidence of healthcare-associated infection. Infection Control and Hospital Epidemiology 2006;27(3):245-51.
Cohen 1991 {published data only}
  • Cohen IL, Bari N, Strosberg MA, Weinberg PF, Wacksman RM, Millstein BH, et al. Reduction of duration and cost of mechanical ventilation in an intensive care unit by use of a ventilatory management team. Critical Care Medicine 1991;19(10):1278-83.
Cohran 1996 {published data only}
  • Cohran J, Larson E, Roach H, Blane C, Pierce P. Effect of intravascular surveillance and education program on rates of nosocomial bloodstream infections. Heart Lung 1996;25:161-4.
Collingnon 2007 {published data only}
  • Collignon PJ, Dreimanis DE, Beckingham DW, Roberts JL, Gardner A. Intravascular catheter bloodstream infections: an effective and sustained hospital-wide prevention program over 8 years. Medical Journal of Australia 2007;187(10):551-4.
Cools 1987 {published data only}
Coopersmith 2004 {published data only}
  • Coopersmith CM, Zack JE, Ward MR, Sona CS, Schallom ME, Everett SJ, et al. The impact of bedside behavior on catheter-related bacteremia in the intensive care unit. Archives of Surgery 2004;139(2):131-6.
Cornia 2003 {published data only}
  • Cornia PB, Amory JK, Fraser S, Saint S, Lipsky BA. Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalised patients. American Journal of Medicine 2003;114:404-7.
Costello 2008 {published data only}
  • Costello JM, Morrow DF, Graham DA, Potter-Bynoe G, Sandora TJ. Systematic intervention to reduce central line-associated bloodstream infection rats in a pediatrics cardiac intensive care unit. Pediatrics 2008;121(5):915-23.
Crouzet 2007 {published data only}
  • Crouzet J, Bertrand X, Venier AG, Badoz M, Husson C, Talon D. Control of duration of urinary catheterization: impact on catheter-associated urinary tract infection. Journal of Hospital Infection 2007;67(3):253-7.
Cruden 2000 {published data only}
Danchaivijitr 2005 {published data only}
  • Danchaivijitr S, Assanasen S, Apisarnthanarak A, Judaeng T, Pumsuwan V. Effect of an education program on the prevention of ventilator-associated pneumonia: a multicenter study. Journal of Medical Association of Thailand 2005;88(Suppl 10):S36-S41.
Dawson 2011 {published data only}
  • Dawson D, Endacott R. Implementing quality initiatives using a bundled approach. Intensive and Critical Care Nursing 2011;27:117-20.
Dinç 2000 {published data only}
  • Dinç L, Erdil F. The effectiveness of an educational intervention in changing nursing practice and preventing catheter-related infection for patients receiving total parenteral nutrition. International Journal of Nursing Studies 2000;37:371-9.
Dries 2004 {published data only}
  • Dries DJ, McGonigal MD, Malian MS, Bor BJ, Sullivan C. Protocol-driven ventilator weaning reduces use of mechanical ventilation, rates of early reintubation, and ventilator-associated pneumonia. Journal of Trauma 2004;56:943-52.
Duane 2009 {published data only}
  • Duane TM, Brown H, Borchers CT, Wolfe LG, Malhotra AK, Aboutanos MB, et al . A central venous line protocol decreases bloodstream infections and length of stay in a trauma intensive care unit population. The American Surgeon 2009;75(12):1166-70.
Du Bose 2008 {published data only}
  • Du Bose JJ, Inaba K, Shiflett A, Trankiem C, Teixeira PGR, Salim A, et al. Measurable outcomes of quality improvement in the trauma intensive care unit: the impact of a daily quality rounding checklist. Journal of Trauma 2008;64(1):22-9.
East 2005 {published data only}
  • East D, Jacoby K. The effect of a nursing staff education program on compliance with central line care policy in the cardiac intensive care unit. Pediatric Nursing 2005;31(3):182-94.
Eggimann 2000 {published data only}
  • Eggimann P, Harbarth S, Costantin, Touveneau S, Chevrolet J-C, Pittet D. Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care. Lancet 2000;355(9218):1864-8.
Espiau 2011 {published data only}
  • Espiau M, Pujol M, Campins-Marti M, Planes AM, Pena Y, Balcells J, et al. Incidence of central line-associated bloodstream infection in an intensive care unit. Anales de Pediatria 2011;75(3):188-93.
Esteve 2009 {published data only}
  • Esteve F, Pujol M, Ariza J, Gudiol F, Verdaguer R, Cisnal M, et al. Impact of a prevention program for catheter-related blood stream infection in the intensive care unit of a tertiary hospital [Impacto de un programa de prevención de la bacteriemia relacionada con el cateter en una unidad de cuidados intensivos de un hospital terciario]. Enfermedades Infecciosas e Microbilogía Clínica 2009;27(10):561-5.
