Interventions to improve professional adherence to ...

Interventions to improve professional adherence to guidelines for prevention of device-related infections (Review) Flodgren G, Conterno LO, Mayhew A, Omar O, Pereira CR, Shepperd S

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2013, Issue 3 http://www.thecochranelibrary.com

Interventions to improve professional adherence to guidelines for prevention of device-related infections (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

TABLE OF CONTENTS HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . . BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.1. Comparison 1 Ventilator-associated pneumonia (VAP) analysis, Outcome 1 VAP change in pre- and postintervention slope at 3 to 6 months. . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.2. Comparison 1 Ventilator-associated pneumonia (VAP) analysis, Outcome 2 VAP 3 months level. . . Analysis 1.3. Comparison 1 Ventilator-associated pneumonia (VAP) analysis, Outcome 3 VAP 6 months level. . . Analysis 1.4. Comparison 1 Ventilator-associated pneumonia (VAP) analysis, Outcome 4 VAP 9 months level. . . Analysis 1.5. Comparison 1 Ventilator-associated pneumonia (VAP) analysis, Outcome 5 VAP 12 months level. . . Analysis 2.1. Comparison 2 Central line-associated blood stream infections (CLABSIs) analysis, Outcome 1 CLABSI change in pre- and post-intervention slope at 4 to 8 months. . . . . . . . . . . . . . . . . . . Analysis 2.2. Comparison 2 Central line-associated blood stream infections (CLABSIs) analysis, Outcome 2 CLABSI 3 months level. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.3. Comparison 2 Central line-associated blood stream infections (CLABSIs) analysis, Outcome 3 CLABSI 6 months level. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.4. Comparison 2 Central line-associated blood stream infections (CLABSIs) analysis, Outcome 4 CLABSI 9 months level. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.5. Comparison 2 Central line-associated blood stream infections (CLABSIs) analysis, Outcome 5 CLABSI 12 months level. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.6. Comparison 2 Central line-associated blood stream infections (CLABSIs) analysis, Outcome 6 CLABSI 18 months level. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.7. Comparison 2 Central line-associated blood stream infections (CLABSIs) analysis, Outcome 7 CLABSI 21 months level. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


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[Intervention Review]

Interventions to improve professional adherence to guidelines for prevention of device-related infections Gerd Flodgren1 , Lucieni O Conterno2 , Alain Mayhew3 , Omar Omar4 , Cresio Romeu Pereira5 , Sasha Shepperd1 1

Department of Public Health, University of Oxford, Oxford, UK. 2 Department of General Internal Medicine and Clinical Epidemiology Unit, Marilia Medical School, Marilia, Brazil. 3 Centre for Practice-Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, Ottawa, Canada. 4 Centre for Statistics in Medicine, Oxford, UK. 5 Infection Control, Municipal Health Department, Ilhabela, Brazil Contact address: Gerd Flodgren, Department of Public Health, University of Oxford, Rosemary Rue Building, Old Road Campus, Headington, Oxford, Oxfordshire, OX3 7LF, UK. [email protected].

Editorial group: Cochrane Effective Practice and Organisation of Care Group. Publication status and date: Edited (no change to conclusions), published in Issue 4, 2013. Review content assessed as up-to-date: 16 July 2012. Citation: 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. Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT Background Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. There are specific risk profiles for each device, but in general, the breakdown of aseptic technique during insertion and care for the device, as well as the duration of device use, are important factors for the development of these serious and costly infections. Objectives To assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device-related infection rates and measures of adherence. Search methods We searched the following electronic databases for primary studies up to June 2012: the Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. We searched reference lists and contacted authors of included studies. We also searched the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews. Selection criteria We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies that complied with the Cochrane EPOC Group methodological criteria, and that evaluated interventions to improve professional adherence to guidelines for the prevention of device-related infections. Interventions to improve professional adherence to guidelines for prevention of device-related infections (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Data collection and analysis Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane EPOC ’Risk of bias’ tool. We contacted authors of original papers to obtain missing information. Main results We included 13 studies: one cluster randomised controlled trial (CRCT) and 12 ITS studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards, and more than 3504 patients and 1406 healthcare professionals. Six of the included studies targeted adherence to guidelines to prevent central line-associated blood stream infections (CLABSIs); another six studies targeted adherence to guidelines to prevent ventilator-associated pneumonia (VAP), and one study focused on interventions to improve urinary catheter practices. We judged all included studies to be at moderate or high risk of bias. The largest median effect on rates of VAP was found at nine months follow-up with a decrease of 7.36 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). The one included cluster randomised controlled trial (CRCT) observed, improved urinary catheter practices five weeks after the intervention (absolute difference 12.2 percentage points), however, the statistical significance of this is unknown given a unit of analysis error. It is worth noting that N = 6 interventions that did result in significantly decreased infection rates involved more than one active intervention, which in some cases, was repeatedly administered over time, and further, that one intervention involving specialised oral care personnel showed the largest step change (-22.9 cases per 1000 ventilator days (standard error (SE) 4.0), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002)) among the included studies. We attempted to combine the results for studies targeting the same indwelling medical device (central line catheters or mechanical ventilators) and reporting the same outcomes (CLABSI and VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among included studies (I2 up to 97%), we did not retain these analyses. Six of the included studies reported post-intervention adherence scores ranging from 14% to 98%. The effect on rates of infection were mixed and the effect sizes were small, with the largest median effect for the change in level (interquartile range (IQR)) for the six CLABSI studies being observed at three months follow-up was a decrease of 0.6 (-2.74 to 0.28) cases per 1000 central line days (six studies and 36 sites). This change was not sustained over longer follow-up times. Authors’ conclusions The low to very low quality of the evidence of studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions involving more than one active element and that are repeatedly administered over time, and interventions employing specialised personnel, who are focused on an aspect of care that is supported by evidence e.g. dentists/ dental auxiliaries performing oral care for VAP prevention.

PLAIN LANGUAGE SUMMARY Can interventions to improve professional adherence to guidelines prevent device-related infections? Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators) that breach the body’s normal defence mechanisms, and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. We identified 13 studies: one cluster randomised controlled trial (CRCT) and 12 interrupted time series (ITS) studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards and more than 1406 healthcare professionals and 3504 patients, which assessed the impact of different interventions to reduce the occurrence of device-related infections for inclusion in this review. We judged all studies to be at moderate to high risk of bias. The effect sizes were small with the largest median effect for studies addressing central line associated blood stream infections (CLABSIs) occurring immediately after the implementation of an intervention to improve adherence to guidelines, in the majority of studies this change was not sustained over longer follow-up times. The median effect for studies aiming to reduce ventilator-associated pneumonia (VAP) was somewhat greater and was sustained up to 12 months follow-up. The results of six studies that reported adherence/nonadherence with infection control recommendations showed very varying adherence scores ranging from 14% to 98%. Interventions to improve professional adherence to guidelines for prevention of device-related infections (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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


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S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]

Interventions to improve professional adherence to guidelines for the prevention of device-related infections compared with standard care Patient or population: patients with an indwelling device Settings: hospital Intervention: interventions to improve professional adherence to guidelines for the prevention of device-related infections Comparison: standard care Outcomes

Change in level effect Number of sites (step change) (number of studies) * Median infection rate per quarter (range) per 1000 device days

Change in trend (slope) Quality of the evidence Median change in in- (GRADE) fection rate between pre- and post-intervention trends (range)

CLABSI rate up to 12 -0.6 to +0.06 cases per 7 to 36 sites (5 to 6 stud- +0.21 (0.43) cases per months 1000 central line days ies) 1000 central line days Number of pre-intervention data points (range): 3 to 11 Number of post-intervenCLABSI rate more than 12 +0.65 to 2.6 cases per 4 to 6 sites (2 to 4 stud- tion data points (range): 4 months 1000 central line days ies) to 8 VAP rate up to 12 months -2.55 to -7.36

⊕

very low

⊕

very low

10 to 15 sites (3 to 6 -0.14 (5.8) cases per ⊕

studies) 1000 ventilator days very low Number of pre-intervention data points (range): 3 to 9 Number of post-intervention data points (range): 3 to 6

* 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 Interventions to improve professional adherence to guidelines for prevention of device-related infections (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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

Description of the condition A healthcare-associated infection (HAI) is defined by Horan 2008 as “an infection that occurs during a hospital admission, for which there is no evidence that it was present or incubating at admission, and that meets body site-specific criteria”. Most HAIs are endemic, and some of them can be associated with inappropriate patient care (Pittet 2006). Although invasive devices are frequently required for optimal patient care, the possibility exists that they are overused (Conterno 2011). Often invasive devices do not meet appropriate indications for their use or they remain in place beyond what is deemed necessary, or both (Gowardman 1998; Saint 2000). Central line-associated blood stream infection (CLABSI) is associated with a number of risk factors: the experience of the health professional performing the insertion, not using maximal sterile techniques, placement of a vascular catheter in the internal jugular or femoral vein rather than in the subclavian vein, the type of catheter used, the nurse-to-patient ratio in the intensive care unit (ICU), contamination of the catheter hub, as well as the frequency of catheter manipulation and duration of catheter placement (Safdar 2002). Several risk factors are associated with the development of ventilator-associated pneumonia (VAP): admitting diagnosis of burns, trauma, central nervous system disease, respiratory disease, cardiac disease, gastroesophageal reflux, use of paralytic drugs, nasotracheal intubation compared to orotracheal intubation, and duration of mechanical ventilation. Specific risk factors for catheter-associated urinary tract infections (CAUTIs) are: female sex, catheter insertion outside operating room, the duration of catheterisation, diabetes mellitus, and colonisation of drainage bag, or catheter or tissues surrounding the urethra, or both (Bernard 2012; Tambyah 2012). Some of these factors can be considered modifiable and related to failure to adhere to the recommended care process, which may lead to infection (Alp 2006; Muscedere 2008).

