Evidence-based Infection Prevention Practices Research Articles

591. The Agency for Healthcare Research and Quality (AHRQ) Safety Program for MRSA Prevention: Impact of an Educational and Implementation Project in United States (US) Hospitals

Abstract Background The AHRQ Safety Program for MRSA Prevention utilizes evidence-based infection prevention interventions and the Comprehensive Unit-based Safety Program (CUSP) framework to decrease invasive methicillin-resistant Staphylococcus aureus (MRSA) infections in intensive care units (ICUs), non-ICUs, surgical services, and long-term care facilities. We report the program's effect on hospital-onset MRSA bacteremia rates (HOB-MRSA) in 106 ICUs and 87 non-ICUs from 94 US hospitals.Table 1.Educational Toolkit Content for the AHRQ Safety Program for MRSA Prevention Methods The ICU/non-ICU Safety Program for MRSA Prevention was implemented from April 2022 to September 2023. The Safety Program aimed to decrease invasive MRSA infections through education, technical support, reinforcement of safety culture, and implementation of evidence-based infection prevention practices. Chlorhexidine bathing and nasal decolonization were major foci of the intervention, along with disinfection of the environment and practices to prevent person-based MRSA transmission and device-related infections. The project team provided 22 live webinars, supporting materials, and other tools to assist units with MRSA prevention (Table 1). Units were also assigned an implementation adviser who provided support through monthly coaching calls. Units submitted monthly data for HOB-MRSA per 10,000 patient days (PD) as well as data regarding process measures. Linear mixed effects models were employed to calculate pre-post intervention changes in HOB-MRSA events. Results 106 ICUs and 87 non-ICUs from 94 hospitals completed the Safety Program, including 31 (33%) academic medical centers (AMC), 37 (39%) non-AMC teaching hospitals, and 26 (28%) non-teaching community/other hospitals. From July-September 2021 to July-September 2023, HOB-MRSA events declined from 5.7 to 1.5 per 10,000 PD among ICUs (p< 0.001)(Figure 1) and from 3.4 to 0.2 for non-ICUs (p< 0.001) (Figure 2). Similar results were found in comparisons among other pre-program vs, end-of-program quarters. Conclusion The AHRQ Safety Program for MRSA Prevention supported implementation of evidence-based infection prevention practices, including decolonization, and was associated with reduced HOB-MRSA rates across participating ICUs and non-ICUs. Disclosures All Authors: No reported disclosures

Assessing equity in preventing central line-associated bloodstream infections and surgical site infections in pediatric patients.

Central line-associated bloodstream infections (CLABSIs) and surgical site infections (SSIs) are major healthcare-associated infections that can be prevented by consistently applying evidence-based infection prevention practices. To assess equity in preventing CLABSIs and SSIs in pediatric patients at a free-standing pediatric hospital, where evidence-based infection prevention practices are consistently implemented. This observational study evaluated 2 cohorts of pediatric patients under 18 years. The CLABSI cohort included inpatients with a central line between 1/1/2016 and 12/31/2022, and the SSI cohort included patients undergoing colon, ventricular shunt, or spinal fusion surgeries between 1/1/2016 and 10/31/2022. The CLABSI rate per 1000 central line days and SSI rate per 100 surgeries were compared across different racial, ethnic, and gender groups. In the CLABSI cohort of 8575 patients, encompassing 243,803 central line days, there were 156 CLABSIs. There was no statistical difference in CLABSI rate across race, ethnicity, and/or gender groups. The SSI cohort included 68 SSIs among 1710 patients who underwent 2230 procedures, including 714 colon, 749 ventricular shunt, and 767 spinal fusion procedures. The SSI rate was statistically higher in multiracial (9.9) and Asian (8.6) groups, compared to Caucasian (2.4) and Black (2.2) groups. A nested case-control study of the SSI cohort showed a higher SSI rate in Asians, compared to Caucasians (Odds Ratio: 3.3; 95% CI: 1.3-8.3). Equity in preventing CLABSIs is achievable through standardized central-line care. Further study is warranted to assess if improvement opportunities exist for achieving equity in preventing SSIs.