Fakih 2010 {published data only}
Frankel 2005 {published data only}
  • Frankel HL, Crede WB, Topal JE, Roumanis SA, Devlin MW, Foley AB. Use of corporate Six Sigma performance-improvement strategies to reduce incidence of catheter-related bloodstream infections in surgical ICU. Journal of American College of Surgeons 2005;201(3):349-58.
French 1989 {published data only}
  • French GL, Wong SL, Cheng AFB, Donna S. Repeated prevalence surveys for monitoring effectiveness of hospital infection control. Lancet 1989;8670(2):1021-3.
García-Rodicio 2009 {published data only}
  • García-Rodicio S, Abajo C, Godoy M, Catalá MA. Development and implementation of an audit tool for quality control of parenteral nutrition. Nutrition in Clinical Practice 2009;24(4):500-7.
Gaynes 2001 {published data only}
  • Gaynes R, Richards C, Edwards J, Emori TG, Horan T, Alonso-Echanove J. Feeding back surveillance data to prevent hospital-acquired infection. Emerging Infectious Diseases 2001;7(2):295-8.
Gnass 2004 {published data only}
  • Gnass SA, Barboza L, Bilicich D, Angeloro P, Treyer W, Grenóvero S, et al. Prevention of central venous catheter-related bloodstream infections using non-technologic strategy. Infection Control and Hospital Epidemiology 2004;25(8):675-7.
Goddard 2006 {published data only}
  • Goddard L, Clayton S, Peto TEA, Bowler ICJW. The 'just-in-case venflon': effect of surveillance and feedback on prevalence of peripherally inserted intravascular devices. Journal of Hospital Infection 2006;64(4):401-2.
Goetz 1999 {published data only}
  • Goetz AM, Kedzuf S, Wagener M, Muder RR. Feedback to nursing staff as an intervention to reduce catheter-associated urinary tract infection. American Journal of Infection Control 1999;27(5):402-4.
Gokula 2007 {published data only}
  • Gokula MR, Smith MA, Hickner J. Emergency room staff education and use of a urinary catheter indication sheet improves appropriate use of foley catheters. American Journal of Infection Control 2007;35(9):589-93.
Gowardman 2005 {published data only}
  • Gowardman JR, Kelaher C, Whiting J, Collignon PJ. Impact of a formal removal policy for central venous catheters on duration of catheterisation. Medical Journal of Australia 2005;182(5):249-50.
Gozu 2011 {published data only}
  • Gozu A, Clay C, Younus F. Hospital-wide reduction in central line-associated bloodstream infections: a tale of two small community hospitals. Infection Control and Hospital Epidemiology 2011;32(6):619-22.
Grap 2003 {published data only}
  • Grap MJ, Strickland D, Tormey L, Keane K, Lubin S, Emerson J. Collaborative practice: development, implementation, and evaluation of a weaning protocol for patients receiving mechanical ventilation. American Journal of Critical Care 2003;12(5):454-60.
Guerin 2010 {published data only}
  • Guerin K, Wagner J, Rains K, Bessesen M. Reduction in central line-associated bloodstream infections by implementation of a post insertion care bundle. American Journal of Infection Control 2010;38(6):430-3.
Guner 2011 {published data only}
  • Guner R, Hasanoglu I, Keske S, Tasyaran MA. Educational approach to reduce catheter-related bloodstream infections and catheter-related urinary tract infection rates in intensive care unit. Clinical microbiology and infection. Proceedings of the 21st ECCMID/27th ICC Conference; 2011. Milan, 2011:S775.
Gunther 2009 {published data only}
  • Gunther SG, Schwebel C, Vésin A, Remy J, Dessertaine G, Timsit JF. Interventions to decrease tube, line, and drain removals in intensive care units: the FRATER study. Intensive Care Medicine 2009;35:1772-6.
Gurskis 2009 {published data only}
  • Gurskis V, Asembergiene J, Kevalas R, Miciulevicine, Pavilonis A, Valinteliene R, et al. Reduction of nosocomial infection and mortality attributable to nosocomial infections in pediatric intensive care units in Lithuania. Medicina (kaunas) 2009;45(2):203-13.
Gusarov 2009 {published data only}
  • Gusarov VG. Impact of pneumonia prevention protocol on the results of treatment in patients in the acute period of stroke. Anesteziologiia i reanimantologiia 2009;May-June(3):34-7.
Hansen 2006 {published data only}
  • Hansen BG. Reducing nosocomial urinary tract infections through process improvement. Journal for Healthcare Quality Web Exclusive 2006;28(2):W2-9.
Harnage 2007 {published data only}
  • Harnage SA. Achieving zero catheter related blood stream infections: 15 months success in a community based medical center. Journal of The Association for Vascular Access 2007;12(4):218-24.
Hatler 2006 {published data only}
  • Hatler CW, Mast D, Corderella J, Mitchell G, Howard K, Aragon J, et al. Using evidence and process improvement strategies to enhance healthcare outcomes for the critically ill: a pilot project. American Journal of Critical Care 2006;15(6):549-55.