Risk factors common to all device-related infections include: the severity of underlying illness, which often prolongs the length of hospital stay, increasing rates of antimicrobial resistance, the development of progressively more complex medical procedures and high bed occupancy (Chalmers 2006; Emmerson 1996; Gravel 2007; Griffiths 2009). Between 5% to 10% of patients admitted to acute care hospitals in high-income countries acquire one or more infections (Emmerson 1996; Gravel 2007; Weinstein 1998; WHO 2011), and in healthcare settings with limited resources, reported HAI rates are higher, varying from 5.7% to 19.1% (Allegranzi 2011). CLABSI, VAP, and CAUTI (as well as surgical site infections, which are outside the scope of this review) together account for more than 80% of all HAIs. The most common sites of HAIs vary according to hospital characteristics, but between 60% and 87% of primary bloodstream infections are CLABSIs, 86% of hospital acquired pneumonia occurrences are VAPs, and 80% to 95% of urinary tract infections are CAUTIs (Emmerson 1996; Gravel 2007; Klevens 2007; Richards 1999). HAIs may have numerous clinical and resource implications including long-term disability, increased resistance of microorganisms to antimicrobials, excess deaths, prolonged hospital stay, additional financial burden for health systems, and high costs for patients and their families (Klevens 2007; Stone 2005; Umscheid 2011). According to a report on device-associated infections in 173 ICUs from 25 countries in Latin America, Asia, Africa, and Europe, crude excess mortality in adult patients was 18.5%, 23.6%, and 29.3% for CAUTI, CLABSI, and VAP respectively (Rosenthal 2010). In ICUs in the United States, approximately 500 to 4000 patients die annually from CLABSIs (Mermel 2000), and the cost of caring for a patient with CLABSI is estimated as USD 36,441 (hospital costs in 2002 USD in Stone 2005). Between 10% and 20% of patients receiving more than 48 hours of mechanical ventilation develop VAP. According to Safdar 2005 the crude death rates of patients with VAP is unknown, since some studies show increased mortality and some do not, but patients who do develop VAP incur more than USD 10,019 (in 2003 USD) in additional hospital costs; cost estimates included increased length of hospital stay, laboratory tests, and antimicrobial treatment. CAUTI is the most frequent and preventable HAI (Umscheid 2011). Each episode of CAUTI costs at least USD 600 (in 1998 USD) (Saint 2000; Tambyah 2002); cost estimates included increased length of hospital stay, laboratory tests and antimicrobial treatment. Each episode of urinary tract-related bacteraemia (bloodstream infections secondary to CAUTI) costs at least USD 2800 (in 1998 USD) (Saint 2000).

Description of the intervention Quality improvement strategies to change clinical practice may be classified into four different main categories according to the EPOC taxonomy (http://epoc.cochrane.org/sites/ epoc.cochrane.org/files/


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uploads/datacollectionchecklist.pdf): i) professional interventions (e.g. distribution of educational material, educational meetings, local consensus processes, educational outreach visits, local opinion leaders, patient mediated interventions, audit and feedback and reminders); ii) financial interventions; iii) organisational interventions (e.g. revision of professional roles, clinical multidisciplinary teams, skill mix changes etc); and iv) regulatory interventions. These quality improvement strategies may be used either alone or in combination when attempting to improve health professionals’ adherence to infection control guidelines. In 2006, the Institute for Healthcare Improvement in the United States developed the concept of a care bundle (Hareden 2006). These bundles are used to monitor, assess, improve performance and increase the consistency of care. Care bundles were first developed for intensive care settings and are a set of evidence based practices that, when performed collectively and reliably, should improve patient outcomes. Care bundles do not cover all the clinical actions that may take place in a period of care, but generally focus on three to five key evidence based practices (http:// www.hps.scot.nhs.uk/haiic/ic/bundles.aspx). Several care bundles have been developed to decrease HAIs (Yokoe 2008b). Evidence from one systematic review (Aboelela 2007), suggests that bundled interventions are effective in decreasing HAIs, while another systematic review, focusing on the ventilator bundle only, suggests that the existing evidence is of too low quality for any conclusions to be drawn about its effectiveness (Zilberberg 2009). Both reviews relied on evidence from non-randomised studies only. Further evidence from a cross-sectional study evaluating the compliance with a CLABSI care bundle in 250 hospitals, suggests that the bundle is associated with lower infection rates only when the hospital had a policy, monitored compliance and where compliance was high (Furuya 2011).

How the intervention might work Avoiding the use of invasive devices and reducing the duration of use, coupled with aseptic insertion and maintenance techniques could reduce the rate of device-related infections. There are numerous clinical recommendations developed by various government institutions and scientific societies to prevent infections related to invasive medical devices (NHMRC 2010; O’Grady 2011; Pratt 2007; Yokoe 2008b). Guidelines for the prevention of device-related infections make general recommendations about educating and training the healthcare personnel who insert and maintain indwelling devices, as well as clinical recommendations. For CLABSI prevention according to O’Grady 2011 the main preventive recommendations are: i) use maximal sterile barriers during central venous catheter (CVC) insertion; ii) use of > 0.5% Chlorhexidine skin preparation with alcohol for skin antisepsis; iii) avoidance of routine replacement of CVCs as a strategy to prevent infection; iv) avoidance of the femoral insertion site in adults; v) changing dressings in a timely manner (when wet, soiled or dislodged) using

aseptic techniques; and vi) performance of daily audits to assess whether each central line is still needed (O’Grady 2011). Clinical interventions to prevent VAP include: i) promoting hand hygiene using alcohol based antiseptics before manipulating the airways; ii) implementing ventilator circuit changes only when clinically indicated; iii) incorporating sedation control protocols; iv) oral care with Chlorhexidine 0.12% every eight hours; and v) intracuff pressure control to reduce leakage of oropharyngeal secretions to the lower airways tract (Rello 2012). Other important clinical recommendations to prevent VAP include: head of bed elevation (with 30º or more); daily “sedation vacation”; and daily assessment of readiness to extubate. Guidelines to prevent CAUTIs include the following clinical interventions: i) assessing the need for using a catheter; ii) the selection of catheter type and system; iii) catheter insertion in the operating room; iv) maintaining a sterile closed system of drainage; and v) the education of patients, relatives, and healthcare professionals (Pratt 2007). All guidelines for the prevention of devicerelated infections identify hand hygiene and aseptic techniques as important preventive interventions. There is evidence for the effectiveness of some of these clinical interventions from systematic reviews (Chlebicki 2007; Phipps 2006; Ramritu 2008); e.g. the use of maximum sterile barriers while placing CVCs (Ramritu 2008); continuous aspiration of subglottic secretions (Shojania 2001); oral decontamination with Chlorhexidine (Chlebicki 2007); and earlier removal of urinary catheters following urogenital surgery (Phipps 2006). One systematic review (Ranji 2007) evaluated the effects of quality improvement strategies (e.g. clinician and patient education, audit and feedback, reminder systems, organisational change, and financial or regulatory incentives for patients or clinicians), on adherence with clinical interventions for the prevention of selected HAIs. No definitive conclusions regarding actionable quality improvement strategies to prevent HAIs could be reached due to the poor quality of included studies, however, based on the limited evidence, the authors suggested that the following strategies might be worthy of further study: use of printed or computer based reminders with automatic stop orders to reduce unnecessary urethral catheterisation; active educational interventions with the use of checklists to improve adherence to central line insertion practices; and active educational interventions such as tutorials to improve adherence to preventive clinical interventions for VAP. Another systematic review (Wilson 2009) suggested that staff education on urinary catheter management, combined with regular monitoring of CAUTI rates could reduce the incidence. A third review (Ramritu 2008), that evaluated risk reduction of CLABSIs in ICUs, concluded that strategies to reduce CLABSIs should include staff education, multifaceted infection control programmes and performance feedback. The design and implementation of interventions to improve adherence with guidelines depends on successful behaviour change interventions (Mitchie 2011), which in turn, require an appropriate method for characterising inter-


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ventions and linking them to an analysis of the targeted behaviour (Grimshaw 2004; Grimshaw 2012). Although there is evidence on how to prevent device-related infections, a significant evidence-to-practice gap still remains. Guideline implementation strategies can improve processes of care, but the impact on outcomes of care is understudied (Garg 2005; Grimshaw 2006). Implementation strategies may be passive or active. Passive strategies include the distribution of educational materials, posters and visual aids; active strategies include reminders, audit and feedback, interactive workshops, and one-to-one academic detailing. One systematic review of the effectiveness of guideline implementation strategies suggested that passive interventions could have modest beneficial effects but they did not result in sustained behaviour change; while active multifaceted strategies of selected interventions, additive in their benefit, appeared to have the greatest impact (Grimshaw 2004).

Why it is important to do this review HAI is the most frequent adverse event in healthcare delivery worldwide. Hundreds of millions of patients are affected each year, leading to significant mortality and costs for health systems (WHO 2011). HAIs are more frequent in resource-limited settings. The prevalence of HAI varies between 5.7% and 19.1% in low- and middle-income countries (Allegranzi 2011). The European Centre for Disease Prevention and Control reports an average prevalence of 7.1% in European countries. These infections annually account for 37,000 attributable deaths in Europe and for 99,000 deaths in the United States. Annual financial costs due to HAIs are estimated at approximately EUR 7 billion in Europe, including direct costs only and reflecting 16 million extra days of hospital stay, and at about USD 6.5 billion in the United States (WHO 2011). Not all HAIs are avoidable. However recent estimates suggest that up to 65% to 70% of all CLABSI and CAUTI cases and 55% of VAP and surgical site infection cases may be preventable if current evidence based strategies of infection prevention are used during the insertion and maintenance of invasive devices (Umscheid 2011). There is therefore potentially a lot to gain, in terms of decreased burden of HAI, deaths and healthcare costs, if professionals can be persuaded to change their behaviour and to always adhere to infection control guidelines. Several Cochrane systematic reviews (e.g. Flodgren 2011; Forsetlund 2009; Giguere 2012; Ivers 2012; O’Brien 2007; Shojania 2009) have assessed the effectiveness of educational and organisational interventions on overall practice, but they did not specifically focus on interventions to improve adherence to guidelines for preventing device-related infections. Another systematic review (Grimshaw 2004) that evaluated the effectiveness and efficiency of guideline dissemination and implementation strategies to improve professional practice in general, concluded that the evidence base to support decisions about which strategies are likely

to be efficient in different circumstances is inadequate. It is therefore of interest to review the existing evidence regarding the effectiveness of interventions to improve professional adherence with infection control guidelines, in order to inform decision makers and policy makers alike on the most effective ways to prevent these serious and costly infections.

OBJECTIVES To assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device-related infection rates and measures of adherence. The specific objectives are to determine the effectiveness of interventions targeting health professionals or the organisation of healthcare in order to: 1. avoid the use of invasive medical devices; 2. reduce the duration of invasive medical device use; and 3. improve the adoption of adequate procedures for insertion, and maintenance of invasive medical devices, and thereby the prevention of device-related infections.