Antibiotic Stewardship in the Neonatal Intensive Care Unit.

Antibiotic stewardship is a multidisciplinary, evidence-based approach to optimize antibiotic use and mitigate development of antibiotic resistance. Neonates have high rates of antibiotic exposure, particularly those born preterm and admitted to the NICU, and mounting evidence describes the adverse consequences of such exposures in the absence of infection. Here, we review the general principles of antibiotic stewardship and how they can be applied in NICUs. The unique characteristics of NICUs and patients cared for in this setting, which warrant unique implementation strategies and special considerations are discussed. We summarize current antibiotic use metrics for assessment of responses to stewardship interventions and changes over time, and review evidence-based infection prevention practices in the NICU. Current recommendations for empiric antibiotic use in the NICU and the utility of infection biomarkers are summarized. Lastly, given the growing global threat of increasing antibiotic resistance, specific threats in the NICU are highlighted.

Prevention of Vascular Access Device-Associated Hospital Onset Bacteremia and Fungemia: A Review of Emerging Perspectives and Synthesis of Technical Aspects.

Significant events impacting healthcare over the last several years have been associated with escalating rates of healthcare-associated infections. This has resulted in increased efforts to reinstitute well-established and evidence-based infection prevention practices, particularly for central line associated bloodstream infections. However, implementation of prevention initiatives beyond central lines has not received the same level of acknowledgement and response as being a considerable risk to patients. This article, authored by infection prevention, infectious disease, and vascular access professionals, provides emerging perspectives and technical aspects associated with the complete lifecycle of a vascular access device. The intent is to provide insight and perspective into enhancing current IP practices in the acute care hospital setting. This will also help prepare hospitals for upcoming broader surveillance and intervention activities aimed at reducing Hospital Onset Bacteremia and Fungemia (HOB) associated with all types of vascular access devices.

Motivational drivers for health professionals in a large quality improvement collaborative project in Brazil: a qualitative study

BackgroundThe success of collaborative quality improvement (QI) projects in healthcare depends on the context and engagement of health teams; however, the factors that modulate teams’ motivation to participate in these projects are still unclear. The objective of the current study was to explore the barriers to and facilitators of motivation; the perspective was health professionals in a large project aiming to implement evidence-based infection prevention practices in intensive care units of Brazilian hospitals.MethodsThis qualitative study was based on content analysis of semistructured in-depth interviews held with health professionals who participated in a collaborative QI project named “Improving patient safety on a large scale in Brazil”. In accordance with the principle of saturation, we selected a final sample of 12 hospitals located throughout the five regions of Brazil that have implemented QI; then, we conducted videoconference interviews with 28 health professionals from those hospitals. We encoded the interview data with NVivo software, and the interrelations among the data were assessed with the COM-B model.ResultsThe key barriers identified were belief that improvement increases workload, lack of knowledge about quality improvement, resistance to change, minimal involvement of physicians, lack of supplies, lack support from senior managers and work overload. The primary driver of motivation was tangible outcomes, as evidenced by a decrease in infections. Additionally, factors such as the active participation of senior managers, teamwork, learning in practice and understanding the reason for changes played significant roles in fostering motivation.ConclusionThe motivation of health professionals to participate in collaborative QI projects is driven by a variety of barriers and facilitators. The interactions between the senior manager, quality improvement teams, and healthcare professionals generate attitudes that modulate motivation. Thus, these aspects should be considered during the implementation of such projects. Future research could explore the cost-effectiveness of motivational approaches.