Helman 2003 {published data only}
  • Helman DL, Sherner JH, Fitzpatrick TM, Callender ME, Shorr AF. Effect of standardized orders and provider education on head-of-bed positioning in mechanically ventilated patients. Critical Care Medicine 2003;31(9):2285-90.
Hendrix 1998 {published data only}
  • Hendrix MS, Fieselmann JF, Bock MJ, Wakefield DS, Helms MC, Bentler SE. Outreach education to improve quality of rural ICU care. American Journal of Respiratory Critical Care Medicine 1998;158:418-23.
Hiemenz 1986 {published data only}
Higuera 2005 {published data only}
  • Higuera F, Rosenthal DV, Duarte P, Ruiz J, Franco G, Safdar N. The effect of process control on the incidence of central venous catheter-associated bloodstream infections and mortality in intensive care units in Mexico. Critical Care Medicine 2005;33(9):2022-7.
Holzmann-Pazgal 2012 {published data only}
  • Holzmann-Pazgal G, Kubanda A, Davis K, Khan AM, Brumley K, Denson SE. Utilizing a line maintenance team to reduce central-line-associated bloodstream infections in a neonatal intensive care unit. Journal of Perinatology 2012;32(4):281-6.
Hong 1990 {published data only}
  • Hong SW, Ching TY, Fung JP, Seto WL. The employment of ward opinion leaders for continuing education in the hospital. Medical Teacher 1991;12(2):209-217.
Horbar 2006 {published data only}
Horvath 2009 {published data only}
  • Horvath B, Norville R, Lee D, Hyde A, Gregurich MA, Hockenberry M. Reducing central venous catheter-related bloodstream infection in children with cancer. Oncology Nursing Forum 2009;36(2):232-8.
Huang 2004 {published data only}
  • Huang WC, Wann SR, Shoa-Lin L, Kunin CM, Kung MH, Lin CH, et al. Catheter-associated urinary tract infections in intensive care can be reduced by prompting physicians to remove unnecessary catheters. Infection Control Hospital Epidemiology 2004;25:975-8.
Hwang 2005 {published data only}
  • Hwang JH, Choi CW, Chang YS, Choe YH, Park WS, Shin SM, et al. The efficacy of clinical strategies to reduce nosocomial sepsis in extremely low birth weight infants. Journal of Korean Medical Science 2005;20:177-81.
Jain 2006 {published data only}
  • Jain M, Miller L, Belt D, King D, Berwick DM. Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Quality on Safety in Health Care 2006;15:235-9.
Jeffreis 2009 {published data only}
  • Jeffries HE, Mason W, Brewer M, Oakes KL, Munoz EI, Gornick W, et al. Prevention of central venous catheter-associated bloodstream infections in paediatric intensive care units: a performance improvement collaborative. Infection Control and Hospital Epidemiology 2009;30(7):645-51.
Jonhson 2009 {published data only}
  • Johnson V, Mangram A, Mitchell C, Lorenzo M, Howard D, Dunn E. Is there a benefit to multidisciplinary rounds in an open trauma intensive care unit regarding ventilator-associated pneumonia. The American Surgeon 2009;75(12):1171-4.
Kalra 2011 {published data only}
  • Kalra S, Nelson Y, Dave P, Wadhwa R. Student assessment of teaching effectiveness of "bundle of changes"- A paired, controlled trial. Journal of Anaesthesiology, Clinical Pharmacology 2011;27(4):506-10.
Karada 2000 {published data only}
  • Karada A, Görgülü S. Devising an intravenous fluid therapy protocol and compliance of nurses with the protocol. Journal of Intravenous Nursing 2000;23(4):232-8.
Kauffmann 2011 {published data only}
  • Kauffmann G, Davis A, Schulwolf E, Press V, Stupay K, Arora V. IBCD: Development and testing of a checklist to improve quality of care for hospitalized general medical patients. Journal of Hospital Medicine 2011;6(4):S117-8.
Kaye 2006 {published data only}
  • Kaye KS, Engemann JJ, Fulmer EM, Clark CC, Noga EM. Favorable impact of an infection control network on nosocomial infection rates in community hospitals. Infection Control and Hospital Epidemiology 2006;27(3):228-32.
Kelleghan 1993 {published data only}
  • Kelleghan SI, Salemi C, Padilla S, McCord M, Mermilliod G, Canola T, et al. An effective continuous quality improvement approach to the prevention of ventilator-associated pneumonia. American Journal of Infection Control 1993;21(6):322-30.
Kellie 2012 {published data only}
  • Kellie SP, Scott MJ, Cavallazzi R, Wiemken TL, Goss L, Parker D, et al. Procedural and educational interventions to reduce ventilator-associated pneumonia (VAP) rate and central line-associated blood stream infections (CLABSI). Chest. 2011; Vol. 140, issue 4:350A. [DOI: 10.1378/chest.1081447]
Khatib 1999 {published data only}
Kidd 2007 {published data only}
  • Kidd KM, Sinkowitz-Cochran RL, Giblin TB, Tokars JI, Cardo DM, Solomon SL. Barriers to and facilitators of implementing an intervention to reduce the incidence of catheter-associated bloodstream infections. Infection Control and Hospital Epidemiology 2007;28(1):103-4.