METHODS

Criteria for considering studies for this review

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

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


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Types of interventions We considered any intervention to avoid the use, or decrease the length of use of invasive medical devices (i.e. urinary catheters, central line catheters, mechanical ventilators), or interventions to improve adoption of measures to prevent device-related infections. The comparative groups received no intervention or different interventions compared to the experimental group. We classified interventions according to the EPOC taxonomy (http://epoc.cochrane.org/sites/epoc.cochrane.org/files/ uploads/datacollectionchecklist.pdf) as follows. • Professional interventions: distribution of educational materials, educational meetings, local consensus processes, educational outreach visits, local opinion leaders, patient mediated interventions, audit and feedback, reminders, marketing, and mass media. • Organisational interventions: revision of professional roles, clinical multidisciplinary teams, formal integration of services, and skill mix changes. • Financial interventions. • Regulatory interventions. Types of outcome measures We included any objective measure of provider performance or patient outcomes.

in 2012 are in Appendix 1, Appendix 2, Appendix 3, Appendix 4, Appendix 5 and Appendix 6; strategies run prior to 2012 are in Appendix 7, Appendix 8 and Appendix 9. We searched the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects (DARE), related systematic reviews and the databases listed below for primary studies. Electronic searches • EPOC Group, Specialised Register, Reference Manager • EBM Reviews, Cochrane Central Register of Controlled Trials (CENTRAL ), April 2012, OvidSP • MEDLINE, 1947-In-Process; Daily Update, OvidSP • EMBASE, 1947-, OvidSP • CINAHL (Cumulative Index to Nursing and Allied Health Literature), 1980- , EbscoHost • EBM Reviews, Cochrane Database of Systematic Reviews, 2005 to May 2012, OvidSP • EBM Reviews, Database of Abstracts and Reviews, 2nd Quarter, 2012, OvidSP • EBM Reviews, Health Technology Assessment, 2nd Quarter 2012, OvidSP • EBM Reviews, NHS Economic Evaluation Database, 2nd Quarter 2012, OvidSP Cochrane Central Register of Controlled Trials (CENTRAL), Issue 6, 2012, Wiley • Science Citation Index (ISI Web of Knowledge) (cited reference searches)

Primary outcomes

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

• • • • •

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

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

Data collection and analysis

Selection of studies

Search methods for identification of studies M. Fiander and Doug Salzwedel, Trials Search Co-ordinators (TSCs) for the EPOC Group, designed search strategies in consultation with the authors. Search strategies for this review were developed and used in 2008 and revised and used between April and June 2012. The revised search strategy included additional terms for infection and employed an up-to-date methodological filter. All searches were from the database start date. Strategies run

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


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disagreements were resolved by discussion between the review authors. Data extraction and management Two review authors (from LOC, AM, GF and CRP) independently undertook data extraction, using a modified version of the EPOC Data Extraction Form and the Data Collection Checklist (http://epoc.cochrane.org/epoc-author-resources). Any disagreements were resolved by discussion between the review authors. For time series analyses, when information on the value of individual observations over time was only reported graphically in the original paper, we derived data by importing the graphs into Microsoft Paint. First, we electronically measured the location of each data point on the y-axis (in pixels) and then we used a scale factor to calculate the value of the data point in natural units.

reported data, except for Cocanour 2006 in which too few data points before and after the interventions were reported to permit calculations of quarterly rates. For the purpose of a meta-analysis we standardised the data by dividing the outcome and standard error (SE) by the pre-intervention standard deviation (SD) as recommended in Ramsay 2001. We reported the results for the main outcomes in Summary of findings for the main comparison. Handling methodological issues in primary studies

We identified twelve ITS studies which we reanalysed to take into account secular trends using time series regression techniques. We used segmented time series regression analysis to estimate the effect of the intervention, whilst taking into account time trend and autocorrelation among the observations. We obtained estimates for regression coefficients corresponding to two standardised effect sizes for each study: a change in level and a change in trend before Assessment of risk of bias in included studies and after the intervention. A change in level was defined as the Two review authors (from LOC, AM, GF and CRP) indepen- difference between the observed level at the first intervention time dently assessed the risk of bias of included studies using the point and that predicted by the pre-intervention time trend. A EPOC ’Risk of bias’ tool described in detail in the EPOC mod- change in trend was defined as the difference between post- and ule http://www.epoc.cochrane.org/sites/epoc.cochrane.org/files/ pre-intervention slopes (Ramsay 2003). A negative change in level and slope indicates an intervention effect in terms of a reduction in uploads/Suginfection rates. We evaluated the direct effect of the intervention gested%20risk%20of%20bias%20criteria%20for%20EPOC%20reviews.pdf Disagreements were resolved by discussion between review au- using the quarter after the intervention started. We also reported the level effects at six months, nine months, yearly, 18 and 21 thors. We assessed the risk of bias of RCTs using nine standard crite- months time points when possible. ria: (i) adequate allocation sequence generation; (ii) adequate con- We identified one RCT that had not taken into account the effect cealment of allocation; (iii) similar baseline outcome measures; of clustering in the analysis, we did not attempt reanalysis of this (iv) similar baseline characteristics; (v) blinding of outcome assess- study as the intracluster correlation coefficient and average number ment; (vi) adequately addressed incomplete outcome data; (vii) of patients per cluster were not reported. adequate protection against contamination; (viii) free from selective reporting; and (ix) free of other risk of bias (Higgins 2011). Grading the quality of evidence For ITS studies, we used the following criteria: (i) intervention We used the GRADE grading tool for assessing the quality of evindependent of other changes; (ii) shape of the intervention preidence of included studies (GRADE 2004): in this assessment of specified; (iii) intervention unlikely to affect data collection; (iv) the studies, we took into account risk of bias, along with inconknowledge of the allocated interventions adequately prevented; sistency, imprecision, indirectness and risk of publication bias. (v) incomplete outcome data adequately addressed; (vi) free from selective outcome reporting; and (vii) free from other risks of bias. Dealing with missing data Measures of treatment effect For each study we reported the main results in natural units and calculated the change data for both the change in level and change in slope if it was not reported. For the included RCT study we reported pre-intervention and post-intervention percentages for both study and control groups, and calculated the absolute change from baseline with 95% confidence intervals (CIs). For ITS studies we extracted data on infection rates from graphs in original papers in order to obtain effect sizes. We calculated the means for quarterly infection rates for all studies with monthly

We requested additional data from authors of original papers by email; we sent one email reminder. One reply was received from the first author of Abbott 2006a but unfortunately the data was no longer available. Assessment of heterogeneity We assessed statistical heterogeneity using I2 and Chi2 statistics. We intended to quantitatively explore the potential sources of heterogeneity by (i) type and characteristics of devices; ii) type of health professionals; iii) patient’s age, diagnosis, and severity of condition; iv) categories of interventions based on the EPOC


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taxonomy; v) setting, for example the type of ICU and ward, community or university affiliated hospitals; and vi) high versus low risk of bias. We were however unable to carry out a quantitative assessment of heterogeneity due to few included studies; instead we report our qualitative assessment of the potential sources of heterogeneity in the Discussion.

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

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

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

RESULTS

Data synthesis

Description of studies

As planned, we attempted pooling the reanalysed results of VAP studies and CLABSI studies respectively using the generic inverse variance method of Review Manager 5.1 (RevMan 2011). We used the standardised changes in level and trend as effect measures in the analysis. However, due to very high heterogeneity among studies, we did not retain the meta-analyses. The main findings (VAP and CLABSI rates) are presented as the median step change (interquartile range, (IQR)) and the median change in slope (IQR) in the text, and as standardised means in forest plots without summary estimates. The results of the reanalysis for the individual studies are reported in Table 1 and Table 2. We used Stata 11 (Stata 2009) for all statistical reanalyses and Review Manager 5.1 (RevMan 2011) for creating the forest plots. We present the median effect sizes (range) for the main outcomes: VAP rate and CLABSI rate in Summary of findings for the main comparison.

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

Subgroup analysis and investigation of heterogeneity

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


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Figure 1. Study flow diagram.


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Included studies

Study design

We included 13 studies in this review; one cluster RCT (Ching 1990) and a total of twelve ITS studies (Beathard 2003; Cocanour 2006; Coopersmith 2002; Kaye 2000; Miller 2010; Parra 2010; Salahuddin 2004; Sannoh 2010; Sona 2009; Warren 2004; Zack 2002). One of the ITS studies reported the results for five different ICUs separately; only four settings were eligible for this review. Each ICU is treated as a separate dataset although the interventions are similar (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4). The twelve ITS studies described the exact time point for when the intervention occurred, but 11 out of 12 studies reported only the means of device-associated infection rates before and after the intervention, ignoring any secular (trend) changes in the analysis. However, since these studies included graphic presentations of the results, and more than three time points before and after the intervention, this allowed us to extract the data and reanalyse these studies using time regression techniques. One of the ITS studies (Miller 2010) did take into account secular trends in their analysis but it was unclear what correlation structure they used. Since this study did not report step and slope changes for effects at three, six, nine or 12 months, we reanalysed the data to allow comparisons with the other ITS studies. In two studies, more than one intervention was implemented with a time interval, but only the effectiveness of the first intervention could be reanalysed, due to an insufficient number of time points in-between the first and second groups of interventions (Cocanour 2006), or an unbalanced number of time points between the first and subsequent interventions (Coopersmith 2002). In Cocanour 2006, after the failure of the ventilator bundle to decrease VAP rates, daily compliance with the ventilator bundle, weekly compliance feedback and in-service education were instituted; and in Coopersmith 2002, based on bedside audit, a behavioural intervention which stressed compliance with all facets of best practice of CVC maintenance and insertion was implemented (Coopersmith 2004). Participants and settings

Providers The number of health professionals targeted by the intervention was reported in four studies: 939 nurses in Ching 1990; 49 nurses, one attending physician and two critical care fellows in Coopersmith 2002; 125 nurses and 30 physicians in Parra 2010;

and 114 respiratory care practitioners and 146 nurses in Zack 2002, resulting in a total of 1406 health professionals. Nine studies did not report the number of healthcare professionals who were targeted by the intervention. Only two of the included studies (Ching 1990; Parra 2010) reported on the characteristics of healthcare professionals: Ching 1990 reported that nurses in the intervention and control groups were similar with respect to gender, number of years postgraduate education and rank; and Parra 2010 reported that years of work experience were similar for participating nurses and physicians. In four studies, the intervention targeted all healthcare staff (Beathard 2003; Cocanour 2006; Miller 2010; Parra 2010). The study with four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) and Kaye 2000 targeted nurses, respiratory therapists and other medical staff. Four studies targeted primarily nurses (Ching 1990; Coopersmith 2002; Sannoh 2010; Sona 2009). In Salahuddin 2004, all ICU nursing staff and junior medical staff were targeted, and in Warren 2004 all nurses and physicians. In Zack 2002 the intervention was directed towards respiratory care practitioners and nurses.

Patients The studies in the review (see Characteristics of included studies table) included more than 3504 patients with invasive devices in total. Over 1073 patients were studied with a central line: 700 patients in Beathard 2003 and 373 in Sannoh 2010. Coopersmith 2002 only reported the total number of patients admitted at the ICU, without specifying how many had a vascular catheter inserted; the number of patients was not reported in three CLABSI studies (Miller 2010; Parra 2010; Warren 2004), or in the one study looking at the non-adherence to guidelines for the care of indwelling urinary catheters (Ching 1990). Over 2431 patients were on continuous mechanical ventilation: 106 patients in the four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4), 677 patients in Salahuddin 2004, and 1648 in Sona 2009. The number of patients was not reported in three VAP studies (Cocanour 2006; Kaye 2000; Zack 2002). Five studies reported on patient characteristics but in varying detail. The mean age (56.6 years) was similar in both pre- and post-intervention groups in Sona 2009. Gender distribution was reported not to differ significantly between pre- (40.2% females) and postintervention periods (44.7% females) in Coopersmith 2002. The most common diagnoses were equally distributed between groups in Salahuddin 2004: sepsis (16% and 19%); pneumonia (10% and 8%); neurosurgical conditions (7% and 7%); and chronic obstructive pulmonary disease (COPD) (6% and 6%) in pre- and postintervention groups respectively. The severity of the condition as


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indicated by the mean APACHE II score (i.e. the acute physiology and chronic health evaluation score, according to Knaus 1985) in Sona 2009 was similar in pre- (17.7) and post-intervention periods (18.1). In the four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4), the mean age of patients was 49 years; 33% were females, with a mean APACHE score of 16, 83% had enteral feeding, and a mean 1.6 years of respiratory disease. However, no data were provided for the pre- and post-intervention periods separately. In Sannoh 2010 the pre- and post-intervention groups were similar with respect to birth weight, percentage of extremely low birth infants, and all other demographic and clinical characteristics.