Best practices to reduce COVID-19 in group homes for individuals with serious mental illness and intellectual and developmental disabilities: Protocol for a hybrid type 1 effectiveness-implementation cluster randomized trial

People with serious mental illness (SMI) and intellectual disabilities and/or developmental disabilities (ID/DD) living in group homes (GHs) and residential staff are at higher risk for COVID-19 infection, hospitalization, and death compared with the general population. We describe a hybrid type 1 effectiveness-implementation cluster randomized trial to assess evidence-based infection prevention practices to prevent COVID-19 for residents with SMI or ID/DD and the staff in GHs. The trial will use a cluster randomized design in 400 state-funded GHs in Massachusetts for adults with SMI or ID/DD to compare effectiveness and implementation of "Tailored Best Practices" (TBP) consisting of evidence-based COVID-19 infection prevention practices adapted for residents with SMI and ID/DD and GH staff; to "General Best Practices" (GBP), consisting of required standard of care reflecting state and federal standard general guidelines for COVID-19 prevention in GHs. External (i.e., community-based research staff) and internal (i.e., GH staff leadership) personnel will facilitate implementation of TBP. The primary effectiveness outcome is incident SARS-CoV-2 infection and secondary effectiveness outcomes include COVID-19-related hospitalizations and mortality in GHs. The primary implementation outcomes are fidelity to TBP and rates of COVID-19 vaccination. Secondary implementation outcomes are adoption, adaptation, reach, and maintenance. Outcomes will be assessed at baseline, 3-, 6-, 9-, 12-, and 15-months post-randomization. This study will advance knowledge on comparative effectiveness and implementation of two different strategies to prevent COVID-19-related infection, morbidity, and mortality and promote fidelity and adoption of these interventions in high-risk GHs for residents with SMI or ID/DD and staff. NCT04726371.

Program Evaluation of Implementation Science Outcomes From an Intervention to Improve Compliance With Chlorhexidine Gluconate Bathing: A Qualitative Study.

Evaluation of implementation science research is warranted to better understand and determine the success of translating evidence-based infection prevention practices at the bedside. The purpose of this program evaluation was to evaluate implementation outcomes from the perspectives of nurses and nursing leaders regarding a previously conducted chlorhexidine gluconate (CHG) bathing implementation science study among 14 critical care units. Focus groups and interviews, using semistructured interview questions, were conducted to examine the perceptions of nurses who participated in a CHG bathing implementation science study. A deductive qualitative analysis using Proctor and colleagues' implementation outcomes framework was used. Transcripts were analyzed and categorized using the framework as a predetermined code list to structure the implementation outcomes of acceptability, appropriateness, adoption, feasibility, and sustainability. A total of 19 nurses and nurse leaders participated in a focus group or interview. Participants noted that both implementation strategies used in the initial study (educational outreach and audit and feedback) were acceptable and appropriate and expressed that the evidence-based CHG bathing practice was feasible to integrate into practice and was being adopted. The program evaluation identified strengths and opportunities for improvement related to the implementation strategies and evidence-based CHG bathing protocol. Findings can inform future studies that seek to implement CHG bathing protocols in the critical care setting using audit and feedback and educational outreach strategies.

Using PDSA cycles to improve oral care compliance

Oral care has been shown to reduce healthcare-associated pneumonia (HAP) rates, however, compliance with this practice is suboptimal. Using quality improvement PDSA cycles over an 8-week period, we saw improvements in oral care documentation compliance through statistical process control charts; HAP rates did not significantly decrease. Infection prevention leadership should consider regularly incorporating PDSA cycles to improve compliance with evidence-based infection prevention practices.

Current Practices in Infection Prevention: A 3-year Survey of Michigan Nursing Homes’ Urinary Tract Infection Prevention Strategies