Kilbride 2003 {published data only}
  • Kilbride HW, Powers R, Wirtschafter DD, Sheehan MB, Charsha DS, LaCorte M. Evaluation and development of potentially better practices to prevent neonatal nosocomial bacteraemia. Pediatrics 2003;111(4 Pt 2):e504–18.
Koff 2011 {published data only}
  • Koff MD, Corwin HL, Beach ML, Surgenor SD, Loftus RW. Reduction in ventilator associated pneumonia in a mixed intensive care unit after initiation of a novel hand hygiene program. Journal of Critical Care 2011;26(5):489-95.
Kulvatunyou 2007 {published data only}
  • Kulvatunyou N, Boonbarwornrattanakul A, Soonthornkit Y, Kocharsanee C, Lertsithichai P. Incidence of ventilator-associated pneumonia (VAP) after the institution of an educational program on VAP prevention. Journal of the Medical Association of Thailand 2007;90(1):89-95.
Lai 2003 {published data only}
  • Lai KK, Baker SP, Fontecchio SA. Impact of a program of intensive surveillance and interventions targeting ventilated patients in the reduction of ventilated patients in the reduction of ventilator-associated pneumonia and its cost-effectiveness. Infection Control and Hospital Epidemiology 2003;24(11):859-63.
Lally 1997 {published data only}
  • Lally R, Farber M, Biorn J. Successful use of a quality improvement team to reduce ventilator-associated pneumonia. Critical Care Nurse 1997;17(6):38-46.
Laux 2006 {published data only}
  • Laux L, Herbert C. Decreasing ventilator-associated pneumonia. Getting on board. Critical Care Nursing Quarterly 2006;29(3):253-8.
Lobo 2005 {published data only}
  • Lobo RD, Levin AS, Gomes LMB, Cursino R, Park M, Figueiredo VB, et al. Impact of an educational program and policy changes on decreasing catheter-associated bloodstream infections in a medial intensive care in Brazil. American Journal of Infection Control 2005;33:85-7.
Lobo 2010 {published data only}
  • Lobo RD, Levin AS, Oliveira MS, Gomes LMB, Gobara S, Park M, et al. Evaluation of interventions to reduce catheter-associated bloodstream infection: Continuous tailored education versus one basic lecture. American Journal of Infection Control 2010;38(6):440-8.
Lolom 2009 {published data only}
  • Lolom I, Deblamgy C, Capelle A, Guerinot W, Bouvet E, Barry B, et al. Effect of a long-term quality improvement program on the risk of infection related to peripheral venous catheters [Impact d'un programme prolonge d'amelioration continur de la qualitye sur le risqué infectieux lie aux catheters veineux peripheriques]. Presse Medicale 2009;38(1):34-42.
Lyerla 2010 {published data only}
  • Lyerla F, LeRouge C, Cooke DA, Turpin D, Wilson L. A nursing clinical decision support system and potential predictors of head-of-bed position for patients receiving mechanical ventilation. American Journal of Critical Care 2010;19:39-47.
Maas 1998 {published data only}
  • Maas A, Flament P, Pardou A, Deplan A, Dramaix M, Struelens MJ. Central venous catheter-related bacteraemia in critically ill neonates: risk factors and impact of a prevention programme. Journal of Hospital Infection 1998;40:211-24.
Marelich 2000 {published data only}
  • Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practioners and nurses. Chest 2000;118(2):459-67.
Marra 2009 {published data only}
  • Marra AR, Cal RG, Silva CV, Caserta RA, Paes AT, Moura DF Jr. Successful prevention of ventilator-associated pneumonia in an intensive care setting. American Journal of Infection Control 2009;37(8):619-25.
Matocha 2011 {published data only}
  • Matocha D. A process improvement approach to the elimination of central line associated bloodstream infections. Proceedings of the Association for Vascular Access Annual Scientific Meeting; 2011 October 3-6; San Jose, California. http://www.avainfo.org/website/download.asp?id=280432 (accessed 1 July 2012).
Mazi 2011 {published data only}
  • Mazi W, Abdullah D, Gasem G, Helali N, Senok A. Reduction of healthcare-associated infections after implementation of bundle programmes in a tertiary care teaching hospital in Saudi Arabia. Clinical Microbiology and Infection. Proceedings of 21st ECCMID/27th ICC Conference. Milan, 2011:S327-8.
Mckee 2008 {published data only}
  • Mckee C, Berkowitz I, Cosgrove SE, Bradley K, Beers C, Peri TM, et al. Redution of catheter-associated bloodstream infections in paediatric patients: experimentation and reality. Pediatric Critical Care Medicine 2008;9(1):40-6.