Setting Studies included in this review (see Characteristics of included studies table) covered a total of 51 ICUs and 27 wards located in 40 hospitals. Nine of the included studies were performed in hospitals affiliated to universities or teaching hospitals (Ching 1990; Cocanour 2006; Coopersmith 2002; Kaye 2000; Parra 2010; Salahuddin 2004; Sona 2009; Warren 2004; Zack 2002). Ten studies including the study with four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) were conducted in the United States (Beathard 2003; Cocanour 2006; Coopersmith 2002; Kaye 2000; Miller 2010; Sannoh 2010; Sona 2009; Warren 2004; Zack 2002), one in Hong Kong (Ching 1990), one in Spain (Parra 2010) and one in Pakistan (Salahuddin 2004). Five studies were carried out in a single ICU: a 20 bed shocktrauma ICU (Cocanour 2006), an 18 bed surgical-burn-trauma ICU (Coopersmith 2002), a 10 bed medical-surgical ICU ( Salahuddin 2004), a 24 bed surgical-trauma-burn ICU (Sona 2009) and a 19 bed medical ICU (Warren 2004). Three studies included more than one adult ICU at the same hospital: four medical-surgical ICUs (the number of beds was not reported) (Kaye 2000), three ICUs (one medical, one post-surgery and one cardiac surgery) (Parra 2010), and five ICUs (one medical, one surgicaltrauma-burn, one medical-surgical, one neurology-neurosurgical and one surgical-cardiothoracic) (Zack 2002). One study involved five ICUs at two hospitals (one burn ICU, one medical ICU, one surgical ICU and two trauma ICUs) but only four settings provided sufficient data to be included (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4). One study (Miller 2010) was conducted in 29 paediatric ICUs (PICUs) located in 27 hospitals (12 PICUs with 10 to 16 beds; 13 PICUs with 17 to 27 beds and four PICUs with 28 to 36 beds). Most of these PICUs were mixed paediatric and cardiac PICUs, with two being solely paediatric cardiac ICUs. One study was conducted in a 50 bed neonatal ICU (Sannoh 2010), another study in 27 wards at the same hospital (Ching 1990) and a third study in a single haemodialysis facility (Beathard 2003).

Description of the intervention

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

Type of indwelling medical device The types of medical devices used in the studies were central line catheters (six studies), mechanical ventilators (six studies), and urinary catheters (one study). The central line catheters used in the included studies were cuffed tunnelled dialysis catheters (Beathard 2003), Chlorhexidine and Silver sulphadiazine-impregnated catheters (1% to 2%) and quadruple-lumen, antibiotic-impregnated catheters (Coopersmith 2002), polyurethane or Teflon central venous catheter (Miller 2010), umbilical artery catheters, umbilical vein catheters and peripherally inserted central venous catheters (Sannoh 2010), and standard catheters (CVCs, dialysis catheters, pulmonary artery catheters) without antimicrobial or antiseptic coatings (Warren 2004). The type of catheter was not reported in one study (Parra 2010). A majority of the included studies did not describe the central line insertion sites, only Warren 2004 described the proportion of femoral vein insertions before and after the intervention. None of the VAP studies reported the type of mechanical ventilator or ventilator equipment used. Ching 1990 did not describe the type of urinary catheters used.

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


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their recommendations on guidelines from scientific societies with some local adaptations (Beathard 2003; Ching 1990), The seven main evidence based recommendations for VAP prevention by a European expert panel (Chlebicki 2007; Rello 2012; Shojania 2001) are presented in Table 5. These recommendations were to varying degrees included in some of the clinical practice guidelines/bundles in the included studies. These recommendations include head of bed elevation of 30 degrees or more (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Cocanour 2006; Salahuddin 2004; Zack 2002); implementing ventilator circuit changes only when clinically indicated (no study); continuous suctioning of subglottic secretions (Cocanour 2006); daily ‘sedation vacation’ and assessment of readiness for weaning (Cocanour 2006); oral care (with Chlorhexidine 0.12% every eight hours), oral care (but unclear if Chlorhexidine was used) in Abbott 2006 dataset 1, Abbott 2006 dataset 2, Abbott 2006 dataset 3 and Abbott 2006 dataset 4, oral care with Chlorhexidine baths twice weekly in Cocanour 2006, oral care with a Chlorhexidine-based oral rinse at least daily in Salahuddin 2004, oral care using Chlorhexidine twice daily in Sona 2009, and oral care with Chlorhexidine only for patients undergoing cardiac surgery in Zack 2002; and intra-cuff pressure control to prevent aspiration (Salahuddin 2004). The four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) and three other studies (Cocanour 2006; Kaye 2000; Salahuddin 2004) included general advice on handwashing in their clinical practice guidelines. Two studies did not provide any hand hygiene recommendations (Sona 2009; Zack 2002). The six main evidence based recommendations for CLABSI prevention (O’Grady 2011) are presented in Table 6. The recommendations that were included in the respective clinical practice guidelines varied across studies: the use of maximal sterile barriers during catheter insertion (Miller 2010; Warren 2004); the use of Chlorhexidine skin preparation with alcohol for skin antisepsis (Miller 2010; Parra 2010); the avoidance of the femoral insertion site in adults (Parra 2010; Warren 2004) (this is not however a requirement for paediatric patients (Miller 2010) or neonates (Sannoh 2010)); the timely changing of dressings using aseptic techniques (all studies); and daily assessment of the need for the central line (Miller 2010). In Coopersmith 2002 “aseptic technique and routine catheter site care” was recommended but it was unclear what was included in ’routine care’; in Warren 2004 “aseptic technique and appropriate skin antisepsis” was recommended, but again it was unclear whether or not this involved the use of Chlorhexidine for skin antisepsis. None of the clinical practice guidelines of the included studies provided recommendations to avoid routine placement of CVCs. In Coopersmith 2002, catheter insertion recommendations were not covered by the clinical practice guideline. In Miller 2010, an insertion and maintenance bundle, both specific to PICUs, were included. In Parra 2010 and Warren 2004, both insertion and

maintenance guidance were included, while in Sannoh 2010 the recommendations included only a hub care and dressing policy (Table 3 and Table 4). Baseline infection rates Among the CLABSI studies, Beathard 2003 was conducted at a dialysis facility, that according to the authors had ’unacceptable high’ infection rates (6.18 cases per 1000 central line days), as compared with catheter-related bacteraemia rates ranging from 2.2 to 5.5 per 1000 catheter days reported in the literature. Coopersmith 2002 compared their infection rate (10.8 cases per 1000 central line days) with the NNIS mean rate of 5.8 cases per 1000 central line days in surgical/burn/trauma ICUs nationwide. The baseline infection rate in paediatric patients in Miller 2010 was around the mean NNIS rate (5.7 cases per 1000 central line days). In Parra 2010 the baseline infection rate was low (3.8 cases per 1000 central line days), and according to the authors acceptable as compared with national rates. In the neonates in Sannoh 2010 the infection rate at baseline (14.8 cases per 1000 central line days) was six times higher than the 50th percentile infection rate reported by the National Healthcare Safety Network (NHSN). Warren 2004 did not compare the baseline infection rate at their medical ICU (9.1 cases per 1000 central line days) with national statistics. In most VAP studies an unacceptable high infection rate was the rationale for implementing the interventions to improve professional adherence with infection control guidelines. In Abbott 2006 dataset 1, Abbott 2006 dataset 2, Abbott 2006 dataset 3 and Abbott 2006 dataset 4, the ICUs were experiencing a sustained VAP rate (between 6.9 to 26.1 cases per 1000 ventilator days the quarter before the intervention started) above the NNIS mean rate. In the trauma ICU in Cocanour 2006 the VAP rate was hovering at the NNIS 90th percentile (30.3 cases per 1000 ventilator days), and in the medical-surgical ICU in Kaye 2000 the infection rate had significantly exceeded the NNIS 90th percentile (21.2 cases per 1000 device days) at the time the intervention was implemented. Salahuddin 2004 reported an outbreak situation before the intervention with a mean infection rate of 16 cases per 1000 ventilator days. In one study (Zack 2002) the infection rate (12.6 cases per 1000 ventilator days) was hovering just above the NNIS mean VAP rate (11.8 per 1000 ventilator days). The baseline infection rate in Sona 2009 was relatively low (5.34 cases per 1000 ventilator days), and the aim of implementing the intervention was to decrease it even further. Interventions to improve professional adherence to guidelines to prevent device-related infections We defined ’active’ interventions as those that require some form of interaction with targeted healthcare professionals e.g. educational meetings, one-to-one teaching, and verbal audit and feedback. We defined ’passive’ interventions as interventions that do not require an individual to convey the intervention e.g. self-study modules, posters, information sheets, visual aids, and educational videos etc.