Background Robust infection prevention and control (IPC) programs with evidence-based policies, audits, staff education and data-sharing are critical to safe nursing home (NH) resident environments. The purpose of this study was to identify outcome and process measure data in NHs to prevent both non-catheter and catheter-associated urinary tract infections (UTIs and CAUTIs). Methods Over a three-year period, 58 NHs participated in a 12-month program to reduce healthcare-associated infections by enhancing relationships between NHs and hospitals. A 36-question survey on IPC characteristics was distributed prior to the start of each cohort for years 2018-2020. All surveys were completed prior to March 2020 when the first case of COVID-19 was identified in Michigan. Surveys were completed by infection preventionists, directors of nursing, or NH administrators. Results 55 NHs (95%) completed the survey. Most were aware of their UTI and CAUTI rates (93%, 87%). Policies on catheter insertion, care and other UTI/CAUTI prevention practices were common, but frequency of staff training was inconsistent with some NHs providing education at hire (55%), annually (70%), “when needed” (60%) or never (4%). Less than half were aware of their hand hygiene rates (45%); 36% were aware of gown/glove use. 100% shared infection data with NH leadership, 70% with bedside nursing staff and 26% with residents and families. UTI/CAUTI prevention strategies included hydration practices (77%); nurse-initiated indwelling urinary catheter (IUC) discontinuation (59%); stop orders (45%); indwelling device rounds (28%); and electronic alerts (25%). 57% used cranberry juice/tablets to prevent UTI/CAUTI despite weak evidence of efficacy. Conclusions While awareness of UTI and CAUTI rates is high, process measures like hand hygiene rates and gown/glove use are not evaluated consistently. Hand hygiene and use of personal protective equipment have heightened priority during the current COVID pandemic. NHs have made significant progress operationalizing many evidence-based infection prevention practices but gaps exist.

Healthcare worker's perspectives on use of memes as an implementation strategy in infection prevention: An exploratory descriptive analysis

New implementation strategies, such as social media platforms, are being used to help disseminate and implement evidence-based practices. This project reports on an Infection Prevention Week Meme Contest and describes healthcare worker's perspectives on using memes as an implementation strategy to improve knowledge and compliance with evidence-based infection prevention practices.

Knowing IS the Battle: Evidence-Based Infection Prevention Practices & Outcome Metrics in Nursing Homes

<h3>Background</h3> A robust infection prevention and control (IPC) program is critical for a safe nursing home (NH) resident environment. Data sharing, auditing with feedback on performance, and implementation of evidence-based practices are cornerstones of an effective IPC program. The purpose of this study was to identify outcome and process measures data that are collected and shared in NHs, and specific IPC strategies used to prevent both non-catheter and catheter-associated urinary tract infections (UTIs and CAUTIs). <h3>Methods</h3> Over a two-year period, 50 NHs participated in a 12-month program to reduce healthcare-associated infections by enhancing relationships between NHs and hospitals. A 36-question survey on IPC facility characteristics was distributed; 11 surveys were administered between January-March 2018 and another 39 administered January-February 2019. Missing responses for individual questions were omitted from analyses. Surveys were completed by infection preventionists, directors of nursing, or NH administrators. <h3>Results</h3> All 50 NHs (100%) completed the survey. 92% of responding NHs were aware of their facility's UTI/CAUTI rates. When asked about process measures, 48% knew their facility's hand hygiene rates and 44% their glove/gown use rates. While all 100% indicated they share infection data with NH leadership, only 72% share infection data with bedside nursing staff and 32% with residents and families. UTI/CAUTI prevention strategies implemented by NHs included hydration practices (83%); nurse-initiated indwelling urinary catheter (IUC) discontinuation (65%); stop orders for IUCs (46%); multidisciplinary rounds examining indwelling devices (33%); and electronic alerts/reminders of IUC need (25%). Despite evidence to the contrary, 56% reported cranberry juice/tablet use to prevent UTI/CAUTI. Two NHs (0.04%) reported having no UTI/CAUTI prevention strategies. <h3>Conclusions</h3> While awareness of UTI and CAUTI rates is high, process measures like facility hand hygiene rates are not evaluated consistently. Additionally, data are not routinely shared with stakeholders. NHs have made significant progress operationalizing many evidence-based infection prevention practices but gaps exist.

Results of a national system-wide quality improvement initiative for the implementation of evidence-based infection prevention practices in Brazilian hospitals