Mckinley 2003 {published data only}
  • Mckinley LL, Moriarty HJ, Short TH, Johnson CC. Effect of comparative data feedback on intensive care unit infection rates in a Veterans Adminstration Hospital Network System. American Journal of Infection Control 2003;31(7):397-404.
McLean 2006 {published data only}
  • McLean SE, Jesen LA, Schoeder DG, Gibney NRT, Skjoddt NM. Improving adherence to a mechanical ventilation weaning protocol for critically ill adults: outcomes after an implementation program. American Journal of Critical Care 2006;15(3):299-309.
Meier 1998 {published data only}
  • Meier PA, Fredrickson M, Catney M, Nettleman MD. Impact of a dedicated intravenous therapy team on nosocomial bloodstream infection rates. American Journal of Infection Control 1998;26:388-92.
Miller 2010a {published data only}
  • Miller RS, Norris PR, Jenkins JM, Talbot TR, Starmer JM, Hutchison AS. Systems initiatives reduce healthcare-associated infections: a study of 22,928 device days in a single trauma unit. The Journal of Trauma 2010;68(1):23-31.
Miranda 2007 {published data only}
Misset 2004 {published data only}
  • Misset B, Timsit JF, Dumay MF, Garrouste M, Chalfine A, Flouriot I, et al. A continuous quality-improvement program reduces nosocomial infection rates in the ICU. Intensive Care Medicine 2004;30(3):395-400.
Ngo 2005 {published data only}
  • Ngo A, Murphy S. A theory-based intervention to improve nurses' knowledge, self-efficacy, and skills to reduce PICC occlusion. Journal of Infusion Nursing 2005;28(3):173.
Ong 2011 {published data only}
  • Ong A, Dysert K, Herbert C, Laux L, Granato J, Crawford J, et al. Trends in central line-associated bloodstream infections in a trauma-surgical intensive care unit. Archives of Surgery 2011;146(3):302-7.
Orsi 2005 {published data only}
  • Orsi GB, Raponi M, Franchi C, Rocco M, Mancini C, Venditti M. Surveillance and infection control in an intensive care unit. Infection Control and Hospital Epidemiology 2005;26(3):321-5.
Parras 1994 {published data only}
  • Parras F, Ena J, Bouza E, Guerrero MC, Moreno S, Galvez T, et al. Impact of an educational program for the prevention of colonization of intravascular catheter. Infection Control and Hospital Epidemiology 1994;15(4):239-42.
Penne 2002 {published data only}
  • Penne K. Using evidence in central catheter care. Seminars in Oncology Nursing 2002;18(1):66-70.
Peredo 2010 {published data only}
  • Peredo R, Sabatier C, Villagrá A, González J, Hernández C, Pérez F, et al. Reduction in catheter-related bloodstream infections in critically ill patients through a multiple system intervention. European Journal of Clinical Microbiology and Infectious Diseases 2010;29(9):1173-7.
Pérez-González 2007 {published data only}
  • Pérez-González LF, Ruiz-González JM, Noyola DE. Nosocomial bacteremia in children: a 15-year experience at a general hospital in Mexico. Infection Control and Hospital Epidemiology 2007;28(4):418-22.
Pethyoung 2005 {published data only}
  • Pethoung W, Picheansathian W, Boonchuang P, Apisarnthanarak A, Danchaivijitr S. Effectiveness of education and quality control work group focusing on nursing practices for prevention of ventilator-associated pneumonia. Journal of the Medical Association of Thailand 2005;88(Suppl 10):S110-114.
Pronovost 2008 {published data only}
  • Pronovost P. Intervention to decrease catheter-related bloodstream infections in the ICU: the Keystone Intensive Care Unit Project. American Journal of Infection Control 2008;36(10):S171.e1-5.
Pronovost 2010 {published data only}
  • Pronovost PJ, Goeschel CA, Colantuoni E, Watson S, Lubomski LH, Berenholtz SM, et al. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ 2010;c:309:1-6.
  • Provonost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine 2006;355(26):2725-32.
Puntis 1990 {published data only}
  • Putins JWL, Holden CE, Smallman S, Finkel Y, George RH, Booth IW. Staff training: a key factor in reducing intravascular catheter sepsis. Archives of Disease in Childhood 1990;65(3):335-7.
Reilly 2006 {published data only}
  • Reilly L, Sullivan P, Ninni S, Fochesto D, Williams K, Fetherman B. Reducing foley catheter device days in an intensive care unit. AACN Advance Critical Care 2006;17(3):272-83.
Rello 2011 {published data only}
  • Rello J, Chastre J, Cornaglia G, Masterton R. A European care bundle for management of ventilator-associated pneumonia. Journal of Critical Care 2011;26(1):3-10.
Rosenthal 2003 {published data only}
  • Rosenthal VD, Guzman S, Pezzotto S, Christopher JC. Effect of an infection control program using education and performance feedback on rates of intravascular device-associated bloodstream infections in intensive care units in Argentina. American Journal of Infection Control 2003;31:405-9.