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i) One active intervention with or without passive reinforcements In two studies the intervention consisted of some type of educational meeting only; one half-day small group tutorial provided by an infection control liaison nurse in Ching 1990, and the delivery of a single 15 minute short lecture in Parra 2010. In one study (Sannoh 2010) a 15 minute educational DVD delivered at a single in-service session was reinforced through checklists and CVC carts in the patient’s room. iii) Two active interventions (i.e. core educational intervention plus one other intervention e.g. audit and feedback), with or without passive reinforcements In three of the included studies the core educational intervention was combined with one other active intervention. In Beathard 2003, a nurse educator gave instructions at educational meetings (of unknown duration and frequency), and performed spot checks (frequency not reported) of the adherence to guidelines. The instructions as well as the spot checks were repeated throughout the study period. In Salahuddin 2004, weekly lectures and departmental presentations were reinforced at the bedside and visual aids posted in the ICU. In the study by Sona 2009, educational meetings (of unknown frequency), with additional passive reinforcements, were combined with bi-weekly feedback on compliance with guidelines and monthly feedback on infection rates; the duration of education and training was not reported. iii) More than two active interventions (i.e. at least two active interventions in addition to the core educational intervention) with passive reinforcements In seven studies the core educational intervention was combined with at least two other active interventions, and with passive reinforcements. One-to-one bedside teaching and briefings (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4), lectures for attending physicians, fellows and residents (Coopersmith 2002), formal didactic lectures (Zack 2002), 45 to 60 minutes in-service lectures (Cocanour 2006; Coopersmith 2002; Kaye 2000; Warren 2004; Zack 2002), four face-to-face learning workshops and monthly telephone conferences (Miller 2010), were combined with audit and feedback (quarterly feedback in Abbott 2006 dataset 1, Abbott 2006 dataset 2, Abbott 2006 dataset 3 and Abbott 2006 dataset 4; monthly in Cocanour 2006, Coopersmith 2002, Warren 2004 and Zack 2002; and weekly in Kaye 2000), with champion leaders (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Miller 2010) and with the efforts of multidisciplinary teams (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Cocanour 2006; Coopersmith 2002; Kaye 2000; Miller 2010; Warren 2006; Zack 2002). It should however be noted that, while not stated in the other studies, audit and feedback was used during both the pre- and post-intervention period in Coopersmith 2002, Warren 2004 and Zack 2002. These multiple active interventions were reinforced also by passive interventions such as story boards, verbal and non-

verbal reminders (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4), self-study modules, fact sheets and posters (Coopersmith 2002; Warren 2004; Zack 2002), newsletters with educational material (Kaye 2000), and guidelines in paper format (Cocanour 2006). Barriers to change and organisational support Five studies described the assessment of barriers to change. In the four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4), a multi-disciplinary team evaluated predisposing barriers to change and considered how this would impact on implementation. Strategies for identifying and coping with the barriers to guidelines/bundle implementation included assessment of factors facilitating or hindering the adoption of guideline related knowledge, attitudes, behaviour, policy and the healthcare system. Factors considered relevant to innovation included the incremental complexity of behaviour change, supporting systems, trialability and benefits to patients and units. Another study described quality improvements which included small tests of change, based on the ’Plan Do Study Act’ (PDSA) quality and service improvement tool http:// www.institute.nhs.uk/quality˙and˙service˙improvement˙tools/ quality˙and˙service˙improvement˙tools/ plan˙do˙study˙act.html (Miller 2010). A third study described the definition of the feedback mechanism for problems encountered during the implementation phase of the study (Warren 2004). In Coopersmith 2002, a multidisciplinary task force evaluated practices and adopted the educational programme to address these, and lastly in Kaye 2000, a multidisciplinary team identified issues, evaluated infection control processes and implemented interventions to improve practice. In Ching 1990, the intervention had full approval and support by the nursing administration and in Kaye 2000, the multidisciplinary team had clear access to hospital management and full administrative support. Format of intervention The educational material delivered to the healthcare providers was printed in five studies (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Coopersmith 2002; Kaye 2000; Warren 2004; Zack 2002) and in one study the material was printed and in audio-visual format (Sannoh 2010). All educational interventions in the included studies involved interpersonal contact to convey the educational message to the healthcare professionals, for example during educational meetings, in-service training, lectures, one-to-one teaching, workshops and conference calls. In one study the format of the quality improvement intervention used was not clear (Cocanour 2006). Reminders were mostly printed, in one study they were delivered by email (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) and in another by audiovisual (DVD) means (Sannoh 2010).


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Outcomes

Primary outcomes The four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) and five other studies (Beathard 2003; Ching 1990; Miller 2010; Sannoh 2010; Sona 2009) reported measures of compliance with their different infection control recommendations. In three of the six studies preintervention as well as post-intervention adherence scores were presented (see Table 7). The manner in which adherence had been assessed and judged varied greatly across studies (see Table 7 for details). Thirteen studies reported the rate of invasive device-related infections: the four datasets and five other studies reported the VAP rate (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Cocanour 2006; Kaye 2000; Salahuddin 2004; Sona 2009; Zack 2002); six studies reported the CLABSI rate (Beathard 2003; Coopersmith 2002; Miller 2010; Parra 2010; Sannoh 2010; Warren 2004); and in one study the primary outcome was incorrect urinary catheter practices (Ching 1990). The four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4); and eight other studies (Cocanour 2006; Coopersmith 2002; Kaye 2000; Miller 2010; Salahuddin 2004; Sannoh 2010; Sona 2009; Warren 2004) based the definition of device-related infections on the CDC or NNIS criteria (http://www.cdc.gov/nhsn/dataStat.html). One study considered a CVC-related blood stream infection to be device-related if it occurred at least 48 hours after admission or up to 48 hours after discharge from the ICU (Parra 2010); another study considered a CLABSI infection as bacteraemia in a patient with tunnelled dialysis catheters (TDCs) with no other etiologic explanation (Beathard 2003); and in a third study the definition used included a modification of CDC criteria for VAP (absence of additional criteria based on serologic testing, viral antigen identification and isolation of etiological organisms by transtracheal aspirate, bronchial brushing, or biopsy) (Zack 2002).

Secondary outcomes

The device utilisation rate (the percentage of patients in which the device was inserted) was presented graphically in one study (Sannoh 2010) in a manner that allowed reanalysis. The four datasets and seven other studies reported data on the duration of invasive device use (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Coopersmith 2002; Parra 2010; Salahuddin 2004; Sannoh 2010; Sona 2009; Warren 2004; Zack 2002). We could not reanalyse any of the other secondary outcomes listed in the protocol of this review (length of hospital stay, mortality and costs) and presented in the original papers (uncontrolled data), because this data was only reported as a mean before and a mean after the intervention (and with no graphs depicting the monthly or quarterly duration). The four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) and three other studies (Coopersmith 2002; Sannoh 2010; Zack 2002) reported on cost savings secondary to the (inappropriately analysed) decreased infection rate; therefore we did not include these results in the review. Excluded studies See Characteristics of excluded studies and the PRISMA study flow chart Figure 1. Of the 185 possible eligible studies identified, we excluded 155 studies after reading the full-texts. The major reasons for exclusion of studies were: (i) uncontrolled before-after studies that could not be reanalysed as ITS studies (111 studies); (ii) CBA studies with less than two control groups or less than two intervention groups (seven studies); (iii) surveillance studies (14 studies); (iv) controlled clinical trials (CCTs) and RCTs which did not target the health professional or reported outcomes that are not relevant for this review (seven studies); and (v) other ineligible study design such as protocols, review papers, qualitative studies or observational studies (16 studies).

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


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


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

’Risk of bias’ assessment of included ITS studies

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

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

we judged this item as unclear. The remaining studies were at low risk of bias for this criteria.

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

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

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

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

Effects of interventions See: Summary of findings for the main comparison The results of the reanalyses of VAP and CLABSI studies, which are reported for two effect sizes, a change in level and the difference


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in the slope of the regression (trend) line, are presented in Table 1 and Table 2. The median effect sizes for the change in level (with IQR) and for the change in the slope of the regression line (with IQR) are presented in the text below. The time interval for each data point is quarterly (i.e. three-month time intervals). All results are reported as the case infection rate per 1000 device days. As we could not pool the data (I2 up to 97%), we have presented standardised effect sizes for each outcome as forest plots (without totals) in the Data and analyses section, to give the reader a visual overview of the results (Analysis 1.1; Analysis 1.2; Analysis 1.3; Analysis 1.4; Analysis 1.5; Analysis 2.1; Analysis 2.2; Analysis 2.3; Analysis 2.4; Analysis 2.5; Analysis 2.6; Analysis 2.7). Ventilator-associated pneumonia (VAP) Six of the 13 studies included in this review investigated the effects of different interventions to improve professional adherence to infection prevention guidelines on VAP infection rates; the four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) and five other studies (Cocanour 2006; Kaye 2000; Salahuddin 2004; Sona 2009; Zack 2002). We excluded data from Cocanour 2006 from the attempted meta-analysis, and from the forest plot, as the results were reported for monthly intervals (five months before the intervention and four months after); we only included these data in the narrative summary. The four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) presented the results separately for the four included ICUs. There was a statistically significant pre-intervention trend (P = 0.048 to 0.001) in one study and in two of four sites from one study (Abbott 2006 dataset 2; Abbott 2006 dataset 4; Sona 2009) indicating a decreased infection rate before the start of the intervention in one study and one of the two study sites (Abbott 2006 dataset 4; Sona 2009) and an increased infection rate in the other study site (Abbott 2006 dataset 2). The median pre-intervention trend (IQR) was 0.35 (-1.31 to 0.62) cases per 1000 ventilator days . Three studies (with an unknown number of educational events in Cocanour 2006; with core educational interventions weekly repeated in Salahuddin 2004; and with at least two active educational events in Zack 2002), based in seven sites and one of the ICUs in the (unknown number of educational events, but with the addition of dentists and dental hygienists performing oral care in Abbott 2006 dataset 2) showed a beneficial effect of the intervention at up to three months (Cocanour 2006), nine months (Salahuddin 2004), and 12 months (Abbott 2006 dataset 2; Zack 2002) (a decreased VAP rate of between 5 and 23 cases per 1000 ventilator days). One study based in four sites (unknown number of educational events in Kaye 2000) and three of the ICUs in the four datasets (unknown number of educational events in Abbott 2006 dataset 1; Abbott 2006 dataset 3; Abbott 2006 dataset 4) reported no statistically significant beneficial effects of the interventions. One study, in which the intervention was limited to involving training and feedback concerning oral care only, reported

a statistically significant increase in VAP rate up to 12 months after the intervention (Sona 2009). The median effect sizes (IQR) for the change in level were -2.6 (-4.92 to 0.82) cases per 1000 ventilator days at three months (five studies and 15 sites); -5.0 (9.33 to 1.38) cases per 1000 ventilator days at six months (five studies and 15 sites); -7.4 (-10.82 to 3.14) cases per 1000 ventilator days at nine months (five studies and 15 sites); and -5.2 (14.21 to 4.62) cases per 1000 ventilator days at 12 months (three studies and nine sites). Only two of the nine VAP study sites showed a change in the slope of the regression line which was indicative of a statistically significantly decreased VAP rate (-6.45 (SE 1.42), P = 0.002) in one study (Abbott 2006 dataset 2) and a statistically increased infection rate after the intervention (1.51 (SE 0.07), P = 0.003) in the other (Sona 2009). The median effect size for the change in slope of the regression line for the nine VAP studies was -0.14 (4.81 to 1.02) cases per 1000 ventilator days. The follow-up time for the VAP studies ranged from three to 12 months. Central line-associated blood stream infections (CLABSIs) Improving professional compliance with guidelines Six of the 13 included studies investigated the effectiveness of interventions to improve professional compliance with guidelines to prevent CLABSIs (Beathard 2003; Coopersmith 2002; Miller 2010; Parra 2010; Sannoh 2010; Warren 2004). The results for all six CLABSI studies showed statistically significant pre-intervention trends (P = 0.05 to 0.001) indicating a significantly decreased CLABSI rate before the intervention started. The median pre-intervention trend (IQR) was -0.6 (-0.69 to -0.59) cases per 1000 central line days. The effects of the interventions varied across studies: three studies based in 31 sites, in which the core education intervention consisted of at least two active interventions, which in some studies was performed more than once (Beathard 2003; Coopersmith 2002; Miller 2010) showed a statistically significant beneficial change in the level effect of the intervention; two studies at up to six months (Beathard 2003; Miller 2010); and one study at up to nine months (Coopersmith 2002) (a decrease in the CLABSI rate by between 1 to 3.5 cases per 1000 central line days). The results for Beathard 2003 and Miller 2010 showed a strong tendency for a significant decrease also at nine months. Three CLABSI studies involving a single core educational event of short duration (15 to 45 minutes) did not show any beneficial effect of the intervention: one study (Warren 2004), based in one site, showed no statistically significant effect (step change). Two studies (based in four sites) reported a statistically significant increase in infection rate: Sannoh 2010 showed a significant increase in infection rate immediately after the intervention, and thereafter no effect, while Parra 2010 showed no effect up to 12 months after the intervention, and after that a significantly increased infection rate. The median effect size for the change in level (IQR) was -0.6 (2.74 to 0.28) cases per 1000 central line days at three months (six studies and 36 sites), -0.3 (-2.24 to 0.73) cases per 1000 central