Quality improvement (QI) methods are recommended to address healthcare-associated infections (HCAIs) in hospitals, but whereas internal initiatives have been widely studied, there is little evidence on the application and effect of a QI approach from an external system-wide perspective. To analyse the effect of a national system-wide QI initiative aimed at promoting HCAI prevention via regulatory interventions in Brazil. A QI cycle approach designed and assessed with a before-and-after quasi-experimental design was implemented by the Brazilian Health Regulatory Agency (ANVISA), targeting 1869 hospitals. Eleven evidence-based quality indicators related to HCAI prevention and a composite measure were assembled, shared, and assessed; the intervention to improve was then based on participatory multifaceted regulatory actions. Absolute and relative improvements were estimated after the intervention. In all, 563 hospitals (30.1% response) totalling 86,837 beds participated in the baseline assessment, and 681 hospitals (36.4% response) totalling 101,231 beds in the second. Ten of the 11 criteria improved (P < 0.05), as well as the composite indicator (P= 0.001) in all the regions of the country, particularly in the group of hospitals participating at baseline. 'Hand hygiene (HH) infrastructure' reached 100% (baseline: 97.9; P= 0.001), 'HH protocol' 96.9% (baseline: 92.9; P= 0.001), 'HH monitoring' 70% (baseline: 60.7; P < 0.001) and 'existence of antimicrobial prescription protocol' 80.7% (baseline: 73.2; P < 0.001), among others. The HCAI rates of the participating hospitals decreased after the intervention (P < 0.05). The QI cycle approach was useful in guiding system-wide interventions for patient safety. External regulation was feasible and effective in promoting internal HCAI prevention nationwide.

Incidence and Impact of Reported Infectious Endophthalmitis Events Following Cataract Surgery in Pennsylvania Ambulatory Surgery Centers

Infectious endophthalmitis is a severe eye infection that can occur following cataract surgery. In this study, we sought to explore post-cataract infectious endophthalmitis events reported by ambulatory surgery centers (ASCs) in Pennsylvania. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) database for post-cataract endophthalmitis events that occurred between 2009 and 2018. In the 10 calendar years analyzed, we identified 174 reports of post-cataract endophthalmitis, with rates per 1000 cataract procedures ranging from 0.05 in 2009 to 0.19 in 2018. The vast majority of these events were classified as serious (93%; n = 162 of 174), reflecting harm to patients, with one resulting in enucleation (the need to remove the affected eye). Healthcare staff and all involved stakeholders should act now by identifying sources of potential perioperative contamination, adhering to evidence-based infection prevention practices, and prioritizing areas of opportunity for improvement.

Education and Consistent Infection Prevention Practices Prevail: An Outbreak of CRE in a Long Term Acute Care Hospital

Carbapenem-resistant Enterobacteriaceae (CRE) infections are difficult to treat and pose a significant threat to public health. In July 2018, an infection preventionist (IP) notified Los Angeles County Department of Public Health (LACDPH) of eight cases of healthcare-onset carbapenem-resistant Klebsiella pneumoniae (CRKP) among residents of a 54-bed long term acute care facility (LTAC). LACDPH initiated an investigation to identify risks for infection and disrupt transmission. A case was defined as a LTAC patient with laboratory confirmation for CRKP or carbapenemase-producing organism from June 28- August 7, 2018 and no previous CRE history. LACDPH conducted two site visits of the facility to observe infection prevention practices. Medical records, staff training records, and infection prevention audits were reviewed. Facility-wide surveillance cultures were collected on three dates. The first facility-wide screening yielded 13 additional cases; no further cases were identified during subsequent screenings. Medical record review found one additional case. A total of 22 cases were identified; overall prevalence was 39%. Site observations revealed missed hand hygiene opportunities, unclear contact precaution signage, and a knowledge deficit among staff regarding CRE and control measures. LACDPH recommended enhanced environmental cleaning, infection control trainings for all staff, hand hygiene and personal protective equipment audits, placing new admissions on contact precautions pending CRE screening results, and the use of an interfacility transfer form upon discharge of all known CRE patients. We identified a high prevalence of CRE in an LTAC, a setting where patients generally have higher invasive device and antibiotic utilization than other settings. However, the implementation of evidence-based infection prevention practices enabled the facility to stop the spread of infection. Identification and containment of a CRE outbreak in a healthcare facility relies on several factors, including the collaboration of a facility's IP with the local health department and continuing frontline staff education.

Hospital Infection Prevention: How Much Can We Prevent and How Hard Should We Try?

