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

  • Review
  • Intervention

Authors


Abstract

Background

Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. There are specific risk profiles for each device, but in general, the breakdown of aseptic technique during insertion and care for the device, as well as the duration of device use, are important factors for the development of these serious and costly infections.

Objectives

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.

Search methods

We searched the following electronic databases for primary studies up to June 2012: the Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. We searched reference lists and contacted authors of included studies. We also searched the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews.

Selection criteria

We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies that complied with the Cochrane EPOC Group methodological criteria, and that evaluated interventions to improve professional adherence to guidelines for the prevention of device-related infections.

Data collection and analysis

Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane EPOC 'Risk of bias' tool. We contacted authors of original papers to obtain missing information.

Main results

We included 13 studies: one cluster randomised controlled trial (CRCT) and 12 ITS studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards, and more than 3504 patients and 1406 healthcare professionals. Six of the included studies targeted adherence to guidelines to prevent central line-associated blood stream infections (CLABSIs); another six studies targeted adherence to guidelines to prevent ventilator-associated pneumonia (VAP), and one study focused on interventions to improve urinary catheter practices. We judged all included studies to be at moderate or high risk of bias.

The largest median effect on rates of VAP was found at nine months follow-up with a decrease of 7.36 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). The one included cluster randomised controlled trial (CRCT) observed, improved urinary catheter practices five weeks after the intervention (absolute difference 12.2 percentage points), however, the statistical significance of this is unknown given a unit of analysis error. It is worth noting that N = 6 interventions that did result in significantly decreased infection rates involved more than one active intervention, which in some cases, was repeatedly administered over time, and further, that one intervention involving specialised oral care personnel showed the largest step change (-22.9 cases per 1000 ventilator days (standard error (SE) 4.0), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002)) among the included studies. 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 and VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among included studies (I2 up to 97%), we did not retain these analyses. Six of the included studies reported post-intervention adherence scores ranging from 14% to 98%. The effect on rates of infection were mixed and the effect sizes were small, with the largest median effect for the change in level (interquartile range (IQR)) for the six CLABSI studies being observed at three months follow-up was 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.

Authors' conclusions

The low to very low quality of the evidence of studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions involving more than one active element and that are repeatedly administered over time, and interventions employing specialised personnel, who are focused on an aspect of care that is supported by evidence e.g. dentists/dental auxiliaries performing oral care for VAP prevention.

Résumé scientifique

Interventions visant à améliorer le respect professionnel des directives en matière de prévention des infections liées aux dispositifs médicaux

Contexte

Les infections liées aux soins de santé (ILSS) constituent une menace majeure pour la sécurité des patients et sont associées à des taux de mortalité allant de 5 % à 35 %. Les facteurs de risque importants associés aux ILSS sont l'utilisation de dispositifs médicaux invasifs (par exemple cathéters centraux, cathéters urinaires et dispositifs de ventilation mécanique), et le manque de respect de la part du personnel des pratiques en matière de prévention lors de l'insertion des dispositifs et lors de leur entretien une fois en place. Chaque dispositif présente un profil de risque spécifique, mais en général, le non-respect de la technique aseptique lors de l'insertion et de l'entretien du dispositif et le non-respect de la durée d'utilisation du dispositif sont des facteurs importants de développement de ces infections graves et coûteuses.

Objectifs

Évaluer l'efficacité des différentes interventions, seules ou en combinaison, qui ciblent les professionnels de santé ou les organismes de soins de santé dans le but d'améliorer le respect professionnel des directives en matière de contrôle des infections sur le taux d'infections liées aux dispositifs médicaux et les mesures du respect.

Stratégie de recherche documentaire

Nous avons effectué une recherche dans les bases de données électroniques suivantes pour les études originales jusqu'à juin 2012 : le registre spécialisé du groupe Cochrane sur l'efficacité des pratiques et l'organisation des soins (EPOC), le registre Cochrane des essais contrôlés - Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE et CINAHL. Nous avons effectué une recherche dans les listes de références et contacté les auteurs des études incluses. Nous avons également effectué des recherches dans la base de données Cochrane Database of Systematic Reviews et la base de données DARE (Database of Abstracts of Reviews of Effectiveness) pour trouver des revues connexes.

Critères de sélection

Nous avons inclus des essais contrôlés randomisés (ECR), des essais contrôlés non randomisés (ECNR), des études contrôlées avant-après (CAA) et des études de séries temporelles interrompues (STI) qui remplissaient les critères méthodologiques du groupe Cochrane EPOC, et qui évaluaient les interventions visant à améliorer le respect professionnel des directives en matière de prévention des infections liées aux dispositifs médicaux.

Recueil et analyse des données

Deux auteurs de la revue ont indépendamment extrait les données et évalué le risque de biais de chaque étude incluse en utilisant l'outil « Risque de biais » du groupe Cochrane EPOC. Nous avons contacté les auteurs des articles originaux afin d’obtenir les informations manquantes.

Résultats principaux

Nous avons inclus 13 études : un essai contrôlé randomisé en grappes (ECRG) et 12 études STI, portant sur 40 hôpitaux, 51 unités de soins intensifs (USI), 27 salles de soins et plus de 3 504 patients et 1 406 professionnels de santé. Six des études incluses portaient sur le respect des directives visant à prévenir les infections de la circulation sanguine associées à un cathéter central (ICSACC) ; six autres études portaient sur le respect des directives visant à prévenir la pneumonie sous ventilation assistée (PVA), et une étude était axée sur les interventions visant à améliorer les pratiques en matière de cathéters urinaires. Nous avons jugé que toutes les études incluses présentaient un risque de biais modéré ou élevé.

L'effet médian le plus important sur les taux de PVA a été observé après neuf mois de suivi avec une diminution de 7,36 (-10,82 à 3,14) cas pour 1 000 jours sous ventilation (cinq études et 15 sites). L'unique essai contrôlé randomisé en grappes (ECRG) inclus a observé une amélioration des pratiques en matière de cathéters urinaires cinq semaines après l'intervention (différence absolue 12,2 points de pourcentage). Cependant, la signification statistique de ces données est inconnue en raison d'une erreur dans l’unité d’analyse. Il convient de noter que N = 6 interventions qui donnaient des taux d'infection significativement réduits portaient sur plus d'une intervention active, qui dans certains cas, était administrée régulièrement, et par ailleurs, qu'une intervention portant sur du personnel spécialisé dans les soins bucco-dentaires a montré le changement progressif le plus important (-22,9 cas pour 1 000 jours sous ventilation (erreur standard (SE) 4,0), et également le changement brutal le plus important (-6,45 cas pour 1 000 jours sous ventilation (SE 1,42, P = 0,002)) parmi les études incluses. Nous avons essayé de combiner les résultats des études portant sur le même dispositif médical à demeure (cathéters centraux ou dispositifs de ventilation mécanique) et présentant les mêmes résultats (taux d'ICSACC et de PVA) dans deux méta-analyses distinctes, mais en raison de l'hétérogénéité statistique très élevée parmi les études incluses (I2 jusqu'à 97 %), nous n'avons pas retenu ces analyses. Six des études incluses indiquaient des scores de respect post-intervention compris entre 14 % et 98 %. L'effet sur les taux d'infection était mitigé et les effets étaient d'une ampleur réduite, l'effet médian le plus important pour le changement de niveau (intervalle interquartile (IQR)) dans les six études sur les ICSACC étant observé après trois mois de suivi était une réduction de 0,6 (-2,74 à 0,28) cas pour 1 000 jours sous cathétérisation (six études et 36 sites). Ce changement ne persistait pas sur des périodes de suivi plus longues.

Conclusions des auteurs

La qualité faible à très faible des données des études incluses dans cette revue ne fournit pas suffisamment de preuves pour déterminer avec certitude quelles sont les interventions les plus efficaces pour modifier le comportement professionnel, et dans quels contextes. Cependant, les interventions qui peuvent justifier des recherches supplémentaires sont les interventions éducatives comportant plus d'un élément actif et qui sont administrées régulièrement, et les interventions employant un personnel spécialisé, qui sont axées sur un certain aspect des soins qui est corroboré par les faits, par exemple dentistes/auxiliaires dentaires dispensant des soins bucco-dentaires.

摘要

改善對於規範的專業遵從性之干預措施,預防器械相關感染

背景

醫療照護相關感染(HAIs)對患者的健康是一個重大的威脅,且與死亡率的相關性有5%至35%的變化。與HAIs相關的重要風險因子有使用侵入性的醫療器材(例如:中心導管、導尿管與呼吸器)、工作人員在插入期間對預防感染的清洗消毒標準流程之低遵從性,以及對於器材置入後的照護。每個器材都有特定的風險取向,但一般來說,無菌技術在插入的過程、對器材的照護及在器材使用期間的失效,是造成這些嚴重而且代價慘重的感染的重要原因。

目的

評估為了改善對器材相關感染率的感染控制規範與遵從性評量之專業遵從性,針對醫療照護專業人士或醫療照護機構的不同干預措施之單獨或集結的效力。

搜尋策略

截至2012年6月,我們為主要的研究搜尋了下列電子資料庫:Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register、Cochrane Central Register of Controlled Trials (CENTRAL)、MEDLINE、EMBASE以及CINAHL等。我們搜尋了參考文獻清單並連絡收錄研究的作者們;也為相關的文獻搜尋了Cochrane Database of Systematic Reviews與Database of Abstracts of Reviews of Effectiveness (DARE)。

選擇標準

我們收錄了遵守Cochrane EPOC Group研究方法標準並評估改善預防器材相關感染規範專業遵從性的干預措施之隨機對照試驗(RCTs)、非隨機對照試驗(NRCTs)、前後對照(CBA)研究與中斷性時間序列(ITS)研究。

資料收集與分析

兩位研究作者獨立地摘錄資料並評估毎一份使用Cochrane EPOC偏誤風險工具的收錄研究之偏誤風險。我們連絡了原始論文的作者們以取得缺失的資訊。

主要結果

我們收錄了13份研究:1篇叢集隨機對照試驗(CRCT)與12篇ITS研究,包含40間醫院、51間加護病房(ICUs)、27間病房、超過3,504位受試者以及1,406位醫療照護專業人士。收錄的研究中有6份以對於預防中心導管相關血流感染(CLABSIs)規範的遵從性為目標;另外6份研究以對於預防呼吸器相關肺炎(VAP)規範的遵從性為目標,並且有1份研究著重在改善導尿管的清洗消毒標準流程。我們判定所有收錄研究的偏誤風險皆為中等或高。

VAP發生率最大的中位數效應在追蹤9個月時發現,每千使用呼吸器日中 (5份研究及15個地點),有7.36個案例減少(-10.82至3.14)。觀察的1個叢集隨機對照試驗(CRCT),在進行干預5週後,導尿管的清洗消毒標準流程改善(絕對差為12.2個百分點);然而,由於1個單位的分析錯誤,其統計顯著性為未知。值得注意的是,在收錄的研究中, N=6的干預方式,包含超過1種現行的干預(在某些案例中是隨著時間重複地執行),的確導致感染率顯著地降低,而且這一種包括專門口腔照護人員的干預措施顯示大幅的階段變化(每千使用呼吸器日中,有22.9個案例減少(標準誤差(SE)為4.0),斜率也有大幅的變化(每千使用呼吸器日中,有6.45個案例減少(SE 1.42, P = 0.002))。我們試圖將針對一樣的留置醫療器械(中心導管或呼吸器)與記錄相同結果(CLABSI與VAP發生率)的研究結論,結合於兩份不同的統合分析中,但由於收錄研究有相當高的統計異質性(I2高達97%),我們沒有保留這些分析。收錄的研究中有6份記錄在干預介入後,遵從性分數範圍由14%至98%。對感染率的影響混雜且影響程度小,6份CLABSI研究變化程度(四分位距(IQR))的最大中位數效應,在追蹤觀察3個月時發現,每千使用中心導管日中,有0.6個(-2.74至0.28)案例減少(6份研究及36個地點)。長期的追蹤則不支持此變化。

作者結論

本文獻收錄研究的低至非常低品質證據,無法提供充分的佐證來肯定地判定哪一種干預措施對於改變專業行為以及在哪種狀況下是最有效的。然而,可能值得更進一步研究的干預措施為超過1種現行且隨時間重複執行的教育性干預,以及由著重於一種受證據支持的照護之專業人士(例如:對預防VAP進行口腔照護的牙醫/牙科輔助人員)執行的干預。

譯註

翻譯者:臺北醫學大學考科藍臺灣研究中心(Cochrane Taiwan)

本翻譯計畫由臺北醫學大學考科藍臺灣研究中心(Cochrane Taiwan)、台灣實證醫學學會及東亞考科藍聯盟(EACA)統籌執行
聯絡E-mail:cochranetaiwan@tmu.edu.tw

Plain language summary

Can interventions to improve professional adherence to guidelines prevent device-related infections?

Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators) that breach the body's normal defence mechanisms, and poor staff adherence to infection prevention practices during insertion and care for the devices when in place.

We identified 13 studies: one cluster randomised controlled trial (CRCT) and 12 interrupted time series (ITS) studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards and more than 1406 healthcare professionals and 3504 patients, which assessed the impact of different interventions to reduce the occurrence of device-related infections for inclusion in this review. We judged all studies to be at moderate to high risk of bias.

The effect sizes were small with the largest median effect for studies addressing central line associated blood stream infections (CLABSIs) occurring immediately after the implementation of an intervention to improve adherence to guidelines, in the majority of studies this change was not sustained over longer follow-up times. The median effect for studies aiming to reduce ventilator-associated pneumonia (VAP) was somewhat greater and was sustained up to 12 months follow-up. The results of six studies that reported adherence/non-adherence with infection control recommendations showed very varying adherence scores ranging from 14% to 98%.

The low to very low quality of the evidence of the studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions consisting of more than one active element and that are repeatedly administered over time, and interventions employing dedicated personnel, who are focused on a certain aspect of care that is supported by evidence e.g. dentists/dental auxiliaries providing oral care. If healthcare organisations and policy makers wish to improve professional adherence to guidelines for the prevention of device-related infections, funding of well designed studies to generate high quality evidence is needed to guide policy.

Résumé simplifié

Les interventions visant à améliorer le respect professionnel des directives peuvent-elles prévenir les infections liées aux dispositifs médicaux ?

Les infections liées aux soins de santé (ILSS) constituent une menace majeure pour la sécurité des patients, et sont associées à des taux de mortalité allant de 5 % à 35 %. Les facteurs de risque importants associés aux ILSS sont l'utilisation de dispositifs médicaux invasifs (par exemple cathéters centraux, cathéters urinaires et dispositifs de ventilation mécanique) qui perturbent les mécanismes de défense normaux de l'organisme, et le manque de respect de la part du personnel des pratiques en matière de prévention des infections lors de l'insertion des dispositifs et lors de leur entretien une fois en place.

Nous avons identifié 13 études : un essai contrôlé randomisé en grappes (ECRG) et 12 études de séries temporelles interrompues (STI), portant sur 40 hôpitaux, 51 unités de soins intensifs (USI), 27 salles de soins et plus de 1 406 professionnels de santé et 3 504 patients, qui évaluaient l'impact des différentes interventions destinées à réduire l'occurrence des infections liées aux dispositifs médicaux pouvant être inclus dans cette revue. Nous avons jugé que toutes les études présentaient un risque de biais modéré à élevé.

L'ampleur des effets était réduite, l'effet médian le plus important pour les études sur les infections de la circulation sanguine associées à un cathéter central (ICSACC) se produisant immédiatement après la mise en œuvre d'une intervention visant à améliorer le respect des directives. Dans la majorité des études, ce changement ne perdurait pas sur des périodes de suivi plus longues. L'effet médian pour les études visant à réduire la pneumonie sous ventilation assistée (PVA) était légèrement plus important et perdurait jusqu'à 12 mois de suivi. Les résultats de six études qui présentaient le respect/non-respect des recommandations en matière de contrôle des infections indiquaient des scores de respect très variables allant de 14 % à 98 %.

La qualité faible à très faible des données des études incluses dans cette revue ne fournit pas suffisamment de preuves pour déterminer avec certitude quelles sont les interventions les plus efficaces pour modifier le comportement professionnel, et dans quels contextes. Cependant, les interventions qui peuvent justifier des recherches supplémentaires sont les interventions éducatives comportant plus d'un élément actif et qui sont administrées régulièrement, et les interventions employant un personnel spécialisé, qui sont axées sur un certain aspect des soins qui est corroboré par les faits, par exemple dentistes/auxiliaires dentaires dispensant des soins bucco-dentaires. Si les organismes de soins de santé et les décideurs politiques souhaitent améliorer le respect professionnel des directives en matière de prévention des infections liées aux dispositifs médicaux, un financement d'études bien conçues pour produire des preuves de grande qualité est nécessaire afin d'orienter la politique.

Notes de traduction

Traduit par: French Cochrane Centre 5th April, 2013
Traduction financée par: Instituts de Recherche en Sant� du Canada, Minist�re de la Sant� et des Services Sociaux du Qu�bec, Fonds de recherche du Qu�bec-Sant� et Institut National d'Excellence en Sant� et en Services Sociaux pour la France: Minist�re en charge de la Sant�

淺顯易懂的口語結論

改善對於規範的專業遵從性干預措施,能夠預防器械相關感染嗎?

