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

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

Editorial Group: Cochrane Effective Practice and Organisation of Care Group

Published Online: 28 MAR 2013

Assessed as up-to-date: 16 JUL 2012

DOI: 10.1002/14651858.CD006559.pub2


How to Cite

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

Author Information

  1. 1

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

  2. 2

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

  3. 3

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

  4. 4

    Centre for Statistics in Medicine, Oxford, UK

  5. 5

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

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

Publication History

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

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Characteristics of included studies [ordered by study ID]
Abbott 2006 dataset 1

MethodsStudy 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)


ParticipantsProviders: 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


InterventionsInfection-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


OutcomesQuarterly 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

MethodsStudy 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)


ParticipantsProviders: 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


InterventionsInfection-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


OutcomesQuarterly 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


NotesStatistical 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

MethodsStudy 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)


ParticipantsProviders: 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


InterventionsInfection-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


OutcomesQuarterly 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


NotesStatistical 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

MethodsStudy 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)


ParticipantsProviders: 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


InterventionsInfection-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


OutcomesQuarterly 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


NotesStatistical 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

MethodsStudy 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)


ParticipantsProviders: 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


InterventionsInfection-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


OutcomesCLABSI 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 riskSee 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

MethodsStudy 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)


ParticipantsProviders: 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


InterventionsInfection-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


OutcomesIncorrect 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 riskIt 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

MethodsStudy 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)


ParticipantsProviders:

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


InterventionsInfection-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


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 reviewer


Risk of bias

BiasAuthors' judgementSupport for judgement

Intervention independent of other changesHigh riskSee 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

MethodsStudy 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)


ParticipantsProviders: 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


InterventionsInfection-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

MethodsStudy 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)


ParticipantsProviders: 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


InterventionsInfection-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

MethodsStudy 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)


ParticipantsProviders: 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


InterventionsInfection-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

MethodsStudy 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)


ParticipantsProviders: 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


InterventionsInfection-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


OutcomesCLABSI 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 riskSee 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

MethodsStudy 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)


ParticipantsProviders: 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


InterventionsInfection-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


OutcomesVAP 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

MethodsStudy 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)


ParticipantsProviders: 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


InterventionsInfection-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 riskSee 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

MethodsStudy 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)


ParticipantsProviders: 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


InterventionsInfection-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


OutcomesVAP 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 riskSee 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

MethodsStudy 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)


ParticipantsProviders: 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


InterventionsInfection-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


OutcomesCLABSI 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 riskSee 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

MethodsStudy 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)


ParticipantsProviders: 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


InterventionsInfection-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


OutcomesVAP 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

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

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

 
Comparison 1. Ventilator-associated pneumonia (VAP) analysis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 
Summary of findings for the main comparison.

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

Patient or population: patients with an indwelling device

Settings: hospital

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

Comparison: standard care

OutcomesChange in level effect (step change)

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

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

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

CLABSI rate up to 12 months

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

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

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

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

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

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

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

* All data reanalysed by review authors
CI: Confidence interval

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

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

 Abbreviations
CLABSI: central line-associated blood stream infection
VAP: ventilator-associated pneumonia
 
Table 1. Adjusted VAP rates

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

 Abbreviations
CI: confidence interval
CLABSI: central line-associated blood stream infection
NA: not available
SD: standard deviation
SE: standard error
VAP: ventilator-associated pneumonia
 
Table 2. Adjusted CLABSI rates

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

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 1.510.79 (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 6.702.33 (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 5.240.55 (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

 Abbreviations
CI: confidence interval
CLABSI: central line-associated blood stream infection
NA: not available
SD: standard deviation
SE: standard error
 
Table 3. Interventions aimed at improving professional adherence to guidelines for prevention of VAP

Author/yearType of intervention;

duration
Clinical practice guidelineKnowledge translation

activities
Distribution of educational materialEducational

meeting
Audit and feedbackReminders,

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 2006More than one active intervention;

unclear duration
  •        
  •  
  •  
 NoNo VAP bundle instituted as part of a performance improvement project

Kaye 2000More than one active intervention;

unclear duration
  •       
  •        
  •        
  •        
  •        
 NoBugline newsletter; handwashing campaign;

equipment and supply purchases; patient and family education

Salahuddin 2004More 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 

 Abbreviations
ICU: intensive care unit
VAP: ventilator-associated pneumonia
 
Table 4. Interventions aimed at improving professional adherence to guidelines for prevention of CLABSIs

 Author/yearType 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
  •        
 NoQuality improvement strategy,

champion leaders

Parra 2010

 
One short active intervention; 15 minutes
  •       
 No No
  •      
 No
  •       
 

Sannoh 2010One 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

 Abbreviations
CVC: central venous catheter
DVD: digital video disc
 
Table 5. VAP prevention recommendations

VAP preventionAbbott 2006 dataset 1;

Abbott 2006 dataset 2;

Abbott 2006 dataset 3;

Abbott 2006 dataset 4a
Cocanour 2006bKaye 2000cSalahuddin 2004dSona 2009eZack 2002f

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

 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
 
Table 6. CLABSI prevention recommendations

CLABSI preventionCoopersmith 2002aMiller 2010bParra 2010cSannoh 2010dWarren 2004e

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

 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
 
Table 7. Adherence with infection control recommendations

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 4aAdoption measurements consisted of observations of infection control practices in accordance with the CPG and were measured using the adoption checklistObservations 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 facilitiesHead-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 reportedCompliance 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 2010Data 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 monthCompliance 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 reportedInsertion-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 protocolCatheter 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%)

 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