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line days at six months (six studies and 36 sites), -0.16 (-1.73 to 1.08) cases per 1000 central line days at nine months (six studies and 36 sites), 0.06 (-1.3 to 0.93) cases per 1000 central line days (five studies and seven sites) at 12 months, 0.65 (-0.60 to 1.93) cases per 1000 central line days (four studies and six sites) at 18 months and 2.6 (1.61 to 3.57) cases per 1000 central line days (two studies and four sites) at 21 months. Two of the six studies showed a statistically significant change in slope (Beathard 2003; Parra 2010) which was indicative of an increased infection rate after the intervention. The median effects size for the change in the slope of the regression line for the six CLABSI studies was +0.2 (0.11 to 0.54) CLABSI cases per 1000 central line days. The follow-up time for the CLABSI studies ranged from nine to 21 months. Use of central line catheters One ITS study reported data on the use of central line catheters (Sannoh 2010), and showed a small statistically significant decrease of -0.05 catheter days per 1000 patient days at three months (P = 0.03; 95% CI -0.09 to -0.01), no statistically significant effect at six months (0.03; P = 0.12; 95% CI -0.02 to 0.08), and a statistically significant increase at nine months (0.11; P = 0.02; 95% CI 0.05 to 0.17) and at 12 months (0.19; P = 0.01; 95% CI 0.12 to 0.27). There was a small but statistically significant change in slope (0.08 catheter days per 1000 patient days: P = 0.002; 95% CI 0.07 to 0.10), and a small but statistically significant preintervention trend (-0.03 catheter days per 1000 patient days; P = 0.01; 95% CI -0.05 to -0.02). Improving professional compliance with infection control guidelines on urinary catheter practices One RCT (Ching 1990) observed a beneficial effect of a short educational intervention on the percentage of incorrect urinary catheter practices; this decreased by 27.1 percentage points (from 63.1% before the intervention to 36.0% after the intervention) for the intervention group and by 19.6 percentage points (from 67.8% before the intervention to 48.2 % after the intervention) for the control group. The absolute difference was 12.2 percentage points. There was no statistically significant difference between groups in the percentage of incorrect urinary catheter practices before the intervention. The follow-up time was five weeks.

DISCUSSION

Summary of main results See Summary of findings for the main comparison for the main results. We included 13 studies in this review (one RCT and 12 ITS studies) investigating the effects of interventions to improve professional adherence to guidelines for the prevention of device-related

infections: central line-associated blood stream infections (CLABSIs) (six studies); ventilator-associated pneumonia (VAP) (six studies); and catheter-associated urinary tract infections (CAUTIs) (one study). The studies, which were of low to very low quality, following an assessment with the GRADE criteria, involved 40 hospitals, 51 ICUs, 27 wards, more than 3504 patients and more than 1406 health professionals. The results for both CLABSI and VAP studies were mixed, with half of the studies showing a beneficial effect of the intervention, and the other half showing no effect or an increased infection rate. We attempted to combine the results for studies targeting the same indwelling medical device (central line catheters or mechanical ventilators) and reporting the same outcomes (CLABSI or VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among the included studies (I2 up to 97%), we did not retain these combined results. The effect sizes were small with the largest median effect for the change in level (IQR) for the six CLABSI studies being observed at three months follow-up with a decrease of 0.6 (-2.74 to 0.28) cases per 1000 central line days (six studies and 36 sites). This change was not sustained over longer follow-up times. The largest median effect for the VAP studies was found at nine months follow-up: -7.4 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). It is worth noting that N = 6 of the interventions that showed significantly decreased infection rates involved more than one active intervention, which in some of the studies, were repeatedly administered over time. Further, that the only intervention that involved specialised oral care personnel showed the largest step change (-22.9 (SE 4.0) cases per 1000 ventilator days), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002) at the longest follow-up among all included studies (Abbott 2006 dataset 2). The one included RCT observed improved urinary catheter practices after the intervention (absolute difference 12.2 percentage points). However the statistical significance of this is unknown given the unit of analysis error. Possible sources of heterogeneity are related to: i) the interventions (e.g. the duration and intensity of the core educational intervention); ii) the population under investigation (e.g. patient’s age, diagnosis and severity of condition; iii) the organisation of care (e.g. staffing, leadership, nurse-to-patient ratio; iv) the healthcare professional (e.g. level of experience, time since graduation, attitudes and acceptability of the intervention); v) and the healthcare environment, in terms of the baseline infection rate. Other factors, specific to the different medical devices, which may have contributed to the heterogeneity are: type of ventilator equipment used, type of catheter and insertion site, antibiotic use, and weaning protocols. In our review, none of the VAP studies reported on weaning protocols, and while the type of central lines used varied across CLABSI studies, only one study provided information on the insertion site (Warren 2004). It has been suggested that weaning protocols may decrease the number of ventilator days and therefore also the VAP rate (Blackwood 2011). The population,


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the organisation of care and the characteristics of the healthcare professionals targeted by the intervention were generally poorly described in the included studies. While the low to very low quality of included studies prevents us from determining with certainty which interventions are most effective in changing professional behaviour and in what contexts, we have, when looking at the individual studies been able to identify some interventions which may be worth further study. Firstly, interventions including more than one active educational element, in some cases repeatedly administered over time, show promise in preventing both CLABSIs (Beathard 2003; Coopersmith 2002; Miller 2010) and VAP (Abbott 2006 dataset 2; Salahuddin 2004; Zack 2002), while for single active educational interventions of short duration (15 to 60 minutes) not repeated over time (Parra 2010; Sannoh 2010; Sona 2009; Warren 2004), no beneficial intervention effect was found. Secondly, the involvement of dedicated specialised personnel for VAP prevention may be worth further study, e.g. only in the ICU in Abbott 2006 dataset 2, in which special oral care equipment was purchased and dentists/ dental auxiliaries were employed to provide oral care for patients with mechanical ventilation, was a significant decrease in the VAP rate found, while no significant intervention effect was found in the other ICUs from the same study. While there is evidence for the effectiveness of oral care in VAP prevention (Snyders 2011), results from an intensive care survey suggest that nurses perceive oral care as a difficult and unpleasant task, and that they are anxious of dislodging endotracheal tubes (Binkley 2004). The content of the clinical practice guidelines varied greatly across the included studies, and none of the VAP or CLABSI studies actually implemented the same guidance. In this review therefore, we could not study the relative importance of the guidance on the intervention effect. It was clear, however, that not all the recommendations actually targeted the risk factors specific to each medical device. Targetting risk factors has been suggested as important for the prevention of device-related infections, by expert panels and national infection control guidelines (see Table 5 and Table 6). It was also unclear if some of the recommendations were evidence based. In Beathard 2003 the preventive recommendations were specific to the dialysis context and population. In some CLABSI studies the guidance included only insertion practices, others only maintenance guidance and some clinical practice guidelines included both (see Table 6). In Kaye 2000 only one of the preventive recommendations listed as important for VAP prevention was included in the clinical practice guideline. Five studies (the four datasets and four others) of six VAP studies (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Cocanour 2006; Salahuddin 2004; Sona 2009; Zack 2002) included recommendations on oral care, which (especially when Chlorhexidine is used for daily rinsing of the mouth) has been suggested effective in decreasing the VAP rate (Snyders 2011). Three of these studies (Cocanour 2006; Salahuddin 2004; Zack

2002) and one ICU site (Abbott 2006 dataset 2) showed a significant decrease in infection rate resulting from implementing oral care. One study, in which the recommendations were restricted to oral care only (see Table 5), and previously implemented comprehensive interventions were in use, reported no beneficial effect (Sona 2009). The degree of administrative and organisational support may impact on the effectiveness of an intervention (Griffiths 2009). However, this was only described in two of the included studies (Ching 1990; Kaye 2000). Since the aetiology of device-related infections is multifactorial and involves factors related to the patient (e.g. age, underlying disease, severity of condition), the organisation (e.g. bed occupancy, number of staff, workload), and the diagnostic and therapeutic procedures (type of invasive device), it can be assumed that hospital infection prevention programmes should be multidisciplinary and multifactorial (Griffiths 2009). Any infection control intervention, requires commitment from all involved parties for success, e.g. support by staff who are charged with implementing the intervention. Positive leadership and organisational changes are also needed to support and maximise these preventive interventions. Factors related to the healthcare professional’s attitude, willingness to change and satisfaction with the intervention may determine the behavioural response to a behavioural change intervention (Mitchie 2011). The prospective assessment of barriers to change, and the subsequent targeting of the intervention to the type of healthcare professionals and the organisational context, may impact on the effectiveness of the interventions (Baker 2010). Five (the four datasets and four other studies) of the 13 included studies (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Coopersmith 2002; Kaye 2000; Miller 2010; Warren 2004) assessed barriers to change, and used this knowledge when implementing the interventions, while in the remaining eight studies the interventions were not tailored to address specific barriers but only the more generic issue of a lack of adherence to guidelines. Not assessing barriers to change is not unusual in evaluations of quality improvement strategies (Grimshaw 2004; Ranji 2007). Further, there are other non-modifiable factors that may have affected the intervention effect. One factor is whether or not guidelines/protocols for healthcare-associated infection (HAI) prevention existed before the intervention, since hypothetically the room for improvement is greater where no previous recommendations are in place. This was the case in two of the included studies that showed a beneficial intervention effect (Beathard 2003; Ching 1990). These results may be contrasted by the results of no effect or non-beneficial effect found in three of the included studies (Sannoh 2010; Sona 2009; Warren 2004), in which previously implemented interventions were on-going or reinforced, or new interventions introduced during the study period. Another factor is related to the baseline infection rate; also here the room for improvement is greater if the baseline infection rate is high. The


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comparatively lower infection rate in two studies (4.0 cases per 1000 device day in Parra 2010; 5.3 cases per 1000 device days in Sona 2009) may have reduced the potential to detect an intervention effect, requiring longer observation periods or larger sample sizes. However, not all studies with a high infection rate did show a beneficial effect of the intervention. For example in the four datasets (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4) in the four ICUs with less than 106 patients, the ICUs with the highest baseline level did not show a significant effect of the intervention (Abbott 2006 dataset 4), while one of the ICUs with a (relatively) lower rate did (Abbott 2006 dataset 2). Five VAP studies (the four datasets and four other studies) reported high baseline rates or even outbreak situations (between 12.1 to 29.6 cases per 1000 ventilator days (Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4; Cocanour 2006; Kaye 2000; Salahuddin 2004; Zack 2002). Four CLABSI studies also exhibited high infection rates (between 6.2 per ward and 14.8 cases per 1000 central line days) (Beathard 2003; Coopersmith 2002; Sannoh 2010; Warren 2004). These figures may be compared with the World Health Organization (WHO) statistics from 2011 in which a pooled cumulative incidence of VAP and CLABSIs among adult ICU patients of 7.9 and 3.5 per 1000 device-days was reported in highincome countries (WHO 2011). Baseline differences depend in part on the location of care, i.e. with lower rates for wards and higher rates for ICUs, but variations exist also between different types of ICUs (Dudeck 2011; WHO 2011), which, since the location varied greatly across the included studies, may explain some of these baseline differences.