醫療照護相關感染(HAIs)對患者的健康是一個重大的威脅,且與死亡率的相關性有5%至35%的變化。 與HAIs相關的重要風險因子有使用破壞身體正常防禦機制的侵入性醫療器材(例如:中心導管、導尿管與呼吸器)、工作人員在插入期間對預防感染的清洗消毒標準流程之低遵從性以及對於器材置入後的照護。

我們收錄了13份研究,有1篇叢集隨機對照試驗(CRCT)與12篇ITS研究,包含40間醫院、51間加護病房(ICUs)、27間病房、超過1,406位醫療照護專業人士與3,504位受試者,評估不同干預措施對降低器械相關感染的影響,以做為本文獻的納入資料。我們判定所有收錄研究的偏誤風險皆為中等或高。

處理與中心導管相關血流感染(CLABSIs)的研究之影響範圍小,而且最大中位數效應在執行對於規範遵從性改善的干預後立刻出現,在大部分的研究中,長期的追蹤則不支持此變化。目標在減少呼吸器相關肺炎(VAP)的研究中,中位數效應稍微大一點且被長達12個月的後續追蹤支持。6份記錄了感染控制建議的遵從性/非遵從性之研究顯示,遵從性分數範圍由14%至98%。

本文獻收錄研究的低至非常低品質證據,無法提供充分的佐證來肯定地判定哪一種干預措施對於改變專業行為以及在哪種狀況下是最有效的。然而,可能值得更進一步研究的干預措施包括超過1種現行且隨時間重複執行的教育性干預,與由著重於一種受證據支持的照護之專業人士(例如:進行口腔照護的牙醫/牙科輔助人員)執行的干預。如果醫療照護機構與政策制定者希望改善對於預防器械相關感染規範的專業遵從性,提供資金給設計良好的研究以產出高品質證據,對於政策的引導是必要的。

譯註

翻譯者:臺北醫學大學考科藍臺灣研究中心(Cochrane Taiwan)

本翻譯計畫由臺北醫學大學考科藍臺灣研究中心(Cochrane Taiwan)、台灣實證醫學學會及東亞考科藍聯盟(EACA)統籌執行
聯絡E-mail:cochranetaiwan@tmu.edu.tw

Laički sažetak

Poboljšanje profesionalnog pridržavanja smjernicama za sprječavanje infekcija povezanih s uređajima

Infekcije povezane sa zdravstvenom skrbi velika su prijetnja sigurnosti pacijenta, a povezane su sa stopom smrtnosti koje variraju od 5% do 35%. Važni čimbenici rizika povezani s tim infekcijama su uporaba invazivnih medicinskih uređaja (npr korištenje cjevčica spojenih na krvotok, mokraćni kateteri i mehanički ventilatori) koje utječu na normalne obrambene mehanizme tijela, kao i loše pridržavanje osoblja prakse prevencije infekcije tijekom umetanja i briga za uređaje jednom kad su postavljeni.

U ovom Cochrane sustavnom pregledu pronađeno je 13 studija na ovu temu: jedna klaster randomizirana nasumična studija i 12 studija s isprekidanim vremenskim slijedom (engl. interrupted time series) u kojima je bilo uključeno 40 bolnica, 51 jedinica intenzivnog liječenja (JIL), 27 odjela i više od 1406 zdravstvenih radnika i 3504 pacijenata, koji ocjenjuju utjecaj različitih intervencija za smanjenje pojave infekcija povezanih s uređajima za uključivanje u ovaj pregled. Za sve studije je procijenjeno da imaju umjeren do visok rizik od pristranosti.

Veličine učinka su bile male s najvećim učinkom za studije sa infekcijama povezanim sa centralnim linijama u krvotoku koje su nastale odmah nakon provedbe intervencije za poboljšanje poštivanja smjernica, međutim, u većini studija ta promjena nije bila dalje vidljiva nakon duljeg razdoblja praćenja. Srednji učinak za studije kojima je cilj smanjiti upale pluća povezane s mehaničkom ventilacijom bio je nešto veći te je održan i nakon 12 mjeseci praćenja. Rezultati šest studija koje su prikazale podatke za pridržavanje / nepridržavanje smjernicama s preporukama za kontrolu infekcije pokazuju vrlo različite rezultate pridržavanja smjernicama, u rasponu od 14% do 98%.

Niska do vrlo niska kvaliteta dokaza studija uključenih u ovom pregledu daje dovoljno dokaza da se sa sigurnošću može utvrditi koje su intervencije najučinkovitije u promjeni profesionalnog ponašanja i u kojem kontekstu. Međutim, intervencije koje može biti korisno dalje istraživati su edukativne intervencije koje se sastoje od više od jednog aktivnog elementa i koje se više puta primjenjuju tijekom vremena, i intervencije koje angažiraju posebno osoblje čiji je zadatak usmjerenost na određeni aspekt skrbi koji je potkrijepljen dokazima, npr. stomatolozi / dentalni asistenti koji pružaju oralnu skrb. Ako zdravstvene organizacije i političari žele poboljšati stručno pridržavanje smjernicama za prevenciju infekcija povezanih s uređajima, nužno je odobriti financiranje dobro ustrojenih studija koje će dati visoko kvalitetne dokaze.

Bilješke prijevoda

Hrvatski Cochrane
Prevela: Božena Armanda
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr

Summary of findings(Explanation)

Summary of findings for the main comparison. 
  1. Abbreviations

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

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

Outcomes

Change 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.

Background

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

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

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.

Table 1. Adjusted VAP rates
  1. Abbreviations
    CI: confidence interval
    CLABSI: central line-associated blood stream infection
    NA: not available
    SD: standard deviation
    SE: standard error
    VAP: ventilator-associated pneumonia

Author/
year
Pre-intervention VAP rate (SD)Change in level (SE); P value, 95% CIPre-intervention trend (SE); P valueChange in trend (SE); P valueAuto-correlation
3 months6 months9 months12 months
Abbott 2006 dataset 17.13 (4.98)1.59 (4.49); P = 0.733; -12.2 to 9.030.47 (4.57); P = 0.920; -10.3 to 11.32.55 (5.07); P = 0.631; -9.43 to 14.54.62 (5.87); P = 0.457; -9.27 to 18.5-1.26 (0.81); P = 0.1642.1 (1.4); P = 0.189-0.15
Abbott 2006 dataset 215.60 (5.62)-3.51 (3.44); P = 0.336; -11.4 to 4.4-9.97 (3.02); P = 0.011; -16.9 to -2.99-16.41 (3.2); P = 0.001; -23.89 to -8.94-22.86 (3.99); P < 0.000; -32.06 to -13.661.32 (0.42); P = 0.014; 0.35 to 2.29-6.45 (1.42); P = 0.002; -9.72 to -3.18-0.57
Abbott 2006 dataset 314.78 (4.00)0.017 (5.97); P = 0.998; -13.74 to 13.78-4.72 (5.41); P = 0.408; -17.19 to 7.75-9.46 (5.89); P = 0.147; -23.06 to 4.13-14.21 (7.22); P = 0.085; -30.85 to 2.440.38 (0.76); P = 0.630; -1.37 to 2.13-4.74 (2.43); P = 0.087; -10.36 to 0.88-0.22
Abbott 2006 dataset 425.11 (5.98)3.2 (5.14); P = 0.552; -8.94 to 15.354.07 (4.4); P = 0.386; -6.34 to 14.474.92 (5.66); P = 0.413; -8.47 to 18.31 NA-1.47 (0.62); P = 0.048; -2.93 to -0.020.86 (3.14); P = 0.793; -6.57 to 8.28-0.17
Kaye 200012.14 (6.30)-4.79 (6.22); P = 0.464; -19.13 to 9.56-9.8 (5.49); P = 0.112; -22.46 to 2.86-14.8 (7.13); P = 0.071; -31.26 to 1.62 NA1.38 (0.69); P = 0.083; -0.23 to 2.98-5.02 (3.83); P = 0.226; -13.84 to 3.810.02
Salahuddin 200412.70 (2.24)-8.85 (2.05); P = 0.012; -14.54 to -3.16-9.17 (1.91); P = 0.009; -14.47 to -3.87 -9.49 (2.37); P = 0.016; -16.08 to -2.90 NA0.32 (0.41); P = 0.478; -0.82 to 1.47-0.32 (1.13); P = 0.791; -3.45 to 2.81-0.69
Sona 20095.34 (2.27)3.37 (0.18); P = 0.003; 2.58 to 4.164.88 (0.23);P = 0.002; 3.88 to 5.89;6.39 (0.29); P = 0.002; 5.12 to 7.677.91 (0.36); P = 0.002; 6.34 to 9.48-2.27 (0.07); P = 0.001; -2.58 to -1.951.51 (0.07); P = 0.003; 1.18 to 1.84-1.33
Zack 200212.48 (1.03)-5.33 (0.9); P = 0.004; -7.83 to -2.82-5.30 (1.02);  P = 0.006; -8.12 to -2.47-5.27 (1.22); P = 0.012; -8.65 to -1.89-5.24 (1.47); P = 0.023; -9.32 to -1.16-0.38 (0.26); P = 0.219; -1.10 to 0.340.03 (0.33); P = 0.934; -0.90 to 0.96-0.73
Table 2. Adjusted CLABSI rates
  1. Abbreviations
    CI: confidence interval
    CLABSI: central line-associated blood stream infection
    NA: not available
    SD: standard deviation
    SE: standard error

Author/yearCLABSI rate pre-intervention level (SD)Change in level (SE); P value, 95% CIPre-intervention trend (SE); P valueChange in trend (SE); P value

Auto-

correlation

3 months6 months9 months12 months18 months21 months
Beathard 20036.18 (1.40)-3.24 (0.56); P = 0.001; -4.56 to -1.93-2.6 (0.69); P = 0.007; -4.23 to -0.96-1.95 (0.84); P = 0.054; -3.95 to 0.04

-1.3 (1.01);

P = 0.236; -3.68 to 1.07

-0.012 (1.35);

P = 0.993; -3.2 to 3.17

0.63 (1.52);

P = 0.689; -2.96 to 4.23

-0.67 (0.18);

P = 0.007; -1.1 to -0.25

0.64 (0.18);

P = 0.009; 0.21 to 1.08

-0.68
Coopersmith 200210.79 (1.90)-3.53 (1.32);  P = 0.028; -6.58 to -0.48-3.30 (1.41); P = 0.047; -6.55 to -0.05-3.06 (1.60); P = 0.087; -6.68 to 0.55-2.83 (1.78); P = 0.151; -6.94 to 1.28-2.36 (2.31); P = 0.336; -7.69 to 2.96 NA

-0.70 (0.26);

P = 0.027; -1.30 to -0.10

0.23 (0.34);

P = 0.519; -0.56 to 1.03

-0.67
Miller 20105.76 (0.76)-1.24 (0.44); P= 0.016; -2.20 to -0.28-1.15 (0.39); P = 0.013; -2.01 to -0.29-1.07 (0.52); P = 0.063; -2.20 to 0.07NANANA

-0.18 (0.04);

P = 0.001; -0.26 to -0.095

0.084 (0.28); P = 0.756; -0.52 to 0.690.21
Parra 20103.97 (0.75)0.04 (0.62); P = 0.954; -1.44 to 1.51

0.79 (0.77);

P = 0.339; -1.03 to 2.61

1.54 (0.94);

P = 0.144; -0.68 to 3.76

2.30 (1.12);

P = 0.080; -0.36 to 4.95

3.80 (1.50);

P = 0.039; 0.24 to 7.36

4.56 (1.70);

P = 0.032; 0.53 to 8.58

-0.59 (0.20);

P = 0.021; -1.06 to -0.12

0.75 (0.21);

P = 0.008; 0.26 to 1.24

-0.24
Sannoh 201014.83 (2.70)3.47 (1.02); P = 0.042; 0.24 to 6.70

2.33 (1.30);

P = 0.172; -1.82 to 6.49

1.19 (1.65);

P = 0.523; -4.08 to 6.46

0.06 (2.03);

P = 0.980; -6.42 to 6.52

 NA NA

-2.37 (0.41);

P = 0.010; -3.68 to - 1.06

-1.14 (0.42); P = 0.074; -2.48 to 0.20-0.75
Warren 20069.08 (2.89)0.36 (2.24); P = 0.874; -4.51 to 5.24

0.55 (2.22);

P = 0.809; -4.30 to 5.40

0.74 (2.32);

P = 0.756; -4.32 to 5.80

0.93 (2.52);

P = 0.718; -4.56 to 6.42

1.30 (3.10);

P = 0.681; -5.46 to 8.08

 NA

-0.61 (0.28);

P = 0.050; -1.23 to -0.0007

0.19 (0.49);

P = 0.708; -0.89 to 1.26

-0.23

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

Description of studies

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).

Figure 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.

Table 3. Interventions aimed at improving professional adherence to guidelines for prevention of VAP
  1. Abbreviations
    ICU: intensive care unit
    VAP: ventilator-associated pneumonia

Author/year

Type of intervention;

duration

Clinical practice guideline

Knowledge translation

activities

Distribution of educational material

Educational

meeting

Audit and feedback

Reminders,

posters or

visual aids

Other

interventions

Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4More than one active intervention; 3 months education period
  •        

  •      

  •  

 
  •       

  •        

Champion leaders;

dedicated oral care personnel performing oral care in one of the included ICUs 

Cocanour 2006

More than one active intervention;

unclear duration

  •        

  •  

  •  

 No No VAP bundle instituted as part of a performance improvement project
Kaye 2000

More than one active intervention;

unclear duration

  •       

  •        

  •        

  •        

  •        

 No

Bugline newsletter; handwashing campaign;

equipment and supply purchases; patient and family education

Salahuddin 2004

More than one active intervention; weekly repeated throughout

the study period

  •        

  •        

 No
  •        

  •        

  •       

 

Sona 2009

 

More than one active intervention; all staff educated within 2 months
  •        

  •       

 No
  •        

  •       

  •        

A pre-printed order set in every admission packet
Zack 2002More than one active intervention; unclear duration
  •        

  •        

  •      

  •        

  •       

 No 
Table 4. Interventions aimed at improving professional adherence to guidelines for prevention of CLABSIs
  1. Abbreviations
    CVC: central venous catheter
    DVD: digital video disc

 Author/year

Type of intervention;

duration

Clinical practice

guideline

Knowledge

translation

activities

Distribution

of

educational material

Educational

meetings

Audit

and feedback

Reminders,

posters,

visual aids

Other

interventions

Beathard 2003

 

More than one active intervention; repeated throughout the study
  •       

 No No
  •        

 No NoNurse educator made spot checks for compliance
Coopersmith 2002More than one active intervention, unclear duration
  •      

  •        

  •        

  •      

  •        

  •        

 
Miller 2010More than one active intervention; unclear duration
  •        

  •        

 No
  •        

  No

Quality improvement strategy,

champion leaders

Parra 2010

 

One short active intervention; 15 minutes
  •       

 No No
  •      

 No
  •       

 
Sannoh 2010

One short active intervention; 15 minute DVD

 

  •       

 No
  •        

  •        

 No
  •        

CVC care cart available,

reinforced previously implemented hand hygiene campaign

Warren 2004One short active intervention; 45 minutes; all staff educated within three months
  •      

  •       

  •      

  •        

  •        

  •        

Promotional campaign for educational programme
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).

Table 5. VAP prevention recommendations
  1. aOral care, but unclear if Chlorhexidine was used. Unclear if alcohol-based antiseptics were used for hand hygiene.
    bOral care, with Chlorhexidine baths twice weekly. Unclear if alcohol-based antiseptics were used for hand hygiene.
    cUnclear if alcohol-based antiseptics were used for hand hygiene.
    dOral care with a Chlorhexidine-based oral rinse at least daily. Handwashing between all patient contact and when leaving or entering the ICU. Unclear if alcohol-based antiseptics were used for hand hygiene.
    eOral care using Chlorhexidine twice daily.
    fOral care, but with Chlorhexidine only for patients undergoing cardiac surgery.

    Abbreviations
    VAP: ventilator-associated pneumonia

VAP prevention

Abbott 2006 dataset 1;

Abbott 2006 dataset 2;

Abbott 2006 dataset 3;

Abbott 2006 dataset 4 a

Cocanour 2006 bKaye 2000 cSalahuddin 2004 dSona 2009 eZack 2002 f
Head of bed elevation 30 
  •  

  No
  •  

  No
  •  

Not implementing ventilator circuit changes unless clinically indicated  No No   No  No  No  No
Continuous suctioning of subglottic secretions  No   No  No  No  No
Daily ‘sedation vacation’ and assessment of readiness for weaning  No   No  No  No  No
Oral care (with Chlorhexidine 0.12% every 8 hours)
  •  

   No 
  •  

  •  

Intra-cuff pressure control  No  No  No 
  •  

  No  No
Hand hygiene using alcohol based antiseptics 
  •  

  •  

  •  

  No  No

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.

Table 6. CLABSI prevention recommendations
  1. aCatheter insertion not covered by guidance.
    bInsertion and maintenance bundle, both specific to PICUs.
    cIncludes both insertion and maintenance guidance.
    dIncludes only hub care and dressing policy.
    eIncludes both insertion and maintenance guidance.
    fUnclear what is included in ‘routine catheter care’ and if it includes the use of Chlorhexidine.
    gUnclear if this includes the use of Chlorhexidine.

    Abbreviations

    CLABSI: central line-associated blood stream infection
    CVC: central venous catheter
    N/A: not applicable

CLABSI preventionCoopersmith 2002 aMiller 2010 bParra 2010 cSannoh 2010 dWarren 2004 e
The use of maximal sterile barriers during catheter insertion  No
  •  

  No  No
  •  

The use of Chlorhexidine skin preparation with alcohol for skin antisepsisAseptic technique and routine catheter site caref
  •  

  •  

  NoAseptic technique and appropriate skin antisepsisg
Avoidance of routine placement of CVCs  No No   No No   No
Avoidance of using the femoral site in adults  NoN/A
  •  

N/A
  •  

Timely dressing changes using aseptic techniques
  •  

  •  

  •  

 
  •  

Daily audits to assess if each central line is still needed  No
  •  

  No  No  No

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).