To summarize the extent to which hospital-acquired infections (HAIs) are preventable and to assess expectations, challenges, and barriers to improve patient outcomes. HAIs cause significant morbidity and mortality. Getting to zero HAIs is a commonly stated goal yet leads to unrealistic expectations. The extent to which all HAIs can be prevented remains debatable and is subject to multiple considerations and barriers. Current infection prevention science is inexact and evolving. Evidence-based infection prevention practices are often incompletely implemented and at times controversial. Highly sensitive surveillance results in overdiagnosis, calling into question the real incidence of HAIs. Perceived reductions in HAIs by gaming the system lead to false conclusions about preventability and may cause harm. Successful HAI reduction programs require executive oversight yet keeping hospital leaders engaged in infection prevention is a challenge given competing priorities. Medicine is not a physical science with precisely defined laws; thus, infection prevention interventions are subject to variable outcomes. Perhaps up to 55-70% of HAIs are potentially preventable. This is subject to a law of diminishing returns as the preventable proportion of HAIs may reduce over time with improvements in patient safety. As the principle tenet of medicine is first do no harm, infection prevention programs should relentlessly pursue reliable, sustainable, and practical strategies for heightened patient safety.

Reducing preventable harm: observations on minimizing bloodstream infections

PurposeThe purpose of this paper is to provide a practical framework that health care organizations could use to decrease preventable healthcare-acquired harms.Design/methodology/approachAn existing theory of how hospitals succeeded in reducing rates of central line-associated bloodstream infections was refined, drawing from the literature and experiences in facilitating improvement efforts in thousands of hospitals in and outside the USA.FindingsThe following common interventions were implemented by hospitals able to reduce and sustain low infection rates. Hospital and intensive care unit (ICU) leaders demonstrated and vocalized their commitment to the goal of zero preventable harm. Also, leaders created an enabling infrastructure in the way of a coordinating team to support the improvement work to prevent infections. The team of hospital quality improvement and infection prevention staff provided project management, analytics, improvement science support, and expertise on evidence-based infection prevention practices. A third intervention assembled Comprehensive Unit-based Safety Program teams in ICUs to foster local ownership of the improvement work. The coordinating team also linked unit-based safety teams in and across hospital organizations to form clinical communities to share information and disseminate effective solutions.Practical implicationsThis framework is a feasible approach to drive local efforts to reduce bloodstream infections and other preventable healthcare-acquired harms.Originality/valueImplementing this framework could decrease the significant morbidity, mortality, and costs associated with preventable harms.

Cumulative impact of periodic top-down communications on infection prevention practices and outcomes in two units.

The problem of interest in this study is the challenge of consistent implementation of evidence-based infection prevention practices at the unit level, a challenge broadly characterized as "change implementation failure." The theoretical literature suggests that periodic top-down communications promoting tacit knowledge exchanges across professional subgroups may be effective for enabling change in health care organizations. However, gaps remain in understanding the mechanisms by which top-down communications enable practice change at the unit level. Our study sought to both validate the theoretical literature and address this gap. Correspondingly, this study posed two research questions. (1) What is the impact of periodic "top-down" communications on practice change at the unit level? (2) What are the "unit-level" communication dynamics enabling practice changes? Whereas this article focuses on addressing the first question, the second question has been addressed in an earlier Health Care Management Review article (Rangachari et al., 2013). A prospective study was conducted in two intensive care units at an academic health center. Both units had low baseline adherence to central line bundle (CLB) and higher-than-expected catheter-related bloodstream infections (CRBSIs). Periodic top-down communication interventions were conducted over 52 weeks to promote CLB adherence in both units. Simultaneously, the study examined (a) unit-level communication dynamics related to CLB through weekly "communication logs," completed by unit physicians, nurses, and managers, and (b) unit outcomes, that is, CLB adherence and CRBSI rates. Both units showed increased adherence to CLB and significant, sustained declines in CRBSIs. Results showed that the interventions cumulatively had a significant negative (desired) impact on "catheter days," that is, central catheter use. Results help validate the theoretical literature and identify evidence-based management strategies for practice change at the unit level. They suggest that periodic top-down communications have the potential to modify interprofessional knowledge exchanges and enable practice change at the unit level, leading to significantly improved outcomes and reduced costs.