Overall completeness and applicability of evidence A majority of the included studies were conducted in high-income countries (10/13 in the United States), and only one study was performed in a lower-middle-income country (Pakistan) (Salahuddin 2004). While the focus of approximately half of the 13 included studies was VAP prevention and the other half CLABSI prevention, only one study (Ching 1990) evaluated the effects of an educational intervention on improving urinary catheter care practices. However, the authors did not assess the effects of the intervention on the CAUTI rate, this despite the known potential for simple interventions to decrease the incidence of CAUTIs (Bernard 2012; Ranji 2007; Tambyah 2012). The main aim for all studies included in this review was to evaluate interventions to improve the adoption of adequate procedures for insertion, and maintenance of invasive medical devices. None of the studies specifically evaluated the effectiveness of interventions to persuade health professionals to avoid the use of invasive medical devices (e.g. decision support systems giving stop orders or asking for reassessment of decisions to use invasive devices), or

to reduce the duration of device use, which must be considered a central part of any programme to prevent device-related infections (O’Grady 2011; Saint 2009 ). This is important as it has been suggested that the insertion of indwelling medical devices may not be appropriate and may be overused (Conterno 2011; Gowardman 1998; Saint 2000). Furthermore, interventions that have previously been shown to be effective in changing professional practice e.g. on-screen point of care computer reminders (Shojania 2009) and other computerised decision support systems (Garg 2005) were not considered in any of the studies included in this review.

Quality of the evidence Most of the evidence in this review comes from non-randomised low quality studies with no control groups, and five of the 12 studies involved only one intervention site. We reanalysed these studies as ITS studies to remove the risk of bias due to secular trends in uncontrolled data. However they were downgraded, using the GRADE criteria, from low to very low quality due to inconsistency (unexplained heterogeneity) among VAP studies, and imprecision of the effect among both VAP and CLABSI studies. In addition, in nine out of 13 studies the intervention was not independent of other changes, or this was not reported. The only included RCT study was judged to be of low quality due to inadequate sequence generation, the unclear blinding of assessors and the very short follow-up time. A vast majority of studies that we found from the electronic searches were uncontrolled before-after studies, and that due to an insufficient number of data points before and after the implementation of one or more intervention(s), we could not reanalyse such studies using time regression techniques. Because of this, we had to exclude 91% of all seemingly relevant studies scrutinised for eligibility, since they did not comply with the EPOC quality criteria for study design (Ballini 2010), leaving only 9% of studies included in this review.

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


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Agreements and disagreements with other studies or reviews We identified three systematic reviews specifically evaluating interventions to improve adherence to infection control guidelines to prevent device-related infections (Aboelela 2007; Ranji 2007; Safdar 2008). These reviews had wider inclusion criteria, in terms of study design, compared to this review and consisted primarily of simple before-after studies with inadequate analyses and controlled before-after (CBA) studies with only one control and one intervention group. The studies included in these reviews were also heterogenous and differed in terms of populations and educational approaches, similar to the studies included in this review, and were often combined with other strategies to prevent HAIs. Ranji 2007 evaluated the effects of quality improvement strategies on promoting adherence to interventions for prevention of HAIs. The review included 64 studies (19 studies addressed CLABSI prevention, 12 VAP prevention, 10 CAUTI prevention, and the remaining studies, surgical site infections). The evidence was of low quality, and no firm conclusions could be drawn about which interventions were the most effective in improving practice. Aboelela 2007 included a total of 33 studies evaluating the effectiveness of interventions to change healthcare workers’ behaviour in reducing HAIs. The authors suggested that educational programmes and multi-disciplinary teams may be effective strategies to reduce HAI rates. Finally, the review by Safdar 2008 evaluated the effect of educational strategies targeted at health professionals to reduce the HAI rate. Twenty of the 26 included studies evaluated the impact on infections related to indwelling devices. The authors suggested that the systematic application of educational interventions may reduce the HAI rate, but they could not determine which particular educational intervention was the most effective. As in our review, the included studies used a variety of approaches, and many in combination with other strategies to prevent HAIs. Unlike a systematic review on the effectiveness of guideline strategies to change practice in general (Grimshaw 2004) in which mostly process outcomes were reported, the main outcome for a majority of the studies included in this review was a patient outcome (infection rate) and only one study (Ching 1990) reported on a professional outcome.

AUTHORS’ CONCLUSIONS Implications for practice The low to very low quality of the included evidence along with the mixed results of this review provide insufficient evidence to draw any firm conclusions about which type of intervention is effective in changing professional behaviour, and in what context. However, interventions that may be worth further study are educational interventions involving more than one active element, in

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

Implications for research There is a great need to undertake further rigorous research (ideally cluster RCTs) to evaluate interventions to reduce HAIs. However, If randomised studies are not feasible, other robust study designs should be used, for example ITS studies with more than three data points both before and after the intervention, that take into account secular trends and cointerventions. More than one intervention site should also be considered. Since many of the studies found by the electronic searches involved care bundle interventions that could not be reanalysed, care should be taken to ensure that future interventions are designed in a way that makes appropriate analysis possible. This may be done either by implementing all parts of the bundle simultaneously, or if implemented consecutively, ensure a sufficient number of data points before and after each part of the bundle, and ensure that these are reported. Future studies should also consider evaluating the effectiveness of interventions aimed explicitly at reducing the use of indwelling medical devices, or to prompt reassessment and discontinuation of device use, for example through the use of on-screen point of care computer reminders (Shojania 2009) and other computerised decision support systems (Garg 2005). It is strongly recommended to include both infection rate and adherence outcomes, as well as the resources required to implement the intervention and the cost (length of hospital stay, laboratory tests, and antimicrobial treatments), to get a fuller picture of the effectiveness and cost-effectiveness of implementing interventions to improve professionals’ adherence to guidelines for the prevention of device-related infections. All future studies should aim to provide information on:


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• relevant patient characteristics for control and intervention conditions;

• the theory base supporting the behavioural change intervention (i.e. behaviour change model).

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

ACKNOWLEDGEMENTS We wish to acknowledge information technologist Douglas Salzwedel for developing and running the search strategy, and information technologist Michelle Fiander for further refining and re-running it. We would like to thank Craig Ramsay, Luke Vale, Jeremy Grimshaw, Russell Gruen, Marlene Miller and E. Andrea Nelson for their helpful comments. We would like to thank Emma Tavender and Clare Dooley for their editorial assistance in publishing this review. We also wish to acknowledge the generous funding received from a NIHR Cochrane Programme Grant and FAPESP that have enabled us to conduct this review.

REFERENCES

References to studies included in this review Abbott 2006 dataset 1 {published data only} Abbott CA, Dremsa T, Stewart DW, Mark DD. Adoption of a ventilator-associated pneumonia clinical practice guideline. Worldviews Evidence Based Nursing 2006;3(4): 139–52. Abbott 2006 dataset 2 {published data only} Abbott CA, Dremsa T, Stewart DW, Mark DD. Adoption of a ventilator-associated pneumonia clinical practice guideline. Worldviews Evidence Based Nursing 2006;3(4): 139–52. Abbott 2006 dataset 3 {published data only} Abbott CA, Dremsa T, Stewart DW, Mark DD. Adoption of a ventilator-associated pneumonia clinical practice guideline. Worldviews Evidence Based Nursing 2006;3(4): 139–52. Abbott 2006 dataset 4 {published data only} Abbott CA, Dremsa T, Stewart DW, Mark DD. Adoption of a ventilator-associated pneumonia clinical practice guideline. Worldviews Evidence Based Nursing 2006;3(4): 139–52. Beathard 2003 {published data only} Beathard GA. Catheter management protocol for catheterrelated bacteraemia prophylaxis. Seminars in Dialysis 2003; 16(5):403–5. Ching 1990 {published data only} Ching TY, Seto WH. Evaluating the efficacy of infection control liaison nurse in the hospital. Journal of Advanced Nursing 1990;15:1128–31.

Cocanour 2006 {published data only} Cocanour CS, Peninger M, Domonoske BD, Li T, Wright B, Valdivia A, et al.Decreasing ventilator-associated pneumonia in a trauma ICU. Journal of Trauma 2006;61: 122–30. Coopersmith 2002 {published data only} Coopersmith CM, Rebmann TL, Zack JE, Ward MR, Corcoran RM, Schallom ME, et al.Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit. Critical Care Medicine 2002;30(1):59–64. Kaye 2000 {published data only} Kaye J, Ashline V, Erickson D, Zeiler K, Gavigan D, Gannon L, et al.Critical care bug team: a multidisciplinary team approach to reducing ventilator-associated pneumonia. American Journal of Infection Control 2000;28:197–201. Miller 2010 {published data only} Miller MR, Griswold M, Harris JM, Yenokyan G, Huskins WC, Moss M, et al.Decreasing PICU catheter-associated bloodstream infections: NACHRI’s quality transformation efforts. Pediatrics 2010;125:206–13. Parra 2010 {published data only} Parra AP, Menárguez MC, Granda MJP, Tomey MJ, Padilla B, Bouza E. A simple educational intervention to decrease incidence of central line-associated bloodstream infection (CLABSI) in intensive care units with low baseline incidence of CLABSI. Infection Control and Hospital Epidemiology 2010;31(9):964–7. Salahuddin 2004 {published data only} Salahuddin N, Zafar A, Sukhyani L, Rahim S, Noor KH, Hussain K, et al.Reducing ventilator-associated pneumonia


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rates through a staff eduction programme. The Journal of Hospital Infection 2004;57:223–7. Sannoh 2010 {published data only} Sannoh S, Clones B, Munoz J, Montecalvo M, Parvez B. A multimodal approach to central venous catheter hub care can decrease catheter-related bloodstream infection. American Journal of Infection Control 2010;38:424–9. Sona 2009 {published data only} Sona CS, Zack JE, Schallon ME, McSweeney M, McMullen K, Thomas J, et al.The impact of a simple, low-cost oral care protocol on ventilator-associated pneumonia rates in a surgical intensive care unit. Journal of Intensive Care Medicine 2009;24(1):54–62. Warren 2004 {published data only} Warren DK, Zack JE, Mayfield JL, Chen A, Prentice D, Fraser VJ, et al.The effect of an educational program on the incidence of central venous catheter-associated bloodstream infection in a Medical ICU. Chest 2004;126:1612–18. Zack 2002 {published data only} Zack JE, Garrison T, Trovillion E, Clinkscale D, Coopersmith CM, Frase VJ, et al.Effect of an educational program aimed at reducing the occurrence of ventilatorassociated pneumonia. Critical Care Medicine 2002;30: 2407–12.