Rosenthal 2004 {published data only}
  • Rosenthal DV, Guzman S, Safdar N. Effect of education and performance feedback on rates of catheter-associated urinary tract infection in intensive care units in Argentina. Infection Control and Hospital Epidemiology 2004;25:47-50.
Rosenthal 2006a {published data only}
  • Rosenthal DV, Guzman, Crnich C. Impact of an infection control program on rates of ventilator-associated pneumonia in intensive care units in 2 Argentinean hospitals. American Journal of Infection Control 2006;34:58-63.
Rosenthal 2008 {published data only}
  • Rosenthal VD. Device-associated nosocomial infections in limited-resources countries: findings of the International Nosocomial Infection Control Consortium (INICC). American Journal of Infection Control 2008;36(10):S171.e7-S171.e12.
Saint 2005 {published data only}
  • Saint S, Kaufman SR, Thompson M, Rogers MAM, Chenoweth CE. A reminder reduces urinary catheterization in hospitalised patients. Journal on Quality and Patient Safety 2005;31(8):455-62.
Sansivero 2011 {published data only}
  • Sansivero G, Galloway M. Registered professional nurses placing central vascular access catheters via the internal jugular vein at the bedside: One year evaluation of a pilot program. Journal of Vascular Access 2011;12(1):84-5.
Santana 2008 {published data only}
  • Santana SL, Furtado GHC, Wey SB, Medeiros EAS. Impact of an education program on the incidence of central line-associated bloodstream infection in 2 medical-surgical intensive care units in Brazil. Infection Control and Hospital Epidemiology 2008;29(12):1171-3.
Scales 2009 {published data only}
  • Scales DC, Dainty K, Hales B, Pinto R, Fowler RA, Adhikari NKJ. An innovative telemedicine knowledge translation program to improve quality of care in intensive care units: protocol for a cluster randomised pragmatic trial. Implementation Science 2009;4(5):1-9. [DOI: 10.1186/1748-5908-4-5]
Scales 2011a {published data only}
  • Scales K. Reducing infection associated with central venous access devices. Nursing Standard 2011;25(36):49-56.
Seguin 2010 {published data only}
  • Seguin P, Laviolle B, Isslame S, Coué A, Mallédant Y. Effectiveness of simple daily sensitization of physicians to the duration of central venous and urinary tract catheterization. Intensive Care Medicine 2010;36(7):1202-6.
Seto 1991 {published data only}
Shapey 2009 {published data only}
  • Shapey IM, Foster MA, Whitehouse T, Jumaa P, Bion JF. Central venous catheter-related bloodstream infections: improving post-insertion catheter care. Hospital Infection Control 2009;71(2):117-22.
Sherertz 2000 {published data only}
  • Sherertz RJ, Ely EW, Westbrook DM, Gledhill KS, Streed SA, Kiger B, et al. Education of physicians-in-training can decrease the risk for vascular catheter infection. Annals of Internal Medicine 2000;132:641-8.
Smith 2011 {published data only}
  • Smith L, Elamin E. Implementation of evidence-based guidelines in reducing catheter related bloodstream infections. Chest. Proceedings of the CHEST Conference. Honolulu, 2011.
Soifer 1998 {published data only}
Sutton 2005 {published data only}
  • Sutton CD, Garcea G, Pollard C, Berry DP, Dennison AR. The introduction of a nutrition clinical nurse specialist results in a reduction in the rate of catheter sepsis. Clinical Nutrition 2005;24:220-3.
Sydnor 2011 {published data only}
  • Sydnor ERM, Perl TM. Hospital epidemiology and infection control in acute-care settings. Clinical Microbiology Reviews 2011; Vol. 24, issue 1:141-73.
Timsit 2011 {published data only}
  • Timsit J-F, Minet C, Lugosi M, Calvino-Gunther S, Ara-Somohano C, Bonadona A, et al. Prevention of catheter-related infections in ICU. Journal des Anti-Infectieux 2011;13(3):161-9.
Tolentino DelosReyes 2007 {published data only}
  • Tolentino Delos Reyes AF, Ruppert SD, Shiao SY. Evidence-based practice: use of the ventilator bundle to prevent ventilator-associated pneumonia. American Journal of Critical Care 2007;16(1):20-27.
Topal 2005 {published data only}
  • Topal J, Conklin S, Camp K, Morris V, Balcezak T, Hebert P. Prevention of nosocomial catheter-associated urinary tract infections through computerized feedback to physicians and a nurse-directed protocol. American Journal of Medical Quality 2005;20(3):121-6.
Troeng 2011 {published data only}
  • Troeng M. Evaluation of an educational programme in management and care of central venous access devices. Journal of Vascular Access 2011;12(1):90.
Tsuchida 2007 {published data only}
  • Tsuchida T, Makimot K, Toki M, Sakai K, Onaka E, Otono Y. The effectiveness of a nurse-initiated intervention to reduce catheter-associated bloodstream infections in an urban acute hospital: An intervention study with before and after comparison. International Journal of Nursing Studies 2007;44:1324-33.