Table 7. Adherence with infection control recommendations
  1. aIndividual study data not reported; all data for four datasets are in one report.

    Abbreviations

    CNS: clinical nurse specialist
    CPG: clinical practice guideline
    DVD: digital video disc
    ICU: intensive care unit
    PICU: paediatric intensive care unit

StudyAssessment of adherence with infection control recommendationsTime-points for assessmentAssessor(s)/assessmentPre-intervention adherence         Post-intervention adherence
Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4 aAdoption measurements consisted of observations of infection control practices in accordance with the CPG and were measured using the adoption checklist

Observations were conducted for a total of 12 weeks: 6 weeks before the education intervention and 6 weeks after the intervention at each site. The care of patients in the five ICUs was observed

and recorded by patient and by unit at each facility. Patient care was observed during hours of the day with the highest rates of patient care activity in 2-hour blocks of time

An experienced critical care research nurse was the only person observing CPG adoption at both facilities

Head-of-bed elevation:

mean = 77% (range 51 to 100)

Oral care:

mean = 22% (range 12 to 28)

Empty condensate:

mean = 94% (range 79 to 100)

 

Before/after patient contact -

handwashing:

mean = 8%/36% (range 4 to 11/17 to 33)

Gloves:

mean = 74% (range 60 to 97)

Head-of-bed elevation:

mean = 69% (range 43 to 83)

Oral care:

mean = 30% (range 12 to 67)

Empty condensate:

mean = 93% (range 85 to 97)

 

Before/after patient contact -

handwashing:

mean = 14%/36% (range 11 to 19/28 to 54)

Gloves:

mean = 90% (range 79 to 97)

Beathard 2003Compliance rates with two infection control policies were assessed through patient interviewsThe patient interviews were performed at unclear time pointsA nurse educator performed an unknown number of interviewsNone reported

Compliance with catheter exit sites being treated with Povidone-iodine ointment for the first 10 to 14 days after placement: 75%

 

Compliance with all catheter exit sites being covered with sterile gauze dressing (non-occlusive) for the entire duration of the catheter placement: 98%

 

Ching 1990Before and after the education programme, prevalence surveys were conducted to detect incorrect practices on urinary catheter care. Three practices evaluated the securing of catheters, presence of kinking and the use of urinary bags with a drainage spigotOne month before the education programme, three prevalence surveys, 10 days apart, were conducted to assess patient-care practices for urinary catheter care. For
each survey, without prior announcement, all 27 wards were visited, within a day, and for every urinary catheter present, violations of the three practices listed were recorded.
Five weeks after the education programme, two more prevalence surveys were conducted. Again, these surveys were unannounced and were conducted 10 days apart
It is not clear who assessed the urinary catheter care practicesBefore education, the percentage of incorrect practices in the test groups was 63%, and 68% in the control groupAfter education, the percentage of incorrect practices in the test group was 36% and 48% in the control group
Miller 2010

Data were collected by using insertion bundle and maintenance-bundle compliance

as the two process measures

 

Once each week, each PICU team self-monitored all central-line insertions that occurred in the PICU and submitted data on compliance with each insertion- bundle element for all of the insertions that occurred each month

Compliance self-assessed by the PICU team.

Compliance for both bundles was assessed as all or none, meaning that
each patient’s insertion or maintenance event had to comply with all of the elements of the respective bundle to be considered compliant

 None reported

Insertion-bundle compliance: 84%

Maintenance-bundle compliance: 82%

Sannoh 2010The level of staff adherence with catheter hub care policy was determined before and after the DVD educational presentationBefore the presentation, 24 nurses were observed at random performing the catheter hub care protocol; after the presentation, 26 nurses were observedAdherence to each of the 9 points of the catheter hub care protocol was scored as either ‘‘yes’’ or ‘‘no’’ by independent observers well versed in the protocol

Catheter hub care protocol adherence score

(mean ± standard deviation): 14 ± 4

Catheter hub care protocol adherence score (mean ± standard deviation): 23 ± 0.7
Sona 2009Staff compliance with the oral care protocol during the 12-month intervention periodTwo unit based CNSs audited the compliance rates via bi-weekly review of the medication administration record and verification of oral care suppliesCompliance was defined as the rate at which patients were enrolled in the protocol with oral care scheduled on the medication administration record and supplies in the patient roomNone reportedCompliance with the oral care protocol: averaged 81% (range 70% to 90%)

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.

Figure 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

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

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

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

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 months8 Effect Size (Random, 95% CI)Totals not selected
2 VAP 3 months level8 Effect size (Random, 95% CI)Totals not selected
3 VAP 6 months level8 Effect size (Random, 95% CI)Totals not selected
4 VAP 9 months level8 Effect size (Random, 95% CI)Totals not selected
5 VAP 12 months level5 Effect size (Random, 95% CI)Totals not selected
Analysis 1.1.

Comparison 1 Ventilator-associated pneumonia (VAP) analysis, Outcome 1 VAP change in pre- and post-intervention slope at 3 to 6 months.

Analysis 1.2.

Comparison 1 Ventilator-associated pneumonia (VAP) analysis, Outcome 2 VAP 3 months level.

Analysis 1.3.

Comparison 1 Ventilator-associated pneumonia (VAP) analysis, Outcome 3 VAP 6 months level.

Analysis 1.4.

Comparison 1 Ventilator-associated pneumonia (VAP) analysis, Outcome 4 VAP 9 months level.

Analysis 1.5.

Comparison 1 Ventilator-associated pneumonia (VAP) analysis, Outcome 5 VAP 12 months level.

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 months6 Effect size (Random, 95% CI)Totals not selected
2 CLABSI 3 months level6 Effect size (Random, 95% CI)Totals not selected
3 CLABSI 6 months level6 Effect size (Random, 95% CI)Totals not selected
4 CLABSI 9 months level6 Effect size (Random, 95% CI)Totals not selected
5 CLABSI 12 months level5 Effect size (Random, 95% CI)Totals not selected
6 CLABSI 18 months level4 Effect size (Random, 95% CI)Totals not selected
7 CLABSI 21 months level2 Effect size (Random, 95% CI)Totals not selected
Analysis 2.1.

Comparison 2 Central line-associated blood stream infections (CLABSIs) analysis, Outcome 1 CLABSI change in pre- and post-intervention slope at 4 to 8 months.

Analysis 2.2.

Comparison 2 Central line-associated blood stream infections (CLABSIs) analysis, Outcome 2 CLABSI 3 months level.

Analysis 2.3.

Comparison 2 Central line-associated blood stream infections (CLABSIs) analysis, Outcome 3 CLABSI 6 months level.

Analysis 2.4.

Comparison 2 Central line-associated blood stream infections (CLABSIs) analysis, Outcome 4 CLABSI 9 months level.

Analysis 2.5.

Comparison 2 Central line-associated blood stream infections (CLABSIs) analysis, Outcome 5 CLABSI 12 months level.

Analysis 2.6.

Comparison 2 Central line-associated blood stream infections (CLABSIs) analysis, Outcome 6 CLABSI 18 months level.

Analysis 2.7.

Comparison 2 Central line-associated blood stream infections (CLABSIs) analysis, Outcome 7 CLABSI 21 months level.

Appendices

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

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

DateEventDescription
12 March 2013AmendedPunctuation corrected

History

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

DateEventDescription
25 August 2008AmendedConverted to new review format

Contributions of authors

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

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

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

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.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Abbott 2006 dataset 1

Methods

Study design: ITS

Data collection: Quarterly VAP rates were collected from the respective infection control officers over the course of the evidence based practice initiative using the NNIS calculation. An experienced critical care research nurse observed CPG adoption using the adaptation checklist. The same research nurse collected the patient information by a record review

Definition of VAP: Based on NNIS definition (CDC 2003)

Ventilators used: Not described in the paper; differences in type of ventilators, differences in mechanical ventilation, respiratory equipment, and antibiotic therapy across units and sites were not controlled for in the study, neither were weaning protocols which also may have had an impact on the duration of ventilation

Targeted behaviour: Improve procedures (adoption of a CPG developed to decrease VAP rate)

Participants

Providers: Unknown number of nurses, technicians, and respiratory therapists (self learning packet); staff physicians, residents, interns, respiratory therapists, housekeeping staff (briefing)

Patients: Patients (n = 106 for all five sites, only four sites included in the analysis;individual site data not reported) on continuous mechanical ventilation for greater than, or equal to, 48 hours, who did not meet the NNIS criteria for a diagnosis of VAP at the time of data collection. Excluded: patients with conditions requiring the head of the bed to be down

Age (range): Mean = 50 years (17 to 91 years)

Gender, number of females (%): 35 (33)

APACHE II score (range): Mean = 15 (3 to 39)

Enteral feeding, no. (%): 85 (83)

ICU length of stay (range): Mean = 15 days (2 to 68 days)

Ventilator days (range): Mean = 10 days (5 to 52 days)

Years of respiratory history (range): Mean = 0 years (0 to 20 years)

Patient characteristics were not presented separately for the pre- and post-intervention period (patient characteristics separated by VAP and non-VAP patients)

Setting: Medical ICU, unknown no. of beds

Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: Mechanical ventilator

Evidence base of intervention: CPG based on review of the literature

Clinical practice guideline

  • Head-of-bed elevation

  • Oral care

  • Ventilator tubing condensate removal

  • Hand hygiene

  • Use of gloves

Type of intervention: Professional intervention

Format: Paper, computer, interpersonal

Description of intervention:

1. Knowledge translation activities

A multidisciplinary education team developed a standard of care for the ventilated patient that included:

a. CPG implementation.

b. Use of standing orders for the care of the ventilated patient

c. Ongoing and open discussion with staff as to the usefulness of implementation strategies.

d. Frequent delivery of data to multidisciplinary team members and quarterly trends to organisation leaders.

e. Briefing of VAP prevention initiative to Joint Commission on Accreditation of Healthcare Organisations during on-site survey.

f. Ongoing assessment of the change process was performed to determine if factors facilitating or hindering the adoption of the VAP CPG were related to knowledge, attitude, behaviour, policy, or system

2. Educational intervention

2.1. Initial education plan

a. VAP self learning packet was incorporated into the orientation for nurses, technicians, and respiratory therapists.

b. Infection control and preventing infection briefing was provided during the critical care course.

c. Briefings to staff physicians, residents, interns, respiratory therapists, housekeeping staff were provided

2.2. Ongoing educational initiatives

a. Development and displaying of educational story boards to reinforce all CPG elements: educational story poster about the change process and audit data for periodic in-service programmes; reminders at the bedside to reinforce initiatives and CPGs.

b.One-to-one bedside teaching was conducted with reminders at the bedside with continuous interaction checks and teaching.

c. Weekly email reminders were sent to staff asking them to email data from hospitals after measurement began

2.3. Feedback

a. Commander-senior executive-level briefed updated progress on status of VAP and reinforced care initiatives.

b. Updated VAP process and status were sent to Patient Care Council, Infection Control Committee, hospital level Performance Improvement Council, and other applicable committees.

c. Feedback on guideline adoption and VAP rate to staff

Timing:

a) Frequency and number of events: Not specified

b) Duration of intervention: Reinforcements of CPG occurred throughout the whole study period

c) Period after the intervention under which data was collected: 24 months

Outcomes

Quarterly VAP rates:

at 3, 6, 9 and 12 months after the intervention

Outcomes that could not be reanalysed and therefore not included in this review:

Adoption rates, ventilator days, length of ICU stay, length of hospital stay, and costs

Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Intervention independent of other changesUnclear riskIt was not explicitly stated in the paper if the intervention was independent of other changes
Shape of the intervention effects pre-specifiedLow riskAlthough the authors described the intended direction of effect of the intervention, they did not describe if they expected a step change or a change in slope. However, since all studies were reanalysed by the review authors the risk of bias was low
Appropriate analysis (secular trends taken into account)Low riskSecular trends were not taken into account in the analysis. Data reanalysed and adjusted for pre-intervention trend by review authors
Intervention unlikely to affect data collectionLow riskRoutine collection of objective outcome data: the quarterly VAP rates were collected from the respective infection control officers for the participating ICUs at each hospital
Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe primary outcome (VAP rate) was objective and based on standardised criteria
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskThere is missing data for quarter two in the pre-intervention period.
Selective reporting (reporting bias)Unclear riskNo mention of protocol for study, therefore we are unable to assess if all outcomes are reported
Other biasLow riskNo other biases identified

Abbott 2006 dataset 2

Methods

Study design: ITS

Data collection: Quarterly VAP rates were collected from the respective infection control officers for each ICU in each hospital over the course of the evidence based practice initiative using the NNIS calculation. An experienced critical care research nurse observed CPG adoption at both facilities, using the adaptation checklist. The same research nurse collected the patient information by a record review

Definition of VAP: Based on NNIS definition (CDC 2003)

Ventilators used: Not described in the paper; differences in type of ventilators, differences in mechanical ventilation, respiratory equipment, and antibiotic therapy across units and sites were not controlled for in the study, neither were weaning protocols which also may have had an impact on the duration of ventilation

Targeted behaviour: Improve procedures (adoption of a CPG developed to decrease VAP rate)

Participants

Providers: Unknown number of nurses, technicians, and respiratory therapists (self learning packet); staff physicians, residents, interns, respiratory therapists, housekeeping staff (briefing)

Patients: Patients (n = 106 for all five sites, only four sites included in the analysis; individual site data not reported) on continuous mechanical ventilation for greater than, or equal to, 48 hours, who did not meet the NNIS criteria for a diagnosis of VAP at the time of data collection. Excluded: Patients with conditions requiring the head of the bed to be down

Age (range): Mean = 50 years (17 to 91 years)

Gender, number of females (%): 35 (33)

APACHE II score (range): Mean = 15 (3 to 39)

Enteral feeding, no. (%): 85 (83)

ICU length of stay (range): Mean = 15 days (2 to 68 days)

Ventilator days (range): Mean = 10 days (5 to 52 days)

Years of respiratory history (range): Mean = 0 years (0 to 20 years)

Patient characteristics were not presented separately for the pre- and post-intervention period (patient characteristics separated by VAP and non-VAP patients)

Setting: Surgical ICU

Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: mechanical ventilator

Evidence base of intervention: CPG based on review of the literature

Clinical practice guideline

  • Head-of-bed elevation

  • Oral care

  • Ventilator tubing condensate removal

  • Hand hygiene

  • Use of gloves

Type of intervention: Professional intervention

Format: Paper, computer, interpersonal

Description of intervention:

1. Knowledge translation activities

A multidisciplinary education team developed a standard of care for the ventilated patient that included:

a. CPG implementation.

b. Use of standing orders for the care of the ventilated patient

c. Ongoing and open discussion with staff as to the usefulness of implementation strategies.

d. Frequent delivery of data to multidisciplinary team members and quarterly trends to organisation leaders.

e. Briefing of VAP prevention initiative to Joint Commission on Accreditation of Healthcare Organisations during on-site survey.

f. Ongoing assessment of the change process was performed to determine if factors facilitating or hindering the adoption of the VAP CPG were related to knowledge, attitude, behaviour, policy, or system

2. Educational intervention

2.1. Initial education plan

a. VAP self learning packet was incorporated into the orientation for nurses, technicians, and respiratory therapists.

b. Infection control and preventing infection briefing was provided during the critical care course.

c. Briefings to staff physicians, residents, interns, respiratory therapists, housekeeping staff were provided

2.2. Ongoing educational initiatives

a. Development and displaying of educational story boards to reinforce all CPG elements: educational story poster about the change process and audit data for periodic in-service programmes; reminders at the bedside to reinforce initiatives and CPGs.

b. One-to-one bedside teaching was conducted with reminders at the bedside with continuous interaction checks and teaching.

c. Weekly email reminders were sent to staff asking them to email data from hospitals after measurement began

2.3. Feedback

a. Commander-senior executive-level briefed updated progress on status of VAP and reinforced care initiatives.

b. Updated VAP process and status were sent to Patient Care Council, Infection Control Committee, hospital level Performance Improvement Council, and other applicable committees.

c. Feedback on guideline adoption and VAP rate to staff

3. Other interventions

a) Special oral care equipment was purchased

b) Dentists and dental hygienists were employed to provide oral care for patients with mechanical ventilation

Timing:

a) Frequency and number of events: Not specified

b) Duration of intervention: Reinforcements of CPG occurred throughout the whole study period

c) Period after the intervention under which data was collected: 20 months

Outcomes

Quarterly VAP rates: at 3, 6, 9 and 12 months after the intervention

Outcomes that could not be reanalysed and therefore not included in this review: Adoption rates, ventilator days, length of ICU stay, length of hospital stay, and costs

Notes

Statistical analyses not reported

Data were extracted from graphs and reanalysed by reviewers

Risk of bias
BiasAuthors' judgementSupport for judgement
Intervention independent of other changesUnclear riskIt was not explicitly stated in the paper if the intervention was independent of other changes
Shape of the intervention effects pre-specifiedLow riskAlthough the authors described the intended direction of effect of the intervention, they did not describe if they expected a step change or a change in slope. However, since all studies were reanalysed by the review authors the risk of bias was low
Appropriate analysis (secular trends taken into account)Low riskSecular trends were not taken into account in the analysis. Data reanalysed and adjusted for pre-intervention trend by review authors
Intervention unlikely to affect data collectionLow riskRoutine collection of objective outcome data: the quarterly VAP rates were collected from the respective infection control officers for the participating ICUs at each hospital
Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe primary outcome (VAP rate) was objective and based on standardised criteria
Incomplete outcome data (attrition bias)
All outcomes
Low riskAll data points included
Selective reporting (reporting bias)Unclear riskNo mention of protocol for study, therefore we are unable to assess if all outcomes are reported
Other biasLow riskNo other biases identified