Translating and Scaling the HHS Action Plan to Prevent Healthcare-associated Infections to the Local Level

The US Department of Health and Human Services National Action Plan to Prevent Healthcare-associated Infections (HAIs) set 5-year national-level goals beginning in 2009 for reducing the most common and serious HAIs. Meeting these goals on the local level depended on generalizing and sustaining evidence-based infection prevention practices at the >5000 US community and federal acute care hospitals. To describe the impact of the Federal and California State HAI Action Plans on UCLA Heath, an academic health system in Los Angeles, in planning and implementing HAI prevention activities and reducing HAI rates. The Context-Input-Process-Product model and the systems functions and properties framework were applied to the evaluation of infection prevention and control activities at UCLA Health. Resource constraints, competing priorities, variation in care practices, provider engagement, and the expanding administrative burden of public reporting were some of the challenges to implementing and sustaining HAI prevention practices at the local level. Progress toward reducing targeted HAI rates in UCLA Health has paralleled the results observed on the state and national level, including declining infections associated with medical devices, surgical procedures, and multidrug-resistant organisms. In California, federal funding supporting the state HAI Action Plans and mandatory public reporting requirements spurred adoption, implementation, and evaluation of HAI prevention efforts and helped to drive collaborative performance improvement and research at the facility level.

Implementing the Central Venous Catheter Infection Prevention Bundle in the Emergency Department: Experiences Among Early Adopters

Central line-associated bloodstream infections (CLABSI) cause preventable morbidity and mortality. Hospitals have reduced CLABSI by using a bundle of evidence-based infection prevention practices. Systems factors in the emergency department (ED) present unique barriers to bundle adoption, and no guidelines exist for bundle implementation. We aim to identify barriers and facilitators to central line bundle adoption in EDs. We used a qualitative, grounded theory approach, enrolling 6 EDs that were early adopters of the central line bundle. We interviewed 49 administrators and staff (nurses and physicians) through 26 semistructured interviews and 3 focus groups of 6 to 8 individuals. Investigators read each transcript and then iteratively built and refined a set of themes that emerged from the data. Barriers to central line bundle adoption included high acuity, time constraints, staffing, space, ED culture, high ED volume and acuity, role ambiguity, and a lack of methods to track compliance and infection surveillance. Facilitators included champions, staff engagement, workflow redesign that includes a checklist and central line kit or cart, clear staff responsibilities, observer empowerment, and compliance and infection surveillance data. The strategies for implementing and sustaining a central line infection prevention bundle in the ED are distinct from those of other clinical settings. Our findings describe the central line bundle workflow in the ED, staff motivations, and the critical systems factors that impede and foster its use. Knowledge of these systems factors should improve bundle adoption in the ED and thereby reduce hospital incidence of CLABSIs.

Infection prevention practices in adult intensive care units in a large community hospital system after implementing strategies to reduce health care-associated, methicillin-resistant Staphylococcus aureus infections

A range of strategies and approaches have been developed for preventing health care-associated infections. Understanding the variation in practices among facilities is necessary to improve compliance with existing programs and aid the implementation of new interventions. In 2009, HCA Inc administered an electronic survey to measure compliance with evidence-based infection prevention practices as well as identify variation in products or methods, such as use of special approach technology for central vascular catheters and ventilator care. Responding adult intensive care units (ICUs) were those considering participation in a clinical trial to reduce health care-associated infections. Responses from 99 ICUs in 55 hospitals indicated that many evidenced-based practices were used consistently, including methicillin-resistant Staphylococcus aureus (MRSA) screening and use of contact precautions for MRSA-positive patients. Other practices exhibited wide variability including discontinuation of precautions and use of antimicrobial technology or chlorhexidine patches for central vascular catheters. MRSA decolonization was not a predominant practice in ICUs. In this large, community-based health care system, there was substantial variation in the products and methods to reduce health care-associated infections. Despite system-wide emphasis on basic practices as a precursor to adding special approach technologies, this survey showed that these technologies were commonplace, including in facilities where improvement in basic practices was needed.