Urrea Ayala 2009 {published data only}
  • Ayala MU, Quesada LR. Catheter-associated blood stream infections: Implementation of a new consensus protocol [La bacteriemia asociada al cateter venoso central: implementación de un nuevo protocolo de consenso]. Anales de Pediatria 2009;71(1):20-4.
Verdier 2006 {published data only}
  • Verdier R, Parer S, Jean-Pierre H, Dujols P, Picot MC. Impact of an infection control program in an intensive care unit in France. Infection Control and Hospital Epidemiology 2006;27(1):60-6.
Wall 2005 {published data only}
  • Wall Rj, Ely EW, Elasy TA, Dittus RS, Foss J, Wilkerson KS, et al. Using real time process measurements to reduce catheter related bloodstream infections in the intensive care unit. Quality and Safety in Health care 2005;14:295-302.
Warren 2003 {published data only}
  • Warren DK, Zack JE, Cox MJ, Cohen MM, Fraser VJ. An educational intervention to prevent catheter-associated bloodstream infections in a non teaching, community medical center. Critcal Care Medicine 2003;31(7):1959-63.
Warren 2006 {published data only}
  • Warren DK, Cosgrove SE, Diekema DJ, Zuccotti G, Climo MW, Bolon MK, et al. A multicenter intervention to prevent catheter-associated bloodstream infections. Infection Control and Hospital Epidemiology 2006;27:662-9.
Weireter 2009 {published data only}
  • Weireter LJ, Collins JN, Britt RC, Reed SF, Novosel TJ, Britt LD. Impact of a monitored program of care on incidence of ventilator-associated pneumonia: results of a long term performance-improvement project. Journal of American College of Surgeons 2009;208:700-5.
Westwell 2008 {published data only}
Williams 2008 {published data only}
  • Williams Z, Rodney C, Kelly E. A single device to increase rate of compliance in maintaining 30-degree head-of-bed elevation in ventilated patients. Critical Care Medicine 2008;36(4):115-7.
Wirtschafter 2010 {published data only}
  • Wirtschafter DD, Pettit J, Kurtin P, Dalsey M, Chance K, Morrow HW. A statewide quality improvement collaborative to reduce neonatal central line-associated blood stream infections. Journal of Perinatology 2010;30:170-81.
Worrall 2010 {published data only}
  • Worrall CL, Anger PB, Simpson KN, Leon SM. Impact of a hospital-acquired/ventilator-associated/healthcare-associated pneumonia practice guideline on outcomes in surgical trauma patients. Journal of Trauma 2010;68:382-6.
Xiao 2007 {published data only}
  • Xiao Y, Seagull J, Bochicchio GV, Guzzo JL, Dutton RP, Sisley A, et al. Video-based training increases sterile-technique compliance during central venous catheter insertion. Critical Care Medicine 2007;35:1302-6.
Yoo 2001 {published data only}
  • Yoo S, Ha M, Choi D, Hynjoo P. Effectiveness of surveillance of central catheter-related bloodstream infection in an ICU in Korea. Infection Control and Hospital Epidemiology 2001;22(7):433-6.
Youngquist 2007 {published data only}
  • Youngquist P, Carroll M, Farber M, Macy D, Madrid P, Ronning J, et al. Implementing a ventilator bundle in a community hospital. Journal of Quality and Patient Safety 2007;33(4):219-25.
Zaydfudin 2009 {published data only}
  • Zaydfundim V, Dosset LA, Starmer JM, Arbogast PG, Feurer ID, Ray AW. Implementation of a real-time compliance dashboard to help reduce SICU ventilator-Associated pneumonia with the ventilator bundle. Archives of Surgery 2009;144:656-62.
Zingg 2009 {published data only}
  • Zingg W, Imhof A, Maggiorini M, Stocker R, Keller E, Ruef C. Impact of a prevention strategy targeting hand hygiene and catheter care on the incidence of catheter-related bloodstream infections. Critical Care Medicine 2009;37(7):2167-73.
Zuschneid 2003 {published data only}
  • Zuschneid I, Schwab F, Geffers C, Ruden H, Gastmeier P. Reducing central venous catheter-associated primary bloodstream infections in intensive care units is possible: data from the German nosocomial infection surveillance system. Infection Control and Hospital Epidemiology 2003;24:501-5.

References to studies awaiting assessment

  1. Top of page
  2. AbstractRésumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. Additional references
Chen 2011 {published data only}
  • Chen YZ, Yan CY. Hematology-oncology port-A: improving nursing care quality. Hu Li Tsa Chih - Journal of Nursing 2011;58(3 Suppl):64-72.
Danchaivijitr 1992 {published data only}
  • Danchaivijitr S, Chokloikaew S, Tangtrakool T, Waitayapiches S. Does indication sheet reduce unnecessary urethral catheterization?. Journal of the Medical Association of Thailand 1992;75(Suppl 2):1-5.