Abbott 2006 dataset 3

Methods

Study design: ITS

Data collection: Quarterly VAP rates were collected from the infection control officers over the course of the evidence based practice initiative using the NNIS calculation. An experienced critical care research nurse observed CPG adoption at both facilities, using the adaptation checklist. The same research nurse collected the patient information by a record review

Definition of VAP: Was based on NNIS definition (CDC 2003)

Ventilators used: Not described in the paper; differences in type of ventilators, differences in mechanical ventilation, respiratory equipment, and antibiotic therapy across units and sites were not controlled for in the study, neither were weaning protocols which also may have had an impact on the duration of ventilation

Targeted behaviour: Improve procedures (adoption of a CPG developed to decrease VAP rate)

Participants

Providers: Unknown number of nurses, technicians, and respiratory therapists (self learning packet); staff physicians, residents, interns, respiratory therapists, housekeeping staff (briefing)

Patients: Patients (n = 106 for all five sites, only four sites included in the analysis;individual site data not reported) on continuous mechanical ventilation for greater than, or equal to, 48 hours, who did not meet the NNIS criteria for a diagnosis of VAP at the time of data collection. Excluded: patients with conditions requiring the head of the bed to be down

Age (range): Mean = 50 years (17 to 91 years)

Gender, number of females (%): 35 (33)

APACHE II score (range): Mean = 15 (3 to 39)

Enteral feeding, no. (%): 85 (83)

ICU length of stay (range): Mean = 15 days (2 to 68 days)

Ventilator days (range): Mean = 10 days (5 to 52 days)

Years of respiratory history (range): Mean = 0 years (0 to 20 years)

Patient characteristics were not presented separately for the pre- and post-intervention period (patient characteristics separated by VAP and non-VAP patients)

Setting: Trauma ICU; unknown number of beds

Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: Mechanical ventilator

Evidence base of intervention: CPG based on review of the literature

Clinical practice guideline

  • Head-of-bed elevation

  • Oral care

  • Ventilator tubing condensate removal

  • Hand hygiene

  • Use of gloves

Type of intervention: Professional intervention

Format: Paper, computer, interpersonal

Description of intervention:

1. Knowledge translation activities

A multidisciplinary education team developed a standard of care for the ventilated patient that included:

a. CPG implementation.

b. Use of standing orders for the care of the ventilated patients

c. Ongoing and open discussion with staff as to the usefulness of implementation strategies.

d. Frequent delivery of data to multidisciplinary team members and quarterly trends to organisation leaders.

e. Briefing of VAP prevention initiative to Joint Commission on Accreditation of Healthcare Organisations during on-site survey.

f. Ongoing assessment of the change process was performed to determine if factors facilitating or hindering the adoption of the VAP CPG were related to knowledge, attitude, behaviour, policy, or system

2. Educational intervention

2.1. Initial education plan

a. VAP self learning packet was incorporated into the orientation for nurses, technicians, and respiratory therapists.

b. Infection control and preventing infection briefing was provided during the critical care course.

c. Briefings to staff physicians, residents, interns, respiratory therapists, housekeeping staff were provided

2.2. Ongoing educational initiatives

a. Development and displaying of educational story boards to reinforce all CPG elements: educational story poster about the change process and audit data for periodic in-service programmes; reminders at the bedside to reinforce initiatives and CPGs.

b.One-to-one bedside teaching was conducted with reminders at the bedside with continuous interaction checks and teaching.

c. Weekly email reminders were sent to staff asking them to email data from hospitals after measurement began

2.3. Feedback

a. Commander-senior executive-level briefed updated progress on status of VAP and reinforced care initiatives.

b. Updated VAP process and status were sent to Patient Care Council, Infection Control Committee, hospital level Performance Improvement Council, and other applicable committees.

c. Feedback on guideline adoption and VAP rate to staff

Timing:

a) Frequency and number of events: Not specified

b) Duration of intervention: Reinforcements of CPG occurred throughout the whole study period

c) Period after the intervention under which data was collected: 20 months

Outcomes

Quarterly VAP rates:

at 3, 6, 9 and 12 months after the intervention

Outcomes that could not be reanalysed and therefore not included in this review :

Adoption rates, ventilator days, length of ICU stay, length of hospital stay, and costs

Notes

Statistical analyses not reported

Data were extracted from graphs and reanalysed by reviewers

Risk of bias
BiasAuthors' judgementSupport for judgement
Intervention independent of other changesUnclear riskIt was not explicitly stated in the paper if the intervention was independent of other changes
Shape of the intervention effects pre-specifiedLow riskAlthough the authors described the intended direction of effect of the intervention, they did not describe if they expected a step change or a change in slope. However, since all studies were reanalysed by the review authors the risk of bias was low
Appropriate analysis (secular trends taken into account)Low riskSecular trends were not taken into account in the analysis. Data reanalysed and adjusted for pre-intervention trend by review authors
Intervention unlikely to affect data collectionLow riskRoutine collection of objective outcome data: the quarterly VAP rates were collected from the respective infection control officers for the participating ICUs at each hospital
Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe primary outcome (VAP rate) was objective and based on standardised criteria
Incomplete outcome data (attrition bias)
All outcomes
Low riskAll data points included
Selective reporting (reporting bias)Unclear riskNo mention of protocol for study, therefore we are unable to assess if all outcomes are reported
Other biasLow riskNo other biases identified

Abbott 2006 dataset 4

Methods

Study design: ITS

Data collection: Quarterly VAP rates were collected from the infection control officers over the course of the evidence based practice initiative using the NNIS calculation. An experienced critical care research nurse observed CPG adoption at both facilities, using the adaptation checklist. The same research nurse collected the patient information by a record review

Definition of VAP: Based on NNIS definition (CDC 2003)

Ventilators used: Not described in the paper; differences in type of ventilators, differences in mechanical ventilation, respiratory equipment, and antibiotic therapy across units and sites were not controlled for in the study, neither were weaning protocols which also may have had an impact on the duration of ventilation

Targeted behaviour: Improve procedures (adoption of a CPG developed to decrease VAP rate)

Participants

Providers: Unknown number of nurses, technicians, and respiratory therapists (self learning packet); staff physicians, residents, interns, respiratory therapists, housekeeping staff (briefing)

Patients: Patients (n = 106 for all five sites, only four sites included in the analysis;individual site data not reported) on continuous mechanical ventilation for greater than, or equal to, 48 hours, who did not meet the NNIS criteria for a diagnosis of VAP at the time of data collection. Excluded: patients with conditions requiring the head of the bed to be down

Age (range): Mean = 50 years (17 to 91 years)

Gender, number of females (%): 35 (33)

APACHE II score (range): Mean = 15 (3 to 39)

Enteral feeding, no. (%): 85 (83)

ICU length of stay (range): Mean = 15 days (2 to 68 days)

Ventilator days (range): Mean = 10 days (5 to 52 days)

Years of respiratory history (range): Mean = 0 years (0 to 20 years)

Patient characteristics were not presented separately for the pre- and post-intervention period (patient characteristics separated by VAP and non-VAP patients)

Setting: One trauma ICU; unknown number of beds

Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: Mechanical ventilator

Evidence base of intervention: CPG based on review of the literature

Clinical practice guideline

  • Head-of-bed elevation

  • Oral care

  • Ventilator tubing condensate removal

  • Hand hygiene

  • Use of gloves

Type of intervention: professional intervention

Format: paper, computer, interpersonal

Description of intervention:

1. Knowledge translation activities

A multidisciplinary education team developed a standard of care for the ventilated patient that included:

a. CPG implementation.

b. Use of standing orders for the care of the ventilated patient

c. Ongoing and open discussion with staff as to the usefulness of implementation strategies.

d. Frequent delivery of data to multidisciplinary team members and quarterly trends to organisation leaders.

e. Briefing of VAP prevention initiative to Joint Commission on Accreditation of Healthcare Organisations during on-site survey.

f. Ongoing assessment of the change process was performed to determine if factors facilitating or hindering the adoption of the VAP CPG were related to knowledge, attitude, behaviour, policy, or system

2. Educational intervention

2.1. Initial education plan

a. VAP self learning packet was incorporated into the orientation for nurses, technicians, and respiratory therapists.

b. Infection control and preventing infection briefing was provided during the critical care course.

c. Briefings to staff physicians, residents, interns, respiratory therapists, housekeeping staff were provided

2.2. Ongoing educational initiatives

a. Development and displaying of educational story boards to reinforce all CPG elements: educational story poster about the change process and audit data for periodic in-service programmes; reminders at the bedside to reinforce initiatives and CPGs.

b.One-to-one bedside teaching was conducted with reminders at the bedside with continuous interaction checks and teaching.

c. Weekly email reminders were sent to staff asking them to email data from hospitals after measurement began

2.3. Feedback

a. Commander-senior executive-level briefed updated progress on status of VAP and reinforced care initiatives.

b. Updated VAP process and status were sent to Patient Care Council, Infection Control Committee, hospital level Performance Improvement Council, and other applicable committees.

c. Feedback on guideline adoption and VAP rate to staff

Timing:

a) Frequency and number of events: not specified

b) Duration of intervention: reinforcements of CPG occurred throughout the whole study period

c) Period after the intervention under which data was collected: 16 months

Outcomes

Quarterly VAP rates:

at 3, 6 and 9 months after the intervention

Outcomes that could not be reanalysed and therefore not included in this review :

Adoption rates, ventilator days, length of ICU stay, length of hospital stay, and costs

Notes

Statistical analyses not reported

Data were extracted from graphs and reanalysed by reviewers

Risk of bias
BiasAuthors' judgementSupport for judgement
Intervention independent of other changesUnclear riskIt was not explicitly stated in the paper if the intervention was independent of other changes
Shape of the intervention effects pre-specifiedLow riskAlthough the authors described the intended direction of effect of the intervention, they did not describe if they expected a step change or a change in slope. However, since all studies were reanalysed by the review authors the risk of bias was low
Appropriate analysis (secular trends taken into account)Low riskSecular trends were not taken into account in the analysis. Data reanalysed and adjusted for pre-intervention trend by review authors
Intervention unlikely to affect data collectionLow riskRoutine collection of objective outcome data: the quarterly VAP rates were collected from the respective infection control officers for the participating ICUs at each hospital
Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe primary outcome (VAP rate) was objective and based on standardised criteria
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskThe authors did not describe how they addressed the missing data for the last quarter in the post-intervention period
Selective reporting (reporting bias)Unclear riskNo mention of protocol for study, therefore we are unable to assess if all outcomes are reported
Other biasUnclear riskNo other biases identified

Beathard 2003

Methods

Study design: ITS with historical controls (the same population and under the same conditions, except for the prophylaxis

protocol)

Data collection: Monthly review of medical charts of patients receiving haemodialysis via a TDC

Definition of catheter related bacteraemia: Defined as bacteraemia in a patient with a TDC with no other etiologic explanation for the infection

Catheters used: Cuffed tunnelled dialysis catheters. All central lines were inserted in an operating room

Targeted behaviour: Improve procedures (to improve care provided to patient with TDC to protect the hub from contamination)

Participants

Providers: All dialysis facility staff; no provider characteristics reported

Patients: Patients (n = 700) with TDC; Pre-intervention period: n = 298; Post-intervention period: n = 402 patients; no patient characteristics reported

Setting: One haemodialysis facility at one hospital; unclear no. of beds

Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: TDC

Evidence base of intervention: Infection prophylaxis protocol based on National Kidney Foundation’s Kidney Disease Outcomes and Quality Initiative Clinical Practice Guidelines for Vascular Access

Clinical practice guideline:

  • Individually wrap both of the catheter hubs with gauze saturated with povidone-iodine solution for 5 minutes prior to the removal of the caps

  • Both the patient and the nurse doing the dialysis hook-up must wear a mask during the entire time that the catheters are being manipulated

  • The nurse must wear a fresh pair of disposable gloves for the hook-up procedure

  • As soon as the cap is removed from the hub, the surface that was covered by the cap must be wiped with a povidone-iodine pledget

  • The catheter hub must be connected immediately. It must never be allowed to remain exposed to the air

  • This procedure must be repeated at the time the patient is disconnected at the end of dialysis or for any other reason

  • Catheter manipulation must be kept to an absolute minimum. If there are flow problems they must be definitively addressed as quickly as possible

Prior to the initiation of the study protocol, no formal protocol existed for the management of TDC hook-up in dialysis facilities

Type of intervention: Professional intervention

Format: Interpersonal

Description of intervention:

1-Knowledge translation activities

Not reported

2-Educational intervention

A nurse educator instructed all dialysis facility staff on the basic principles of the protocol and did spot checks for compliance with the protocol on a regular basis throughout the study period

Timing:

a) Frequency and number of events: Not specified

b) Duration of intervention: Repeated education and spot checks for compliance with the protocol occurred throughout the study period

c) Period after the start of the intervention during which data was collected: 24 months

Outcomes

CLABSI rates at 3, 6 ,9 ,12, 18 and 21 months after the intervention

Outcomes that could not be reanalysed and therefore not included in this review :

Compliance rates

NotesThe study ignored secular (trend) changes and performed a simple t-test of the pre- versus post-intervention periods. Data were extracted from graph and reanalysed by reviewers
Risk of bias
BiasAuthors' judgementSupport for judgement
Intervention independent of other changesLow risk

See p.104, Col 1, Para 3

Quote:

"Except for the institution of the study protocol, all conditions of care and use of the TDC were the same for the control and study periods"

Shape of the intervention effects pre-specifiedLow riskAlthough the authors described the intended direction of effect of the intervention, they did not describe if they expected a step change or a change in slope. However, since all studies were reanalysed by the review authors the risk of bias was low
Appropriate analysis (secular trends taken into account)Low riskSecular trends were not taken into account in the analysis. Data reanalysed and adjusted for pre-intervention trend by review authors
Intervention unlikely to affect data collectionLow riskRoutine collection of objective outcome data: data was collected retrospectively in the pre-intervention period through the review of medical charts, while data collection was prospective in the post-intervention period. However, the authors stated that data was collected under the same conditions throughout the study period
Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe primary outcome (CLABSI rate) was objective and based on a standard definition
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo information in the text
Selective reporting (reporting bias)Unclear riskNo mention of protocol for study, therefore we are unable to assess if all outcomes are reported

Ching 1990

Methods

Study design: RCT

Data collection: Three prevalence surveys, 10 days apart, were conducted to assess patient-care practices for urinary catheter care in all 27 wards. Five weeks after the education programme, two more prevalence surveys were conducted. These surveys were unannounced and were conducted 10 days apart

Definitions: Incorrect urinary catheter practices were defined by three factors: improper securing of catheters, the presence of kinking of catheters and the use of urine bags without a drainage spigot

Type of catheters: Indwelling urinary catheters

Targeted behaviour: Improve procedures (decrease incorrect practices for urinary catheter care)

Participants

Providers: n = 939 nurses; Intervention group: n = 838 nurses (28%) from 24 wards; Control group:n = 101 nurses (29%) from 3 wards

Rank:

Student nurses: Intervention: n = 239; Control: n = 31

Registered nurses: Intervention: n = 462; Control: n = 56

Enrolled nurses: Intervention: n = 34; Control: n = 6

Officers: Intervention: n = 103; Control: n = 8

Gender: number male/female. Intervention: n = 90/748; Control: 14/87

Years postgraduate:

0 (students): Intervention: n = 239; Control: n = 31

1 to 7 years: Intervention: n = 433; Control: n = 48

8 to 14 years: Intervention: n = 129; Control: n = 15

>14 years: Intervention: n = 37; Control: n = 7

The nurses in the intervention and control groups were similar with respect to gender, number of years postgraduate and rank

The number of nurses (%) who attended the in-service lecture: Intervention: 238 (28); Control: 29 (29)

Patients: Unknown number of in-patients; no patient characteristics provided

Setting: 27 public wards in a 1000 bed university teaching hospital

Country: Hong Kong

Interventions

Infection-associated invasive medical device addressed by intervention: Indwelling urinary catheter

Evidence base of recommendation:

Guideline for urinary catheter care was drafted by the infection control team, and adapted from guidelines by Wong and Hooton 1981 and Kurun 1987

Clinical practice guideline:

  • Urinary catheter is to be properly secured

  • Urinary catheter and collection tube must be kept from kinking

  • The urine bags are to be emptied by the draining spigot into a collecting container

Before introducing the new guideline, the usual practice was to use urine bags with no draining spigot and the bag was changed daily. There was no official guideline or urinary catheter care in the hospital before the intervention

Type of intervention: Professional intervention

Format: Interpersonal

Description of intervention:

1-Knowledge translation activities

The nursing administration of the hospital selected the infection control liaison nurse for the education programme. In consultation with their nursing officers, a nursing officer II was appointed as the infection control liaison nurse for each of the 24 wards in the test group, and a registered nurse was appointed as the assistant. The new guideline was presented and controversial points were discussed

2-Educational intervention:

Intervention group:

All infection control liaison nurse and their assistants were requested to attend a 3-hour training session by the infection control team. The infection control liaison nurse and their assistants were released from normal duties for half a day to conduct demonstration tutorials for all nurses in their wards. The format of these tutorials was similar to the lecture, but they were conducted for small groups of six to 10 nurses within their own ward area. All nurses in the ward were required to attend. Their attendance was recorded and submitted to the infection control liaison nurse. A 30-minute lecture on the new guideline was given by the nurse

Control group :

Also the control group received the 30-minute lecture on the new guideline given by the nurse

Timing:

a) Frequency and number of events: Two events (one that only the intervention group received)

b) Duration of intervention: One 30 minutes lecture and a half day tutorial

c) Period after the start of the intervention during which outcomes were reported: Five weeks

Outcomes

Incorrect practices on urinary catheter care

Outcomes that could not be reanalysed and therefore not included in this review : none

Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

It was not clear how the random draw was executed, and it was therefore unclear if the sequence generation was unpredictable

Quote:

"The control groups consisted of three wards (surgical, medical and gynaecology), selected by a random draw, and the remaining 24 wards were the test group"

Allocation concealment (selection bias)Unclear riskUnclear if the concealment of allocation was adequate
Protection against contaminationLow riskIt is unlikely that the control group received the intervention
Baseline characteristicsLow riskBaseline characteristics of health professionals were reported and did not differ between groups
Baseline outcomes measurementsLow riskIncorrect practices were measured prior to the intervention and no significant differences were found between intervention and control group
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskIt is unclear if the outcome assessors performing the observation surveys of incorrect urinary catheter care practices were blinded to the allocation of intervention and control wards, and since the outcomes assessed were not completely objective, the risk of bias for this item was unclear
Incomplete outcome data (attrition bias)
All outcomes
Low riskThere could be no incomplete outcome data, since all catheters present at the ward were assessed at the time of the observation surveys performed before and after the intervention, and thus the risk of bias was low
Selective reporting (reporting bias)Low riskThere was no evidence of selective reporting, since results for all outcomes listed in the methods section were presented
Other biasHigh riskThe analysis did not allow for clustering

Cocanour 2006

Methods

Study design: ITS

Data collection: The Infection Control Practitioner reviewed the patients charts, cultures, and radiology results several times per week and monitored the patients for development of nosocomial infections

Definition of VAP: Based on the NNIS definition

Type of ventilators/respiratory equipment: Not specified in the paper

Targeted behaviour: Improve procedures (appropriate management of mechanically ventilated patients to prevent VAP)

Participants

Providers:

ICU team (unclear number of PGY-2 and PGY-1 surgery residents, PGY-3 and PGY-1 anaesthesia residents, surgical and anaesthesia critical care fellows and a critical care board certified surgeon or anaesthesiologist attending); no provider characteristics reported

Patients: Unclear number of (primarily) trauma patients on mechanical ventilator (approximately 10% to 15% were general surgery and other surgical subspecialty patients). Cardiovascular, neurosurgery, burn, and transplant patients were not admitted to this unit; no patient characteristics reported

Setting: 20 beds shock trauma ICU at a 690 bed tertiary university affiliated Texas hospital

Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: Mechanical ventilator

Evidence base of recommendation: The intervention was based on CDC guidelines for prevention of nosocomial pneumonia

Clinical practice guideline:

The ventilator bundle incorporated the CDC Guidelines for Prevention of Nosocomial pneumonia and included

  • Head of bed elevation

  • Peptic ulcer prophylaxis

  • Endotracheal tube suctioning

  • Handwashing

  • Getting the patient out of bed

  • Oral care

  • Glove and nonpermeable apron use

  • Use of sleeved Yankauers

  • Changing nasogastric irrigation fluids daily

  • Chlorhexidine baths twice weekly

  • Strict glucose control

Type of intervention: Professional intervention

Format: Unclear, defined only as a performance improvement project

Description of intervention:

1-Knowledge translation activities

The STICU Infection Control Guidelines were published and made available to the STICU faculty and staff. A core group of leaders in the hospital and shock trauma ICU was assembled that included the hospital’s director of performance improvement, the short term ICU medical director, the infection control practitioner assigned to the shock trauma ICU, the shock trauma ICU Pharmacist, the shock trauma ICU respiratory supervisor, the shock trauma ICU nursing director, shock trauma ICU nurse manager, and senior nursing leaders from both the day and night shift, who were all involved with either or both of the improvement projects

2-Educational intervention: No information

3-Feedback on infection rate

Data on shock trauma ICU infection rate was reported to the shock trauma ICU personnel, shock trauma ICU attendings, and the hospital’s performance improvement committee and Infection Control Committee on a monthly basis

Timing:

a) Frequency and number of events: Not specified

b) Duration of intervention: June 2002 to September 2002 (4 months)

c) Period after the intervention during which outcomes were measured: 4 months

Outcomes
  • VAP rate three months after the intervention

Outcomes that could not be reanalysed and therefore not included in this review :

VAP rate after the second intervention (audit and feedback on the VAP bundle); compliance rates, total cost of shock trauma ICU and the patients' costs

Notes

The study ignored secular (trend) changes and performed a simple t-test of the pre- versus post-intervention periods

Data were extracted from graph and reanalysed by reviewer

Risk of bias
BiasAuthors' judgementSupport for judgement
Intervention independent of other changesHigh risk

See p.123, Col 1, Para 3

Quote:

"In addition to the ventilator bundle implementation, tight glucose control was a separate performance improvement project"

This project started in March 2002, during the baseline period for the VAP bundle intervention. Two separate improvement projects (not further described) took place at the time of the intervention, and the ventilator bundle was part of one of them

Shape of the intervention effects pre-specifiedLow riskAllthough the authors described the intended direction of effect of the intervention, they did not describe if they expected a step change or a change in slope. However, since all studies were reanalysed by the review authors the risk of bias was low
Appropriate analysis (secular trends taken into account)Low riskSecular trends were not taken into account in the analysis. Data reanalysed and adjusted for pre-intervention trend by review authors
Intervention unlikely to affect data collectionLow riskRoutine collection of objective outcome data: Infection Control Practitioner reviewed their charts, cultures, and radiology results several times per week
Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe primary outcome (VAP rate) was objective and based on a standard definition
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo information in the text
Selective reporting (reporting bias)Low riskNo mention of protocol for study, therefore we are unable to assess if all outcomes are reported
Other biasHigh riskRisk of performance bias due to a decreased turnover of shock trauma ICU registered nurses and utilisation of agency nurses during the intervention

Coopersmith 2002

Methods

Study design: ITS

Data collection: All patients admitted to the ICU were followed prospectively for CLABSIs by an infection control team.

Definition of CLABSIs: CLABSIs were classified as primary or secondary based upon CDC NNIS definition. Primary bloodstream infection (bacteraemia) was defined as 1) recognised pathogen isolated from blood culture not related to infection at another site or 2) fever 38.5°C, chills or hypotension, and either of the following: a) common skin contaminant isolated from two blood cultures drawn on separate occasions, within 24 hrs, unrelated to infection at another site, or b) common skin contaminant isolated from a blood culture from a patient with an intravascular device and the physician institutes appropriate antimicrobial therapy. Secondary bacteraemia was defined as bloodstream infection, which develops as a result of a documented infection with the same microorganism at another body site

Catheters used: A small number (estimated to be between 1% and 2%) of Chlorhexidine and Silver sulphadiazine-impregnated catheters were inserted when patients were clinically judged to need four CVC lumens for access purposes. Quadruple-lumen,antibiotic-impregnated catheters were used in both the pre- and post-intervention time periods, but their accessibility was specifically limited after the implementation of the education module. Peripherally inserted central lines were excluded from analysis

Targeted behaviour: improve procedures (CVC insertion and care to decrease the rate of primary CLABSIs)

Participants

Providers: 52 healthcare professionals (49 nurses, 1 attending physician, and 2 critical care fellows);

no characteristics of healthcare professionals provided

Patients: All patients (4283) admitted to the ICU; pre-intervention period: 2188 patients; Post-intervention period: 2095 patients

Age: not reported

Gender: Percentage females; Pre-intervention: 40.2; Post-intervention: 44.7

APACHE score: not reported

Ventilated patients, month: Pre-intervention: 68.3; Post-intervention: 66.3

Length of mechanical ventilation, days: Pre-intervention: 2.5; Post-intervention: 2.8

Patient characteristics were similar during both time periods

Setting: One 18 bed surgical/burn/traumaI ICU at an urban teaching hospital;

Patient census, month: Pre-intervention: 121.6; Post-intervention: 115.6

Occupancy, %: Pre-intervention: 85.8; Post-intervention: 83.7

Length of stay, days 3: Pre-intervention: 3.7; Post-intervention: 4.0

CVCs placed, month Pre-intervention: 40.2; Post-intervention: 40.4

Country: USA

Targeted behaviour: improved CVC insertion and care

Interventions

Infection-associated invasive medical device addressed by intervention: Central line catheters

Evidence base of recommendation: Based on local policy and CDC guideline

The clinical practice guideline addressed:

  • Handwashing and aseptic technique

  • Methods for detecting potential clinical signs and symptoms of local infection

  • Technique for sending catheter-tip culture

  • Routine catheter site care

  • Replacing administration sets and fluids

  • Cleaning and changing injection ports and luer-lock caps

  • How to handle parenteral fluids and multidose vials, and procedure for drawing blood cultures

The guideline for catheter maintenance included:

  • Changing injection caps and intravenous tubing for fluids and medications every 72 hrs (or immediately if blood accumulated in or around the cap or its integrity was compromised)

  • Changing transparent line dressings every 7 days

  • Changing gauze dressings every 48 hrs

  • Immediate replacement of dressings that were either soiled or no longer occlusive

Type of intervention:

Format: Paper, interpersonal,

Description of intervention:

1-Knowledge translation activities

a. A multidisciplinary task force (a physician and infection control practitioners) compared hospital policy with CDC recommendations on insertion and care of CVCs

b. Registered nurses in the ICU completed a 17-question survey about their own CVC care practice, and filled out a 13-question observation survey documenting physician practice they witnessed during CVC insertion

c. Based upon this information, the task force designed an education module to improve practices related to CVC insertion and care

2-Educational intervention

a. The educational programme consisted of a 10-page self study module on risk factors and practice modifications involved in catheter-related infections as well as a verbal in-service at staff meetings

b. Each participant was required to take a pretest before taking the study module and an identical test after its completion

c. Fact sheets and posters reinforcing the information in the study module were also posted throughout the ICU

d. Lectures were given to a subset of attending physicians, fellows, and a single group of residents rotating through the ICU. No resident placing CVCs participated in the full education module

3-Feedback: Monthly updates on the ICU’s infection rate and comparisons to the NNIS data were presented at staff meetings pre- and post-intervention

Timing:

a) Frequency and number of events: Not reported

b) Duration of intervention: Not reported

C) Period after the start of the intervention under which outcomes were measured: 18 months

Two other interventions were implemented sequentially in the ICU (bedside audit and behavioural intervention), however the number of data between them were too small to permit reanalysis, and these interventions were excluded

Outcomes
  • CLABSI rate at 3, 6, 9 and 12 months post-intervention reanalysed by the review authors

Outcomes that could not be reanalysed and therefore not included in this review :

  • Cost savings

NotesThe study ignored secular (trend) changes and performed a simple t-test of the pre- versus post-intervention periods. Data were extracted from graph and reanalysed by reviewers
Risk of bias
BiasAuthors' judgementSupport for judgement
Intervention independent of other changesUnclear riskIt was not explicitly stated in the paper if the intervention was independent of other changes
Shape of the intervention effects pre-specifiedLow riskAlthough the authors described the intended direction of effect of the intervention, they did not describe if they expected a step change or a change in slope. However, since all studies were reanalysed by the review authors the risk of bias was low
Appropriate analysis (secular trends taken into account)Low riskSecular trends were not taken into account in the analysis. Data reanalysed and adjusted for pre-intervention trend by review authors
Intervention unlikely to affect data collectionLow riskRoutine collection of objective outcome data: all patients admitted to the ICU were followed in a similar fashion to those admitted in the pre-intervention period
Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe primary outcome (CLABSI rate) was objective and based on a standard definition
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo information in the text
Selective reporting (reporting bias)Unclear riskNo mention of protocol for study, therefore we are unable to assess if all outcomes are reported
Other biasHigh riskDifferent type of catheters were used before (antimicrobic coated) and after the intervention (not coated)

Kaye 2000

Methods

Study design: ITS

Data collection: Not reported

Definition of VAP: Pneumonia was defined in accordance with NNIS Manual criteria. The patient must have rales or dullness to percussion or a chest radiograph with new or progressive infiltrates, consolidation, cavitation, or pleural effusion. Further, the patient must meet at least one of the following requirements: new onset of purulent sputum or change in character of sputum; organisms collected from blood cultures; isolated pathogen from transtracheal aspirate, bronchial brushing, or biopsy; isolation of virus or detection of viral antigen in respiratory secretions; or histopathologic findings of pneumonia. Nosocomial pneumonia was determined to be VAP if onset of infection was within 48 hours of ventilator use

Type of ventilator/respiratory equipment: Not described

Targeted behaviour: Improve procedures (changes of all aspect of care of patient requiring mechanical ventilation)

Participants

Providers: Unclear number of nurses, respiratory therapists, and other medical staff; no provider characteristics provided

Patients: Unclear number of patients requiring mechanical ventilation; no patient characteristics provided

Setting: 4 medical-surgical ICUs at a university hospital; unclear no of beds

Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: mechanical ventilator

Evidence base of intervention: guideline development based on literature review

The Clinical practice guideline included:

  • Identification of indication for endotracheal intubation

  • Handwashing before and after therapy

  • Assemble the required equipment

  • Insert endotracheal tube while monitoring the patient's heart rate blood pressure, and arterial oxygen level by oxymetry

  • Assess for proper tube placement after insertion

  • Maintain endotracheal tube placement

  • Identify criteria for endotracheal extubation; documents all pertinent information

Type of intervention:

A- Organisational intervention

1-Equipment and supply purchases

2-Change in routine procedures: discontinuation of saline irrigation and requests for bicarbonate lavage orders for tenacious secretions; sterile tracheostomy tubes were substituted for obturator taped to the wall

3-Development of ventilator management protocol to decrease ventilator days

B- Professional intervention

Format: Paper, interpersonal,

Description of intervention:

1-Knowledge translation activities: A multidisciplinary Critical Care Bug Team identified issues, evaluated patient care processes, performed literature searches, monitored compliance, implemented policy and procedure changes, purchased equipment and devised a VAP protocols and competency-based orientation programmes to decrease ventilator days

2-Educational intervention:

Self education study packet was devised to ensure staff competency and provide a source of ongoing instruction for nurses, respiratory therapists, and other medical staff The clinical implications of resistant pathogens were added to curricula, and a monthly Bugline newsletter was developed for hospital distribution. Each month, Bugline features an important aspect of infection control with a self learning section and accompanying education credit

3-Audit and feedback

Formal surveys performed by registered nurses and clinical nurse specialist evaluated equipment maintenance and application, adherence to protocols, infection control practices,and standard nursing care. Weekly list of infection and graphics of infection rates were provided for staff

4-Handwashing campaign: Patient and family education, and a hospital-wide campaign to increase handwashing compliance was done

a) Frequency and number of events: Not reported

b) Duration of intervention: Some elements of intervention occurred during whole study period

c) Period after the start of intervention during which outcomes were measured: 9 months

Outcomes
  • VAP rates at 3, 6 and 9 months after the intervention

Outcomes that could not be reanalysed and therefore not included in this review : none

NotesThe study has ignored secular (trend) changes and performed a simple t-test of the pre- versus post-intervention periods. Data extracted from graph and reanalysed by reviewers
Risk of bias
BiasAuthors' judgementSupport for judgement
Intervention independent of other changesHigh riskIt was not explicitly stated in the paper if the intervention was independent of other changes
Shape of the intervention effects pre-specifiedLow riskAlthough the authors described the intended direction of effect of the intervention, they did not describe if they expected a step change or a change in slope. However, since all studies were reanalysed by the review authors the risk of bias was low
Appropriate analysis (secular trends taken into account)Low riskSecular trends were not taken into account in the analysis. Data reanalysed and adjusted for pre-intervention trend by review authors
Intervention unlikely to affect data collectionHigh riskNo information about the process of data collection in the text. Further, the VAP diagnoses were based in part on subjective judgements, and therefore the risk of bias was high
Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe primary outcome (VAP rate) was objective and based on a standard definition
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo information in the text
Selective reporting (reporting bias)Low riskAll relevant outcomes in the methods section are reported in the result  section

Miller 2010

Methods

Study design: ITS

Data collection: PICU teams monthly collected and submitted the data

Definition of CLABSI: Based on the CDCs criteria used for CLABSI

Type of catheters: Polyurethane or Teflon CVC catheters

Targeted behaviour: Improve procedures (appropriate insertion and management of central line catheters)

Participants

Providers: Unclear number and type of health care professionals; no provider characteristics reported

Patients: Unclear number of patients with a CLABSI; no patient characteristics reported

Setting: 29 PICUs at 27 hospital (12 PICUs with 10 to 16 beds; 13 PICUs with 17 to 27 beds and 4 PICUs with 28 to 36 beds; most of the PICUs were mixed paediatric and cardiac PICUs, with 2 being solely paediatric cardiac ICUs. The majority of sites had level 1 trauma centres and performed solid-organ transplants, bone marrow transplants, and extracorporeal membrane oxygenation

Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: Central line catheters

Evidence base of recommendation:

1. The insertion bundle: Included evidence based procedures recommended by the CDC that have been proven to be effective in adult patients or in a single institutional PICU

2. The maintenance bundle: Created by using some of the pertinent CDC guidelines; however, consensus of mostly expert paediatric physicians and nurses were involved in the development of this effort

Clinical practice guideline:

Insertion bundle:

  • Wash hands before the procedure

  • For all children aged 2 months, Chlorhexidine gluconate should be used to scrub the insertion site for 30 seconds for all areas except the groin, which should be scrubbed for 2 minutes. Scrubbing should be followed by 30 to 60 seconds of air drying

  • No iodine skin prep or ointment should be used at the insertion site

  • Prepackage or fill the insertion cart, tray, or box including full sterile barriers

  • Create an insertion checklist, which empowers staff to stop a non-emergent procedure if it does not follow sterile insertion practices

  • Use only polyurethane or Teflon catheters

  • Conduct insertion training for all care providers, including slides and videos

Maintenance bundle:

  • Assess daily whether catheter is needed

  • Catheter-site care: iodine ointment should not be used; use a Chlorhexidine gluconate scrub to sites for dressing changes (30-seconds scrub, 30-seconds air-dry)

  • Change gauze dressing every 2 days unless they are soiled, dampened, or loosened

  • Change clear dressings every 7 days unless they are soiled, dampened, or loosened

  • Use a prepackaged dressing-change kit or supply area

  • Catheter hub, cap, and tubing care: replace administration sets, including add-on devices, no more frequently than every 72 hours unless they are soiled or suspected to be infected

  • Replace tubing that is used to administer blood, blood products, or lipids within 24 hours of initiating infusion

  • Change caps no more often than every 72 hour (or according to manufacturer recommendations); however, caps should be replaced when the administration set is changed

  • The prepackaged cap-change kit, or supply area elements to be designated by the local institution

Type of intervention: Professional intervention

Format: Computer, interpersonal

1. Knowledge translation activities

2- Educational intervention

Quality-improvement methods was used by teams at the participating PICUs to support adoption of the bundles. Each team (leader/physician champion, quality improvement leaders, infectious disease physicians) used methods of small tests of change, tested and implemented changes to make their care practices commensurate with the collaborative’s recommended central line insertion and maintenance-care practices

The PICU teams participated in four face-to-face learning workshop and monthly conference calls.