Eid 2011 {published data only}
  • Eid R, Domingues F, Barretto JKS, Marra AR, Silva CV, Paes AT, et al. Successful prevention of tracheostomy associated pneumonia in step-down units. American Journal of Infection Control 2011;39(6):500-5.
Kaplan 2011 {published data only}
  • Kaplan HC, Lannon C, Walsh MC, Donovan EF, Ohio Perinatal Quality Collaborative. Ohio statewide quality-improvement collaborative to reduce late-onset sepsis in preterm infants. Pediatrics 2011;127(3):427-35.
Khouli 2011 {published data only}
  • Khouli H, Jahnes K, Shapiro J, Rose K, Mathew J, Gohil A, et al. Performance of medical residents in sterile techniques during central vein catheterization randomized trial of efficacy of simulation-based training. Chest 2011;139(1):80-7.
Latif 2012 {published data only}
  • Latif RK, Bautista AF, Memon SB, Smith EA, Wang C, Wadhwa A, et al. Teaching aseptic technique for central venous access under ultrasound guidance: a randomized trial comparing didactic training alone to didactic plus simulation-based training. Anesthesia and Analgesia 2012;114(3):626-33.
Longmate 2011 {published data only}
  • Longmate AG, Ellis KS, Boyle L, Maher S, Cairns CJ, Lloyd SM, et al. Elimination of central-venous-catheter-related bloodstream infections from the intensive care unit. BMJ Quality and Safety 2011;20(2):174-80.
Lopez 2011 {published data only}
  • Lopez AC. A quality improvement program combining maximal barrier precaution compliance monitoring and daily chlorhexidine gluconate baths resulting in decreased central line bloodstream infections. Dimensions of Critical Care Nursing 2011;30(5):293-8.
Marra 2011 {published data only}
  • Marra AR, Camargo TZS, Goncalves P, Sogayar AMCB, Moura Jr DF, Guastelli LR, et al. Preventing catheter-associated urinary tract infection in the zero-tolerance era. American Journal of Infection Control 2011;39:500-5.
Miller 2011 {published data only}
  • Miller MR, Niedner MF, Huskins WC, Colantuoni E, Yenokyan G, Moss M, et al. Reducing PICU central line-associated bloodstream infections: 3-year results. Pediatrics 2011;128(5):e1077-83.
Morris 2011 {published data only}
  • Morris AC, Hay AW, Swann DG, Everingham K, McCulloch C, McNulty J, et al. Reducing ventilator-associated pneumonia in intensive care: impact of implementing a care bundle. Critical Care Medicine 2011;39(10):2218-24.
Munhoz 2012 {published data only}
  • Munoz-Price LS, Dezfulian C, Wyckoff M, Lenchus JD, Rosalsky M, Birnbach DJ, et al. Effectiveness of stepwise interventions targeted to decrease central catheter-associated bloodstream infections. Critical Care Medicine 2012;40(5):1464-9.
Papadimos 2008 {published data only}
  • Papadimos TJ, Hensley SJ, Duggan JM, Khuder SA, Borst MJ, Fath JJ, et al. Implementation of the "FASTHUG" concept decreases the incidence of ventilator-associated pneumonia in a surgical intensive care unit. Patient Safety in Surgery 2008; Vol. 2, issue 3. [DOI: 10.1186/1754-9493-2-3]
Resende 2011 {published data only}
  • Resende DS, Ó JM, Brito DV, Abdallah VO, Gontijo Filho PP. Reduction of catheter-associated bloodstream infections through procedures in newborn babies admitted in a university hospital intensive care unit in Brazil. Revista da Sociedade Brasileira de Medicina Tropical 2011; Vol. 44, issue 6:731-4.
Scales 2011 {published data only}
  • Scales DC, Dainty K, Hales B, Pinto R, Fowler RA, Adhikari NK, et al. A multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial. JAMA 2011;305(4):363-72.
Speroff 2011 {published data only}
Tong 2011 {published data only}
  • Tong L, Zhong Y, Feng B-L, Yu Z-Y. Preventing peripheral central venous catheter-related bloodstream infections through process management. Chinese Journal of Clinical Nutrition 2011;19(1):56-8.

Additional references

  1. Top of page
  2. AbstractRésumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. Additional references
Aboelela 2007
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Allegranzi 2011
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Alp 2006
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Baker 2010
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Bernard 2012
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Conterno 2011
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Giguere 2012
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Gravel 2007
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Grimshaw 2006
Grimshaw 2012
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Horan 2008
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Ivers 2012
Klevens 2007
  • Klevens RM, Edwards JR, Richards CL Jr, Horan TC, Gaynes RP, Pollock DA, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Reports 2007;122(2):160-6.
Knaus 1985
Mermel 2000
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  • Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science 2011;6(42):1-11.
Muscedere 2008
  • Muscedere J, Dodek P, Keenan S, Fowler R, Cook D, Heyland D. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: prevention. Journal of Critical Care 2008;23(1):126-37.
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