Timing:

a) Frequency and number of events: Monthly

b) Duration of intervention: Unclear

c) Period after the start of the intervention during which outcomes were reported: 16 months

Outcomes
  • CLABSI rate at 3, 6,9 and 12 months after the intervention

Outcomes that could not be reanalysed and therefore not included in this review :

  • Compliance rate

NotesThe study had taken into account secular (trend) changes, but to facilitate comparison with the other reanalysed studies, the raw data were extracted from graphs and reanalysed by reviewers
Risk of bias
BiasAuthors' judgementSupport for judgement
Intervention independent of other changesUnclear riskIt was not explicitly stated in the paper if the intervention was independent of other changes
Shape of the intervention effects pre-specifiedLow riskAlthough the authors described the intended direction of effect of the intervention, they did not describe if they expected a step change or a change in slope. However, since all studies were reanalysed by the review authors the risk of bias was low.
Appropriate analysis (secular trends taken into account)Low riskSecular trends were not taken into account in the analysis. Data reanalysed and adjusted for pre-intervention trend by review authors
Intervention unlikely to affect data collectionLow riskRoutine collection of objective outcome data: The number of CLABSI cases and the monthly total of central line days per PICU were collected by trained, hospital-based, infection control practitioners in accordance with CDC definitions
Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe primary outcome (CLABSI rate) was objective and based on a standard definition
Incomplete outcome data (attrition bias)
All outcomes
Low riskThe effects of the missing data, 2 sensitivity analyses models by imputing data for each missing data point were ran
Selective reporting (reporting bias)Unclear riskNo mention of protocol for study, therefore we are unable to assess if all outcomes are reported

Parra 2010

Methods

Study design: ITS

Data collection: A designated nurse in each ICU recorded and reported monthly to a Committee for Infection Control and Antibiotics Policy member the numbers of confirmed episodes of CLABSI and CVC-days

Definition of CLABSI: Infectious Diseases Society of America and CDC criteria was used to define CLABSI. A CLABSI was considered to be ICU-related if it occurred at least 48 hours after admission to or up to 48 hours after discharge from the ICU

Type of catheters: Not described in the paper

Targeted behaviour: Improve procedures (care provided to patients with central line catheters to prevent CLABSI)

Participants

Providers: Healthcare workers (n = 155): n = 125 nurses (including 22 students) and n = 30 physicians (including 10 residents); no characteristics of health professionals provided

Patients: Unclear number of patients with a central line catheter who developed CLABSI; no patient characteristics reported

Setting: 3 adult ICUs (medical, general post-surgery, and cardiac post-surgery; 60 beds in total) at a university hospital

Country: Spain

Interventions

Infection-associated invasive medical device addressed by intervention: Central line catheters

Evidence base of recommendation: Based on guidelines for the prevention of intravascular catheter–related infection from Infectious Diseases Society of America CDC:

Clinical practice guideline:

  • Use of a full sterile sheet when preparing the CVC insertion site

  • Choose the subclavian vein as the preferred site of insertion

  • Use closed needleless catheter connection systems

  • Desinfect of clean skin with 2% Chlorhexidine gluconate solution before CVC insertion

CVC site dressing regimens

  • Aseptic technique during CVC care and maintenance (handwashing and use of gloves)

  • Optimal frequency of CVC dressing replacement

  • Use of parenteral nutrition through a multilumen CVC

Management of suspected CLABSI (change avoiding guide wire technique)

Replacement of administration sets,needleless systems, and parenteral fluids

Type of intervention: Professional intervention

Format: Interpersonal, paper

Description of intervention:

1-Knowledge translation activities: Not reported

2-Educational intervention: A short lecture (15 minutes) on 10 main points of the IDSA-CDC guidelines for the prevention of intravascular catheter–related infections was given to all ICU workers (physicians, residents, nurses, and students) on all shifts. The lecture was preceded (a few minutes before) and followed (6 months after) by identical multiple-choice questionnaires to assess healthcare worker knowledge of the 10 selected points. Each test took an average of 15 to 20 minutes to complete

Timing:

a) Frequency and number of events: One

b) Duration of intervention: 15 minutes

c) Period after the start of the intervention during which outcomes were reported: 26 months

Outcomes

CLABSI rate at 3, 6, 9, 12, 18 and 24 months after the start of the intervention

Outcomes that could not be reanalysed and therefore not included in this review : none

NotesThe study ignored secular (trend) changes and performed a simple t-test of the pre- versus post-intervention periods. Data were extracted from graphs and reanalysed by reviewers
Risk of bias
BiasAuthors' judgementSupport for judgement
Intervention independent of other changesLow risk

See p.964, Col 2, Para 3

Quote:

"No other interventions potentially affecting the incidence of CLABSI were performed: there were no changes in hospital policy on prevention of CLABSI or in the availability of supplies used (type of central venous catheter [CVC], connectors,antiseptics, or other supplies used in CVC insertion and care). No changes in CLABSI diagnosis procedures were introduced in the microbiology laboratory. The staff members responsible for data collection did not change during the study period"

Shape of the intervention effects pre-specifiedLow riskAlthough the authors described the intended direction of effect of the intervention, they did not describe if they expected a step change or a change in slope. However, since all studies were reanalysed by the review authors the risk of bias was low
Appropriate analysis (secular trends taken into account)Low riskSecular trends were not taken into account in the analysis. Data reanalysed and adjusted for pre-intervention trend by review authors
Intervention unlikely to affect data collectionLow riskRoutine collection of data: The staff members responsible for data collection did not change during the study period
Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe primary outcome (CLABSI rate) was objective and based on a standard definition
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot stated in the paper
Selective reporting (reporting bias)Unclear riskNo mention of protocol for study, therefore we are unable to assess if all outcomes are reported

Salahuddin 2004

Methods

Study design: ITS

Data collection: Infection control nurses collected and reported VAP rate

Definitions: VAP was defined using the CDC criteria of: new or progressive chest radiographic infiltrates persisting for 72 hours and two or more of the following: temperature > 38.8 C or < 35.5 C, leucocytosis > 10 X 109/L or < 3 X 109/L, positive endotracheal secretion culture (> 104 cfu/mL)

Type of ventilators/respiratory equipment:Not described

Targeted behaviour: I mprove procedures (appropriate management of mechanically ventilated patients to prevent VAPs)

Participants

Providers: Certified intensives, anaesthetist and clinical, resident house staff, critical care nurses and technicians; provider characteristics not reported

Patients: Patients on continuous mechanical ventilation for > 48 hours (n = 677);

Pre-intervention period: n = 333 patients; Post-Intervention period: n = 344 patients

Medicine patients: Pre-intervention period: 212 (64%); Post-intervention period: 247 (72%)

Surgical patients: Pre-intervention period: 121 (36%); Post-intervention period: 97 (28%)

Most common diagnosis:

Sepsis: Pre-intervention period: 52 (16%); Post-intervention period: 64 (19%), P = 0.302

Pneumonia: Pre-intervention period: 33 (10%); Post-intervention period: 28 (8%), P = 0.421

Neurosurgical: Pre-intervention period: 24 (7%); Post-intervention period: 24 (7%), P = 0.907

COPD: Pre-intervention period: 20 (6%); Post-intervention period: 22 (6%), P = 0.834

Quarterly ventilator day: Pre-intervention period: 789 (731 to 832); Post-intervention period: 728 (711 to 739), P = 0.061

non-invasive positive pressure ventilation: Pre-intervention period: 42 (13%); Post-intervention period: 53 (15%), P = 0.295

Setting: One 10 bed Medical and Surgical ICU at a 495 bed, primary and tertiary care teaching hospital

Country: Pakistan

Interventions

Infection-associated invasive medical device addressed by intervention: Mechanical ventilator

Evidence base of recommendation:

Two physicians and the ICU head nurse reviewed the results of a literature search of articles on prevention of VAP. A preventive practice guideline was devised based on this search

Clinical practice guideline:

  • Handwashing between all patient contacts on entering and exiting the ICU

  • Protective gown and glove use for specific groups of patients as recommended by the CDC and Prevention guidelines

  • Place mechanically ventilated patients in a semirecumbent position by maintaining the head of the bed at approximately

  • Avoid gastric over-distension; monitor gastric residual volumes before administering scheduled enteral feedings (maximum gastric residual 150 to 200 mL)

  • Use non-invasive positive pressure ventilation to avoid endotracheal intubation

  • Use non-invasive positive pressure ventilation to facilitate early extubation, to minimise the duration of endotracheal intubation

  • Use orogastric tubes whenever possible; as nasogastric tubes may increase the incidence of nosocomial sinusitis

  • Provide adequate sedation to avoid accidental extubation; sedation score scale maintained between 3 to 5

  • Prevent accidental extubation by securing the endotracheal tube at the bedside and using soft restraints according to hospital policy; whenever necessary to avoid self-extubation

  • Provide oral hygiene with a Chlorhexidine-based oral rinse at least daily

  • Dispense with inline humidifies from the ventilator circuits and use heat and moisture exchange filters

Type of intervention: Professional intervention

Format: Interpersonal, paper

Description of intervention:

1. Knowledge translation activities: Not reported

2. Educational intervention

1-Multidisciplinary: weekly lectures, departmental presentations

2-Reinforcement at the bedside

3. Reminders Visual aids posted in the ICU

Timing:

a) Frequency and number of events: Weekly lectures, unknown frequency of departmental presentations

b) Duration of intervention: Throughout the study

c) Period after the start of the intervention during which outcomes were reported: 12 months

Outcomes

VAP rates at 3, 6 and 9 months after start of the intervention.

Outcomes that could not be reanalysed and therefore not included in this review : none

NotesThe study ignored secular (trend) changes and performed a simple t-test of the pre- versus post-intervention periods. Data extracted from graphs and reanalysed by reviewers
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk 
Allocation concealment (selection bias)Low risk 
Intervention independent of other changesUnclear riskIt was not explicitly stated in the paper if the intervention was independent of other changes
Shape of the intervention effects pre-specifiedLow riskAlthough the authors described the intended direction of effect of the intervention, they did not describe if they expected a step change or a change in slope. However, since all studies were reanalysed by the review authors the risk of bias was low
Appropriate analysis (secular trends taken into account)Low riskSecular trends were not taken into account in the analysis. Data reanalysed and adjusted for pre-intervention trend by review authors
Intervention unlikely to affect data collectionLow riskRoutine collection of data: The hospital infection control team regularly surveyed all ICU patients for occurrence of VAP
Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe primary outcome (VAP rate) was objective and based on a standard definition
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot reported in the text
Selective reporting (reporting bias)Unclear riskNo mention of protocol for study, therefore we are unable to assess if all outcomes are reported
Other biasUnclear riskThe comparatively larger proportion medicine patients, and lower number of surgical patients (not tested for statistical significance) in the post-intervention group, may have biased the results

Sannoh 2010

Methods

Study design: ITS

Data collection: Infection control nurse did the surveillance of the CVC infection using standard definitions

Definition of CLABSI: A positive blood culture with a catheter in situ for at least 48 hours without any other source of infection

Type of catheters: umbilical artery catheters, (VYGON Corporation,Montgomeryville, PA) and umbilical vein catheters had a stop cork (Smith Medical MD, Inc,St. Paul, MN), with either a Luer Lock and an attached syringe for blood draws (Becton Dickinson, Franklin Lakes, New Jersey) or a Smartsite needless connector (Alaris,CareFusion, San Diego, California) for continuous or intermittent infusions, and peripherally inserted CVC catheters

No of catheters: Pre-intervention period: 36 Broviac catheters, 76 PICCs, 60 umbilical artery catheters and umbilical vein catheters, and 70 umbilical vein catheters;;

Post-intervention period: 41 Broviac catheters, 93 peripherally inserted CVC catheters, 77 umbilical artery catheters and umbilical vein catheters, and 97 umbilical vein catheters

Targeted behaviour: Improve procedures (appropriate management of neonates with CVC to reduce CLABSI)

Participants

Providers: Nurses; about 90% of the neonatal ICU nurses; no characteristics of healthcare professionals provided;

CVC insertion and maintenance are performed primarily by nurses

Patients: Neonates with a CVC in place for more than 24 hours; n = 373; Pre-intervention period: n = 163; Post-intervention period: n = 210; patient demographic and clinical characteristics were similar in the two periods.

Birth weight, g: Pre-intervention period: 1769 ± 1136; 1275 [499 to 5418]; Post-intervention period: 1751 ± 1079; 1365 [305 to 4495]

Birth weight, 1000 g: pre-intervention period: 40% (65); Post-intervention period: 38% (79)

Gestational age, weeks: pre-intervention period: 31 ± 5; 29 [23 to 42]; Post-intervention period: 31 ± 6; 30 [21 to 41]

Female sex: Pre-intervention period: 46% (75); Post-intervention period: 46% (96)

Ventilator-days: Pre-intervention period: 14 ± 19; 6 [1 to 113]: Post-intervention period: 16 ± 21; 6 [1 to 164]

Length of stay, days: Pre-intervention period: Time 1: 46 days; Time 2: 6 days; Time 3: 38 days; Mean 37 (range 1 to 194 days); Post-intervention period: Time 1:43 days; Time 2: 6 days; Time 3: 38 days; Mean: 30 days, (range 2 to 273 days)

Mortality : Pre-intervention period: 13% (22); Post-intervention period: 15% (31)

Country: USA

Setting: 50-bed regional neonatal intensive care referral unit

Interventions

Infection-associated invasive medical device addressed by intervention: central line catheters

Evidence base of recommendation: based on CDC recommendations

Clinical practice guideline:

Catheter hub care policy and new catheter dressing policy:

  • During catheter hub access, the surface area of the needleless port and the outer surface of the stop cork or Luer-lock threads of the catheter hub must be scrubbed in a circular motion with friction using 2% Chlorhexidine in 70% isopropyl alcohol for 10 seconds and allowed to dry for 30 seconds

  • It is mandatory: standard hand hygiene, the use of clean gloves and the establishment of sterile fields with 4’’ 3 4’’ gauze under the catheter port and the syringes used to access the hub with medications and flushing solution

  • Change dressings only when soiled, instead of routine weekly changes

Type of intervention: Professional intervention

Format: Interpersonal, audio-visual, paper

Description of intervention:

1. Knowledge translation activities

Not reported

2. Educational intervention

1. One month of in-service was provided to the health care team in multiple sessions. Each session consisted of a 15-minute DVD demonstrating the 9 steps of catheter hub care to the health care team in small groups

2. The DVD was available on the neonatal ICU Web site for the health care team to view at any time

3 Reminders:Catheter hub care checklists were placed at every bedside

4. CVC care cart: Placed in each room to facilitate ready access to cleaning materials

5. Hand hygiene campaigns: Implemented throughout the study period

Timing:

a) Frequency and number of events: In-service consisting of one 15-minute DVD session

b) Duration of intervention: One month

c) Period after the start of the intervention during which outcomes were reported: 12 months for CLABSI and device utilisation rates

Outcomes
  • CLABSI rate at 3, 6, 9 and 12 months after the start of the intervention

  • Device utilisation rate at 3, 6, 9 and 12 months after the start of the intervention

Outcomes that could not be reanalysed and therefore not included in this review :

  • CLABSI rate by catheter type and birth weight category

  • adherence score

  • cost savings secondary to the decrease in CLABSI

NotesThe study ignored secular (trend) changes and performed a simple t-test of the pre- versus post-intervention periods. Data extracted from graphic and reanalysed by reviewers
Risk of bias
BiasAuthors' judgementSupport for judgement
Intervention independent of other changesHigh risk

See p.425, Col 2, Para 2

Quote:

"Hand hygiene campaigns that had been implemented were reinforced throughout the study period"

Shape of the intervention effects pre-specifiedLow riskAlthough the authors described the intended direction of effect of the intervention, they did not describe if they expected a step change or a change in slope. However, since all studies were reanalysed by the review authors the risk of bias was low
Appropriate analysis (secular trends taken into account)Low riskSecular trends were not taken into account in the analysis. Data reanalysed and adjusted for pre-intervention trend by review authors
Intervention unlikely to affect data collectionLow riskRoutine collection of data: Surveillance for CVC infection was done by an infection control nurse, using standard definitions
Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe primary outcome (CLABSI rate) was objective and based on a standard definition
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot specified in the text
Selective reporting (reporting bias)Unclear riskNo mention of protocol for study, therefore we are unable to assess if all outcomes are reported
Other biasLow riskNo evidence of other risk of bias. The 2 groups were similar with respect to birth weight, percentage of extremely low birth weight infants, and all other demographic and clinical characteristics (Table 2)

Sona 2009

Methods

Study design: ITS

Data collection: All patients admitted to the ICUs were prospectively surveyed for the occurrence of VAP by members of the Hospital Infection Control Team

Definition of VAP: Based on NNIS criteria

Type of ventilators: Not described

Targeted behaviour: Improve procedures (oral care of patients with mechanical ventilator to reduce VAP)

Participants

Providers: Attending and fellow medical staffs and incoming residents (unclear number); 80-member registered nursing staff; no characteristics of healthcare professionals provided

Patients: All patients admitted to the surgical ICU that required mechanical ventilation n = 1648; Pre-intervention period: n= 777; Post-intervention period n = 871 patients

Age (years): Pre-intervention: 56.2 (17 to 95); Post-intervention: 57.1 (14 to 99), P = 0.58

Ventilator days: Pre-intervention: 4606;  Post-intervention: 4158, P < 0.001

Ventilator days per patient: Pre-intervention: 5.9 4.8, P < .01

APACHE II score: Pre-intervention: 17.7 (2 to 41); Post-intervention: 18.1 (3 to 48), P = 0.36

ICU length of stay (days): Pre-intervention: 8.9 (0.3 to 70.4); Post-intervention: 9.8 (.02 to 62.1), P = 0.15

Hospital length of stay of patients (days): Pre-intervention: 26.4 (1 to 144); Post-intervention: 23.5 (1 to 193), P = 0.09

Setting: One 24-bed surgical ICU in 1344-bed tertiary care, university-affiliated teaching hospital (surgical ICU admits all non-cardiothoracic and non-neurosurgical critical care surgical and trauma patients in the hospital)

Unit admissions: Pre-intervention period: n = 1520; Post-intervention period:n = 1747

Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: Mechanical ventilator

Evidence base of recommendation:

The hospital policy was based on literature reviews of evidence

Clinical practice guideline:

  • Mechanical cleaning of the teeth or gums to remove plaque and application of an oral antimicrobial

  • Brush teeth for 1 to 2 minutes using floor stock brush and paste containing the active ingredient sodium mono fluoro phosphate 0.7% every 12 hours

  • Rinse the mouth with tap water with an irrigating syringe and suction with an oral suction handle

  • For patients without teeth, clean the gums with toothpaste on a foam sponge, and then rinse with water and suction as above

  • Immediately following water rinse, apply 15 mL of Chlorohexidine to all oral surfaces using a foam sponge, suction all excess solution from the mouth

  • No further oral swabbing or liquids are allowed for 30 minutes after the procedure. Document the full oral care protocol every 12 hours on the medication administration record

Type of intervention: Professional intervention

Format: Interpersonal, paper,

Description of intervention:

1. Knowledge translation activities

Not reported

2. Educational intervention:

The attending and fellow medical staffs of the unit were educated on the protocol through the SICU Quality Improvement meeting. Monthly updates were provided to all incoming residents about the oral care protocol and order set.

Education content and materials included rationale and aims of the study, review of the preprinted order sets, written protocol, and pictorials demonstrating all steps of the procedure including documentation

3. Reminders:

A preprinted order set was designed and placed in all admission packets.The pictorials demonstrating all steps of the procedure were laminated and placed in resource manuals at every patient bedside

4. Audit and feedback:

Two Clinical Nurse Specialists audited the compliance rates via biweekly review of the medication administration record and verification of oral care supplies. If a patient did not have an order and was an appropriate candidate, the nursing staff approached the medical team to obtain an order. If the order was present but the protocol had not been initiated, the clinical nurse specialist discussed it with the patient’s nurse and assisted with implementation of the protocol.

Updates on the unit’s VAP rates were reported monthly at the unit’s quality improvement multidisciplinary meeting. Monthly graphs were reviewed comparing pre-intervention rates within the surgical ICU as well as published NNIS rates in comparable units

Timing:

a) Frequency and number of events: Monthly update to all incoming residents, bi-weekly reviews of compliance

b) Duration of intervention: Not clear

c) Period after the start of the intervention during which outcomes were reported: 12 months

Outcomes

VAP rate (and cost) at 3, 6 and 12 months after start of intervention (reanalysed by reviewers)

Outcomes that could not be reanalysed and therefore not included in this review :

protocol compliance, organism profile

NotesThe study ignored secular (trend) changes and performed a simple t-test of the pre- versus post-intervention periods and therefore the data were extracted from graphs and reanalysed by reviewers
Risk of bias
BiasAuthors' judgementSupport for judgement
Intervention independent of other changesLow risk

See p.56, Col 1, Para 3

Quote:

"The previously implemented interventions to reduce VAP were maintained in the same fashion as they had been done in the previous 5 years. No other interventions or studies were implemented between study periods"

Shape of the intervention effects pre-specifiedLow riskAlthough the authors described the intended direction of effect of the intervention, they did not describe if they expected a step change or a change in slope. However, since all studies were reanalysed by the review authors the risk of bias was low
Appropriate analysis (secular trends taken into account)Low riskSecular trends were not taken into account in the analysis. Data reanalysed and adjusted for pre-intervention trend by review authors
Intervention unlikely to affect data collectionLow riskRoutine collection of objective outcome data: All patients admitted to the SICU were prospectively followed for VAP by an infection control team throughout the study period
Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe primary outcome (VAP rate) was objective and based on a standard definition
Incomplete outcome data (attrition bias)
All outcomes
Low risk 
Selective reporting (reporting bias)Unclear riskNo mention of protocol for study, therefore we are unable to assess if all outcomes are reported
Other biasUnclear riskFew patient characteristics were reported, and it is unclear if the pre- and post-intervention group are comparable

Warren 2004

Methods

Study design: ITS

Data collection: Data were prospectively recorded by one of the investigators

Definition of CLABSI: CLABSI was defined as primary bacteraemia in the presence of a CVC. Secondary bacteraemia was defined as bloodstream infection that develops as a result of a documented infection with the same microorganism at another body site (CDC definition)

Type of catheters: The intravascular catheters (e.g., CVCs, dialysis catheters, pulmonary artery catheters) employed throughout the hospital during this study period were standard catheters without antimicrobial or antiseptic coatings. Arterial catheters were not surveyed as part of this investigation

Targeted behaviour: Improve procedures (care of patients with CVC to reduce CLABSI)

Participants

Providers: Unclear number of nurses and physicians; no provider characteristics presented

Patients: All patients admitted to the medical ICU with CVC (unclear number of patients); no patient characteristics provided

Country: USA

Setting: One medical 19-bed ICU at a university affiliated urban teaching hospital

Interventions

Infection-associated invasive medical device addressed by intervention: Central line catheters

Evidence base of intervention: ICU infection control committee revised the policies and procedures for CVC insertion and site maintenance

Clinical practice guideline:

  • Wash hands thoroughly or use an alcohol-based waterless disinfectant before and after patient contact

  • DIsinfect hands and wear sterile gloves when touching or changing the dressing on the catheter

  • Femoral catheters should be avoided

  • When placed in an emergency situation, the femoral catheter should be discontinued as soon as feasible

  • The person placing the catheter must wear sterile gown, sterile gloves, a mask, and a cap

  • Excessive hair around insertion site can be removed with scissors or clippers only

  • The insertion site and an area of at least 15 cm in diameter around the site shall be cleared with the appropriate skin antiseptic

  • Drape the insertion site using full sterile drape

  • Use sterile technique to apply transparent dressing to insertion site

  • Do not apply antimicrobial ointment to the insertion site unless the CVC is a dialysis catheter

  • Avoid changing catheters over a guide wire

  • Change transparent membrane dressing no more than every 7 d or when dressing becomes damp, loosened, or soiled

  • Follow hospital protocol for changing IV fluid administration sets and cleaning of injection ports with appropriate antiseptic prior to accessing

Type of intervention: Professional intervention

Format: Interpersonal, paper, computer

Description of intervention:

1. Knowledge translation activities

Monthly meetings of ICU infection control were held to educate the leadership of the unit on the problem of catheter-associated bloodstream infection; to review in detail the optimal practices for catheter insertion and maintenance in the unit, to describe the components of the education programme and their local implementation; to foster team building; to develop a strategy for the education of resident and attending physicians, and to have a feedback mechanism for potential problems encountered during the implementation phase of the study. Additional meetings were held by members of the ICU infection control committee to revise the policies and procedures for CVC insertion and site maintenance

2. Educational intervention

The educational programme included: a self-study module on risk factors and practice modifications involved in CLABSI; a 45 min lecture; posters, and fact sheets were distributed at each patient computer terminal located directly outside the patient room

3. Reminders

Fact sheets, and posters were displayed throughout the ICU describing the programme, and photographic guidelines were available at each bedside computer station illustrating the correct procedure for the insertion of CVCs and their subsequent maintenance to included dressing of the insertion site

4. Promotional campaign

Regular administration of lapel buttons to a staff member promoting the education programme was launched

5. Feedback: Monthly up-date of the CLABSI rates was posted in the ICU in multiple locations

Timing:

a) Frequency and number of events: Not reported

b) Duration of intervention: Not clear

c) Period after the start of the intervention during which outcomes were reported: 24 months

Outcomes

CLABSI rate at 3, 6, 9,12, 18 and 21 months after the start of the intervention (reanalysed by review authors)

Outcomes that could not be reanalysed and therefore not included in this review :

Costs

NotesThe study ignored secular (trend) changes and performed a simple t-test of the pre- versus post-intervention periods. Data extracted from graphic and reanalysed by reviewers
Risk of bias
BiasAuthors' judgementSupport for judgement
Intervention independent of other changesHigh risk

See p.1613, Col 1, Para 4

Quote:

"Patient-care policies and protocols in the medical ICUs remained unchanged during the study period except for the prevention of ventilator-associated pneumonia. A new policy for the prevention of ventilator-associated pneumonia was introduced in October 2000 and maintained throughout the duration
of the study"

Shape of the intervention effects pre-specifiedLow riskAlthough the authors described the intended direction of effect of the intervention, they did not describe if they expected a step change or a change in slope. However, since all studies were reanalysed by the review authors the risk of bias was low
Appropriate analysis (secular trends taken into account)Low riskSecular trends were not taken into account in the analysis. Data reanalysed and adjusted for pre-intervention trend by review authors
Intervention unlikely to affect data collectionLow riskRoutine collection of objective outcome data: During a 4-year period all patients admitted to the medical ICU were prospectively followed up by members of the hospital infection control team and surveyed for the occurrence of CVC-associated infection
Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe primary outcome (CLABSI rate) was objective and based on a standard definition
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot specified in the text
Selective reporting (reporting bias)Unclear riskNo mention of protocol for study, therefore we are unable to assess if all outcomes are reported
Other biasLow riskNo evidence of other risk of bias. The patients in the pre- and post-intervention groups were comparable

Zack 2002

  1. a

    Abbreviations
    APACHE II score: acute physiology and chronic health evaluation score
    CDC: Centers for Disease Control and Prevention
    CLABSI: central line-associated bloodstream infection
    CVC: central venous catheter
    DVD: digital video disc
    ICU: intensive care unit
    ITS: interrupted time series
    NNIS: National Nosocomial Infections Surveillance system
    PGY: post-graduate year
    PICU: paediatric intensive care unit
    RCT: randomised controlled trial
    TDC: tunnelled dialysis catheter
    USA: United States of America
    VAP: ventilator-associated pneumonia

Methods

Study design: ITS

Data collection: All patients admitted to the ICUs were prospectively surveyed for the occurrence of VAP by members of the Hospital Infection Control Team

Definition of VAP: VAP was defined by the occurrence of a new and persistent radiographic infiltrate in conjunction with one of the following: positive pleural/blood cultures for the same organism as that recovered in the tracheal aspirate or sputum; radiographic cavitation; histopathological evidence of pneumonia; or two of the following: fever, leukocytosis, and purulent tracheal aspirate or sputum. Persistence of an infiltrate was defined as having the infiltrate present radio graphically for 72 hrs. Fever was defined as an increase in the core temperature of 1°C or higher and a core temperature 38.3°C. Leukocytosis was defined as a 25% increase in the circulating leukocytes from the baseline and a value 10x 109/L. Tracheal aspirates were considered purulent if abundant neutrophils were present per high-power field by using Gram’s stain (i.e.> 25 neutrophils per high-power field). VAP complicating community-acquired pneumonia was considered to be present if a new infiltrate developed 48 hrs after the start of mechanical ventilation and empirical antibiotic treatment for community-acquired pneumonia were also required to be stable or improving in their radiographic appearance for 48 hrs before the development of the new infiltrates

Type of ventilator/respiratory equipment: Not described

Targeted behaviour: Improve procedures (care of patients with mechanical ventilator to reduce VAP)

Participants

Providers: Respiratory care practitioners (n = 114) and ICU nurses (n = 146; 64.9%); no provider characteristics provided

Patients: Unclear number of patients requiring mechanical ventilation and who developed VAP; no patient characteristics provided

Setting: Five ICUs at a 1000-bed primary and tertiary care urban teaching hospital (medical: 19 beds, surgical/trauma/burns: 18 beds, medical/surgical: 12 beds, surgical cardiothoracic: 17 beds, neurology and neurosurgical: 20 beds)

Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: Mechanical ventilator

Evidence base of recommendation:

The hospital policy was derived in large part from two literature reviews (authored by one of the task force members). The task force also compared the new hospital policy to the CDC recommendations for the prevention of VAP

Clinical practice guideline:

  • Place mechanically ventilated patients in a semirecumbent position by maintaining the head of the bed at approximately 30° or greater above the horizontal plane as tolerated by the patient

  • Intubate the trachea orally whenever possible to minimize the risk of nosocomial sinusitis; avoid nasotracheal intubation because of the association between nosocomial sinusitis and VAP

  • Use oral-gastric tubes rather than nasogastric tubes; nasogastric tubes may increase the possibility of nosocomial sinusitis.

  • Extubate patients and remove orogastric tubes as soon as clinically indicated

  • Prevent accidental extubation; adequately secure the endotracheal tube to the patient and/or restrain the patient per hospital policy, if necessary, to prevent accidental self-extubation

  • Provide adequate sedation to prevent unexpected extubation

  • Avoid gastric overdistention; monitor gastric residual volumes before administering scheduled enteral feedings (gastric residual maximum 150 to 200 mL)

  • Provide oral hygiene at least once daily

  • Drain condensate from ventilator circuits regularly with gloved hands; open ventilator circuit and carefully drain condensate into an open container, being careful not to touch the circuit tip to the container; reconnect tubing carefully to avoid contamination; empty container contents into hopper immediately; do not empty fluid into the trash can or onto the floor

  • Use in-line valved t-adapters or holding chambers for aerosolized medication delivery

  • Use non-invasive mechanical ventilation via face mask when appropriate to minimize the need for tracheal intubation

  • Avoid overuse of antibiotics

  • Provide daily chlorhexidine oral rinse (only for patients undergoing cardiac surgery)

  • Provide immunisations for influenza and Streptococcus pneumonia

Type of intervention: Professional intervention

Format: Interpersonal, paper

Description of intervention:

1. Knowledge translation activities

A multidisciplinary task force designed an education module to improve practices related to the prevention of VAP

2. Educational intervention:

Self study module, in-service education provided by one of the infection control personnel at scheduled meeting times, and for respiratory care practitioners two one hour lectures on the pathogenesis and prevention of VAP

3. Reminders: Four to six sheets and one poster taken directly from the study module were posted throughout the ICUsat the initiation of the intervention

4. Feedback: Monthly updates on the VAP rates with comparisons to the NNIS data from the CDC were presented at monthly ICUand respiratory care services staff meetings during both pre- and post-intervention periods

Timing:

a) Frequency and number of events: Educational module one month, in services at staff meeting, monthly updates on ICU VAP

b) Duration of intervention: Unclear

c) Period after the start of the intervention during which outcomes were reported:12 months

Outcomes

VAP rate at 3, 6, 9 and 12 months after start of the intervention (reanalysed by review authors)

Outcomes that could not be reanalysed and therefore not included in this review :

Cost saving

NotesThe study ignored secular (trend) changes and performed a simple t-test of the pre- versus post-intervention periods. Data extracted from graphic and reanalysed by reviewers
Risk of bias
BiasAuthors' judgementSupport for judgement
Intervention independent of other changesUnclear riskIt was not explicitly stated in the paper if the intervention was independent of other changes
Shape of the intervention effects pre-specifiedLow riskAlthough the authors described the intended direction of effect of the intervention, they did not describe if they expected a step change or a change in slope. However, since all studies were reanalysed by the review authors the risk of bias was low
Appropriate analysis (secular trends taken into account)Low riskSecular trends were not taken into account in the analysis. Data reanalysed and adjusted for pre-intervention trend by review authors
Intervention unlikely to affect data collectionLow riskRoutine collection of objective outcome data: All patients admitted to the ICUs were followed prospectively in a similar fashion during all study period by members of the Infection Control Team and surveyed for the occurrence of VAP
Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe primary outcome (VAP rate) was objective and based on a standard definition
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot specified in the text
Selective reporting (reporting bias)Unclear riskNo mention of protocol for study, therefore we are unable to assess if all outcomes are reported
Other biasUnclear riskIt was unclear if the pre- and post-intervention groups were comparable

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
  1. a

    Abbreviations
    CBA: controlled before-after
    CCT: clinical controlled trial
    RCT: randomised controlled trial

Abramczyk 2011Uncontrolled before-after study that could not be reanalysed as a time series study
Apisarnthanarak 2007Controlled before-after study with two control groups but only one intervention group
Apisarnthanarak 2008Uncontrolled before-after study with no proper baseline measurement
Babcock 2004Uncontrolled before-after study that could not be reanalysed as a time series study
Barsuk 2009Controlled before-after study with only one control group and one intervention group
Baxter 2005Uncontrolled before-after study that could not be reanalysed as a time series study
Berenholtz 2004aUncontrolled before-after study that could not be reanalysed as a time series study
Berenholtz 2004bControlled before-after study with only one control group and one intervention group
Berg 1995Uncontrolled before-after study that could not be reanalysed as a time series study
Berhe 2006Uncontrolled before-after study that could not be reanalysed as a time series study
Bird 2010Uncontrolled before-after study that could not be reanalysed as a time series study
Bizarro 2010Uncontrolled before-after study that could not be reanalysed as a time series study
Björnestam 2000Uncontrolled before-after study that could not be reanalysed as time series study
Bruminhent 2010Uncontrolled before-after study that could not be reanalysed as a time series study
Brunelle 2003Uncontrolled before-after study that could not be reanalysed as a time series study
Burns 2003Uncontrolled before-after study that could not be reanalysed as a time series study
Camp 2009Uncontrolled before-after study that could not be reanalysed as a time series study
Casey 2003Case-control study
Castello 2011Uncontrolled before-study that could not be reanalysed as a time series study
Cherry-Bukowiec 2011The aim of the intervention was not to improve adherence with infection control guidelines
Chrdle 2012Surveillance study with no proper baseline measurement
Christenson 2006Surveillance study with no proper baseline measurement
Cohen 1991Uncontrolled before-after study that could not be reanalysed as a time series study
Cohran 1996Surveillance study with no proper baseline measurement
Collingnon 2007Surveillance study with no proper baseline measurement
Cools 1987Uncontrolled before-after study that could not be reanalysed as a time series study
Coopersmith 2004Uncontrolled before-after study that could not be reanalysed as a time series study. Study derived from Coopersmith 2002
Cornia 2003No-randomised crossover study
Costello 2008Uncontrolled before-after study that could not be reanalysed as a time series study
Crouzet 2007Uncontrolled before-after study that could not be reanalysed as a time series study
Cruden 2000Uncontrolled before-after study that could not be reanalysed as a time series study
Danchaivijitr 2005Uncontrolled before-after study that could not be reanalysed as a time series study
Dawson 2011Narrative review
Dinç 2000Uncontrolled before-after study that could not be reanalysed as a time series study
Dries 2004Uncontrolled before-after study that could not be reanalysed as a time series study
Du Bose 2008Uncontrolled before-after study that could not be reanalysed as a time series study
Duane 2009Uncontrolled before-after study that could not be reanalysed as a time series study
East 2005Uncontrolled before-after study that could not be reanalysed as a time series study
Eggimann 2000Controlled before-after study with only one control group and one intervention group
Espiau 2011Uncontrolled before-after study that could not be reanalysed as a time series study
Esteve 2009Uncontrolled before-after study that could not be reanalysed as a time series study
Fakih 2010Uncontrolled before-after study that could not be reanalysed as a time series study
Frankel 2005Uncontrolled before-after study that could not be reanalysed as a time series study
French 1989Surveillance study
García-Rodicio 2009Uncontrolled before-after study that could not be reanalysed as a time series study
Gaynes 2001Surveillance study
Gnass 2004Surveillance study
Goddard 2006Surveillance study
Goetz 1999Uncontrolled before-after study that could not be reanalysed as a time series study
Gokula 2007Uncontrolled before-after study that could not be reanalysed as a time series study
Gowardman 2005Uncontrolled before-after study that could not be reanalysed as a time series study
Gozu 2011Uncontrolled before-after study that could not be reanalysed as a time series study
Grap 2003Uncontrolled before-after study that could not be reanalysed as a time series study
Guerin 2010Uncontrolled before-after study that could not be reanalysed as a time series study
Guner 2011Inappropriately analysed time series study. No full-text and no graph which could have permitted reanalysis
Gunther 2009Uncontrolled before-after study that could not be reanalysed as a time series study
Gurskis 2009Uncontrolled before-after study that could not be reanalysed as a time series study
Gusarov 2009Retrospective one site before-after study
Hansen 2006Uncontrolled before-after study that could not be reanalysed as a time series study
Harnage 2007Uncontrolled before-after study that could not be reanalysed as a time series study
Hatler 2006Uncontrolled before-after study that could not be reanalysed as a time series study
Helman 2003Uncontrolled before-after study that could not be reanalysed as a time series study
Hendrix 1998Study that did not report the rates of nosocomial infections separately of other nosocomial events
Hiemenz 1986Descriptive study
Higuera 2005Uncontrolled before-after study that could not be reanalysed as a time series study
Holzmann-Pazgal 2012Inappropriately analysed (one site) time series study. The graph provided does not permit reanalysis (i.e. it does not present the infection rate)
Hong 1990Uncontrolled before-after study that could not be reanalysed as a time series study
Horbar 2006Controlled before-after study with only one control group
Horvath 2009Uncontrolled before-after study that could not be reanalysed as a time series study
Huang 2004Uncontrolled before-after study that could not be reanalysed as a time series study
Hwang 2005Uncontrolled before-after study that could not be reanalysed as a time series study
Jain 2006Uncontrolled before-after study that could not be reanalysed as a time series study
Jeffreis 2009Uncontrolled before-after study that could not be reanalysed as a time series study
Jonhson 2009Uncontrolled before-after study that could not be reanalysed as a time series study
Kalra 2011Knowledge the only outcome
Karada 2000Uncontrolled before-after study that could not be reanalysed as a time series study
Kauffmann 2011Inappropriately analysed (one site) time series study. No graph with results data which could have permitted reanalysis. Intervention (checklist) targets not only indwelling device infections but a number of other conditions e.g. bed sores
Kaye 2006Surveillance study with no proper baseline measurement
Kelleghan 1993Uncontrolled before-after study that could not be reanalysed as a time series study
Kellie 2012Uncontrolled before-after study that could not be reanalysed as a time series study
Khatib 1999Uncontrolled before-after study that could not be reanalysed as a time series study
Kidd 2007Qualitative study
Kilbride 2003Descriptive study
Koff 2011Uncontrolled before-after study that could not be reanalysed as a time series study
Kulvatunyou 2007Uncontrolled before-after study that could not be reanalysed as a time series study
Lai 2003Uncontrolled before-after study that could not be reanalysed as a time series study
Lally 1997Uncontrolled before-after study that could not be reanalysed as a time series study
Laux 2006Uncontrolled before-after study with no interpretable outcomes
Lobo 2005Uncontrolled before-after study that could not be reanalysed as a time series study
Lobo 2010Controlled before-after study with one control group
Lolom 2009Surveillance study with no proper baseline measurement
Lyerla 2010Uncontrolled before-after study that could not be reanalysed as a time series study
Maas 1998Uncontrolled before-after study with only one data point before the intervention
Marelich 2000Intervention was not directed at health professionals
Marra 2009Uncontrolled before-after study that could not be reanalysed as a time series study
Matocha 2011Uncontrolled before-after study that could not be reanalysed as a time series study
Mazi 2011Inappropriately analyses time series study. Protocol only. No full-text. No graphs which could have permitted reanalysis
Mckee 2008Uncontrolled before-after study that could not be reanalysed as a time series study
Mckinley 2003Intervention aimed to improve surveillance
McLean 2006Uncontrolled before-after study that could not be reanalysed as a time series study
Meier 1998Uncontrolled before-after study that could not be reanalysed as a time series study
Miller 2010aUncontrolled before-after study that could not be reanalysed as a time series study
Miranda 2007Controlled clinical trial that reported the comparative data of self reported practice during catheter insertion
Misset 2004Uncontrolled before-after study that could not be reanalysed as a time series study
Ngo 2005Uncontrolled before-after study that could not be reanalysed as a time series study
Ong 2011Uncontrolled before-after study that could not be reanalysed as a time series study
Orsi 2005Uncontrolled before-after study that could not be reanalysed as a time series study
Parras 1994Uncontrolled before-after study that could not be reanalysed as a time series study
Penne 2002Uncontrolled before-after study that could not be reanalysed as a time series study
Peredo 2010Uncontrolled before-after study with missing data points
Pethyoung 2005Uncontrolled before-after study that could not be reanalysed as a time series study
Pronovost 2008Uncontrolled before-after study that could not be reanalysed as a time series study
Pronovost 2010Surveillance study derived from Provonost 2006
Puntis 1990Uncontrolled before-after study that could not be reanalysed as a time series study
Pérez-González 2007Uncontrolled before-after study that could not be reanalysed as a time series study
Reilly 2006Uncontrolled before-after study that could not be reanalysed as a time series study
Rello 2011Descriptive study
Rosenthal 2003Uncontrolled before-after study that could not be reanalysed as a time series study
Rosenthal 2004Uncontrolled before-after study that could not be reanalysed as a time series study
Rosenthal 2006aUncontrolled before-after study that could not be reanalysed as a time series study
Rosenthal 2008Surveillance study
Saint 2005Controlled before-after study with only one control and one intervention site
Sansivero 2011The aim of the intervention was not to improve adherence with infection control guidelines
Santana 2008Uncontrolled before-after study that could not be reanalysed as a time series study
Scales 2009Protocol for a randomized trial
Scales 2011aOverview paper
Seguin 2010Uncontrolled before-after study that could not be reanalysed as a time series study
Seto 1991Uncontrolled before-after study that could not be reanalysed as a time series study
Shapey 2009Surveillance study
Sherertz 2000Uncontrolled before-after study that could not be reanalysed as a time series study
Smith 2011Retrospective chart review
Soifer 1998Controlled clinical trial with no clear separation between the groups
Sutton 2005Uncontrolled before-after study that could not be reanalysed as a time series study
Sydnor 2011Overview paper
Timsit 2011Review paper
Tolentino DelosReyes 2007Uncontrolled before-after study that could not be reanalysed as a time series study
Topal 2005Uncontrolled before-after study that could not be reanalysed as a time series study
Troeng 2011Observational study. No full-text available. No graph which could have permitted reanalysis
Tsuchida 2007Uncontrolled before-after study that could not be reanalysed as a time series study
Urrea Ayala 2009Uncontrolled before-after study that could not be reanalysed as a time series study
Verdier 2006Uncontrolled before-after study that could not be reanalysed as a time series study
Wall 2005Uncontrolled before-after study that could not be reanalysed as a time series study
Warren 2003Uncontrolled before-after study that could not be reanalysed as a time series study
Warren 2006Uncontrolled before-after study that could not be reanalysed as a time series study
Weireter 2009Uncontrolled before-after study that could not be reanalysed as a time series study
Westwell 2008Uncontrolled before-after study that could not be reanalysed as a time series study
Williams 2008Uncontrolled before-after study that could not be reanalysed as a time series study
Wirtschafter 2010Uncontrolled before-after study that could not be reanalysed as a time series study
Worrall 2010Uncontrolled before-after study that could not be reanalysed as a time series study
Xiao 2007Not a randomized trial
Yoo 2001Uncontrolled before-after study that could not be reanalysed as a time series study
Youngquist 2007Uncontrolled before-after study that could not be reanalysed as a time series study
Zaydfudin 2009Uncontrolled before-after study that could not be reanalysed as a time series study
Zingg 2009Uncontrolled before-after study that could not be reanalysed as a time series study
Zuschneid 2003Surveillance study with no proper baseline measurement

Characteristics of studies awaiting assessment [ordered by study ID]

Chen 2011

MethodsITS study
ParticipantsHospitalised haematology-oncology patients with port A
InterventionsThe establishment of a standardised port-A care protocol, implementation of a more appropriate dressing type; performance of irregular audits of port-A care techniques; educational training; establishment of skin care instructions for patients and families
OutcomesHaematology-oncology port-A related infections
NotesOne haematology-oncology clinic in Taiwan, abstract in English but full-text paper in Taiwanese

Danchaivijitr 1992

MethodsRCT
ParticipantsPatients assessed for need of urethral catheterisation
InterventionsIndication sheet
OutcomesRates of catheterisation; rates of catheterisation without proper indication
NotesThirteen hospitals in Thailand

Eid 2011

MethodsITS study
ParticipantsPatients with tracheostomies
InterventionsProcedures to prevent ventilator-associated pneumonia and monitoring and educational sessions
OutcomesRate of pneumonia
NotesTwo step down units in one hospital

Kaplan 2011

MethodsITS study
ParticipantsInfants born at 22 to 29 weeks’ gestation
InterventionsThe Institute for Healthcare Improvement Breakthrough Series quality-improvement model
OutcomesCompliance with catheter insertion component; compliance with evidence based indwelling catheter care; infection rate
NotesTwenty-four Ohio NICUs in the USA

Khouli 2011

MethodsRCT
ParticipantsMedical residents
InterventionsSimulation-based plus video training or video training alone
OutcomesPerformance scores and rates of catheter-related bloodstream infections
Notes 

Latif 2012

MethodsRCT
ParticipantsInterns and student nurse anaesthetists
InterventionsSimulation training of aseptic techniques
OutcomesScores in aseptic techniques
Notes 

Longmate 2011

MethodsITS study
ParticipantsICU patients with a CVC
InterventionsEstablishment of infection surveillance and introduction of bundles of care processes relating to insertion and maintenance of CVCs. The changes were supported by educational interventions
OutcomesCLABSI rate
NotesOne ICU in the UK

Lopez 2011

MethodsITS study
ParticipantsICU patients with a CVC
InterventionsAn ongoing compliance-tracking programme for maximal barrier precautions was instituted, and caregivers were re-educated on the importance of central-line-bundle prevention efforts. A quality improvement intervention of daily CHG baths for all ICU patients was introduced
OutcomesCLABSI rate
NotesOne medical-surgical ICU in a regional medical centre in Greece

Marra 2011

MethodsITS study
Participantsall ICU and step-down units patients requiring urinary catheters
InterventionsImplementation of the Centers for Disease Control and Prevention‒recommended evidence based practices; performance monitoring;implementation of the Institute for Healthcare Improvement’s bladder bundle for patients with urinary catheter
OutcomesCAUTI rate
NotesOne medical-surgical ICU and in two step-down units , in Brasil or USA

Miller 2011

MethodsNon-randomised, factorial design
ParticipantsStaff at 29 paediatric ICUs
InterventionsBundles and monitoring of behaviours
OutcomesCLABSI rates
Notes 

Morris 2011

MethodsA before-after study conducted within the context of an existing, independent, infection surveillance programme
ParticipantsAll patients admitted to intensive care for 48 hrs or more during the periods before and after intervention
InterventionsA four-element VAP prevention bundle, consisting of head-of-bed elevation, oral chlorhexidine
gel, sedation holds, and a weaning protocol implemented as part of the Scottish Patient Safety Program using Institute of Health Care Improvement methods
OutcomesCompliance with head-of-bed elevation and chlorhexidine, “wake and wean” elements, and overall bundle compliance; VAP rate
NotesOne mixed medical–surgical teaching hospital ICU in Scotland

Munhoz 2012

MethodsITS study
ParticipantsAll consecutive central catheter-associated bloodstream infection cases as determined by the Infection Control Department
InterventionsDaily nursing rounds aimed at assuring compliance with an intensive care unit goal-oriented checklist
OutcomesCentral catheter-associated bloodstream infections
Notes 

Papadimos 2008

MethodsITS study
ParticipantsPatients on mechanical ventilation
InterventionsAggressive oral care, early extubation, management of soiled or malfunctioning respiratory equipment, handwashing surveillance, and maximal sterile barrier precautions, plus an evaluative concept called FASTHUG (daily evaluation of patients' feeding, analgesia, sedation, thromboembolic prophylaxis, elevation of the head of the bed, ulcer prophylaxis, and glucose control)
OutcomesVAP rate
NotesOne surgical ICU in the USA

Resende 2011

MethodsITS study
ParticipantsNeonates with a CVC
InterventionsAn intervention designed to reduce CLABSI with five evidence based procedures was conducted (stepwise introduction of evidence based intervention and intensive and continuous education)
OutcomesCLABSI rate
NotesOne neonatal in Brazil

Scales 2011

MethodsCluster RCT
Participants15 ICUs
InterventionsA video conference-based forum including audit and feedback, expert-led educational sessions, and dissemination of algorithms to sequentially improve delivery of 6 evidence based practices
OutcomesThe summary ratio of odds ratios (ORs) for improvement in adoption (determined by daily data collection) of all 6 practices during the trial in intervention vs control ICUs.
NotesFifteen community hospital ICUs in Ontario, Canada

Speroff 2011

MethodsCluster RCT
ParticipantsICUs of 60 hospitals
InterventionsVirtual collaborative intervention; versus a toolkit-only approach
OutcomesCLABSI and VAP rates
NotesSixty hospital ICUs in the USA

Tong 2011

  1. a

    Abbreviations
    CLABSI: central line-associated bloodstream infection
    CVC: central venous catheter
    ICU: intensive care unit
    ITS: interrupted time series
    VAP: ventilator-associated pneumonia

MethodsITS study
ParticipantsUnclear - full-text not available
InterventionsA standard process management policy for management of infections
OutcomesPeripheral central venous CLABSI
NotesArticle in Chinese, translation not available at time of review submission

Ancillary