References to studies excluded from this review Abramczyk 2011 {published data only} Abramczyk ML, Carvalho WB, Medeiros E. Preventing catheter-associated infections in the paediatric intensive care unit: impact of an educational program surveying policies for insertion and care of central venous catheters in a Brazilian teaching hospital. Brazilian Journal of Infectious Diseases 2011;15(6):573–7. Apisarnthanarak 2007 {published data only} Apisarnthanarak A, Pinitchai U, Thongphubeth K, Yuekyen C, Warren DK, Zack JE, et al.Effectiveness of an educational program to reduce ventilator-associated pneumonia in a tertiary care center in Thailand: a 4-year study. Clinical Infectious Disease 2007;45(6):704–11. Apisarnthanarak 2008 {published data only} Apisarnthanarak A, Suwannakin A, Maungboon P, Warren DK, Fraser VJ. Long-term outcome of an intervention to remove unnecessary urinary catheters, with and without a quality improvement team, in a Thai tertiary care center. Infection Control Hospital Epidemiology 2008;29:1094–5. Apisarnthanarak A, Thongphubeth K, Sirinvaravong S, Kitkangvan D, Yuekyen C, Warachan B, et al.Effectiveness of multifaceted hospital wide quality improvement programs featuring an intervention to remove unnecessary urinary catheters at a tertiary care center in Thailand. Infection Control Hospital Epidemiology 2007;28(7):791–8. Babcock 2004 {published data only} Babcock HM, Zack JE, Garrison T, Trovillion E, Jones M, Fraser VJ, et al.An educational intervention to reduce ventilator-associated pneumonia in an integrated health

system: a comparison of effects. Chest 2004;125(6): 2224–31. Barsuk 2009 {published data only} Barsuk JH, Cohen ER, Feiglass J, McGahie WC, Wayne DB. Use of simulation-based education to reduce catheterrelated bloodstream infections. Archives of Internal Medicine 2009;169(15):1420–3. Baxter 2005 {published data only} Baxter AD, Allan J, Bedard J, Malone-Tucker S, Slivar S, Langill M, et al.Adherence to simple and effective measures reduces the incidence of ventilator-associated pneumonia. Canadian Journal of Anaesthesia 2005;52(5):535–41. Berenholtz 2004a {published data only} Berenholtz SM, Milanovich S, Faircloth A, Prow TD, Earsing K, Lipsett P, et al.Improving care for the ventilated patient. Joint Commission Journal on Quality and Safety 2004;30(4):195–204. Berenholtz 2004b {published data only} Berenholtz SM, Provonost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, et al.Eliminating catheter-related bloodstream infections in the intensive care unit. Critical Care Medicine 2004;32(10):2014–20. Berg 1995 {published data only} Berg DE, Hershow RC, Ramirez CA, Weinstein RA. Control of nosocomial infections in an intensive care unit in Guatemala city. Clinical Infectious Diseases 1995;21: 588–93. Berhe 2006 {published data only} Berhe M, Edmond MB, Bearman G. Measurement and feedback of infection control process measures in the intensive care unit: Impact on compliance. American Journal of Infection Control 2006;34(8):537–9. Bird 2010 {published data only} Bird D, Zambuto A, O’Donnell C, Silva J, Korn C, Burke R, et al.Adherence to ventilator-associated pneumonia bundle and incidence of ventilator-associated pneumonia in the surgical intensive care unit. Archives of Surgery 2010; 145(5):465–70. Bizarro 2010 {published data only} Bizzarro MJ, Sabo B, Noonan M, Bonfiglio M, Northrup V, Diefenbach K, Central Venous Catheter Initiative Committee. A quality improvement initiative to reduce central line-associated bloodstream infections in a neonatal intensive care unit. Infection Control and Hospital Epidemiology 2010;31(3):241–8. Björnestam 2000 {published data only} Björnestam B, Hedborg K, Ulrika R, Yigael F. The effect of a 1-hour nurse training program on the frequency of bacteremia in patients receiving parenteral nutrition. Journal of Intravenous Nursing 2000;23:154–7. Bruminhent 2010 {published data only} Bruminhent J, Keegan M, Lakhani A, Roberts IM, Passalacqua J. Effectiveness of a simple intervention for prevention of catheter-associated urinary tract infections in a community teaching hospital. American Journal of Infection Control 2010;38:689–93.


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Brunelle 2003 {published data only} Brunelle D. Impact of a dedicated infusion therapy team on the reduction of catheter-related nosocomial infections. Journal of Intravenous Nursing 2003;26(6):362–6. Burns 2003 {published data only} Burns SM, Earven S, Fisher C, Lewis R, Merrell P, Schubart JR, et al.Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: One-year outcomes and lessons learned. Critical Care Medicine 2003;31:2752–63. Camp 2009 {published data only} Camp SL, Stamou SC, Stiegel RM, Reames MK, Skipper ER, Madjarov J. Quality improvement program increases early tracheal extubation rate and decreases pulmonary complications and resource utilization after cardiac surgery. Journal of Cardiac Surgery 2009;24:414–23. Casey 2003 {published data only} Casey J, Davies J. A nurse led central line insertion service. EDTNA/ERCA Journal 2003;29(4):203–5. Castello 2011 {published data only} Castello FV, Maher A, Cable G. Reducing bloodstream infections in pediatric rehabilitation patients receiving parenteral nutrition. Pediatrics 2011;128(5):e1273–8. Cherry-Bukowiec 2011 {published data only} Cherry-Bukowiec JR, Denchev K, Dickinson S, Chenoweth CE, Zalewski C, Meldrum C, et al.Prevention of catheterrelated blood stream infection: Back to basics?. Surgical Infections 2011;12:27–32. Chrdle 2012 {published data only} Chrdle A, Stropková R, Smítková S, eho ová I, Chmelík V. [Katétrové infekce krevního intervence].

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Christenson 2006 {published data only} Christenson M, Hitt JA, Abbott G, Septimus EJ, Iversen N. Improving patient safety: Resource availability and application for reducing the incidence of healthcareassociated infection. Infection Control and Hospital Epidemiology 2006;27(3):245–51.

over 8 years. Medical Journal of Australia 2007;187(10): 551–4. Cools 1987 {published data only} Cools HJM, van der Meer JWM. Infection Control in a skilled nursed facility: a 6 year survey. Journal of Hospital Infection 1987;12:117–24. Coopersmith 2004 {published data only} Coopersmith CM, Zack JE, Ward MR, Sona CS, Schallom ME, Everett SJ, et al.The impact of bedside behavior on catheter-related bacteremia in the intensive care unit. Archives of Surgery 2004;139(2):131–6. Cornia 2003 {published data only} Cornia PB, Amory JK, Fraser S, Saint S, Lipsky BA. Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalised patients. American Journal of Medicine 2003;114:404–7. Costello 2008 {published data only} Costello JM, Morrow DF, Graham DA, Potter-Bynoe G, Sandora TJ. Systematic intervention to reduce central lineassociated bloodstream infection rats in a pediatrics cardiac intensive care unit. Pediatrics 2008;121(5):915–23. Crouzet 2007 {published data only} Crouzet J, Bertrand X, Venier AG, Badoz M, Husson C, Talon D. Control of duration of urinary catheterization: impact on catheter-associated urinary tract infection. Journal of Hospital Infection 2007;67(3):253–7. Cruden 2000 {published data only} Cruden E, Boyce C, Woodman H, Bray B. An evaluation of the impact of ventilator care bundle. Nursing Critical Care 2005;10(5):242–6. Danchaivijitr 2005 {published data only} Danchaivijitr S, Assanasen S, Apisarnthanarak A, Judaeng T, Pumsuwan V. Effect of an education program on the prevention of ventilator-associated pneumonia: a multicenter study. Journal of Medical Association of Thailand 2005;88(Suppl 10):S36–S41. Dawson 2011 {published data only} Dawson D, Endacott R. Implementing quality initiatives using a bundled approach. Intensive and Critical Care Nursing 2011;27:117–20.

Cohen 1991 {published data only} Cohen IL, Bari N, Strosberg MA, Weinberg PF, Wacksman RM, Millstein BH, et al.Reduction of duration and cost of mechanical ventilation in an intensive care unit by use of a ventilatory management team. Critical Care Medicine 1991; 19(10):1278–83.

Dinç 2000 {published data only} Dinç L, Erdil F. The effectiveness of an educational intervention in changing nursing practice and preventing catheter-related infection for patients receiving total parenteral nutrition. International Journal of Nursing Studies 2000;37:371–9.

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Dries 2004 {published data only} Dries DJ, McGonigal MD, Malian MS, Bor BJ, Sullivan C. Protocol-driven ventilator weaning reduces use of mechanical ventilation, rates of early reintubation, and ventilator-associated pneumonia. Journal of Trauma 2004; 56:943–52.

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decreases bloodstream infections and length of stay in a trauma intensive care unit population. The American Surgeon 2009;75(12):1166–70. Du Bose 2008 {published data only} Du Bose JJ, Inaba K, Shiflett A, Trankiem C, Teixeira PGR, Salim A, et al.Measurable outcomes of quality improvement in the trauma intensive care unit: the impact of a daily quality rounding checklist. Journal of Trauma 2008;64(1): 22–9. East 2005 {published data only} East D, Jacoby K. The effect of a nursing staff education program on compliance with central line care policy in the cardiac intensive care unit. Pediatric Nursing 2005;31(3): 182–94. Eggimann 2000 {published data only} Eggimann P, Harbarth S, Costantin, Touveneau S, Chevrolet J-C, Pittet D. Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care. Lancet 2000;355(9218):1864–8. Espiau 2011 {published data only} Espiau M, Pujol M, Campins-Marti M, Planes AM, Pena Y, Balcells J, et al.Incidence of central line-associated bloodstream infection in an intensive care unit. Anales de Pediatria 2011;75(3):188–93. Esteve 2009 {published data only} Esteve F, Pujol M, Ariza J, Gudiol F, Verdaguer R, Cisnal M, et al.Impact of a prevention program for catheter-related blood stream infection in the intensive care unit of a tertiary hospital [Impacto de un programa de prevención de la bacteriemia relacionada con el cateter en una unidad de cuidados intensivos de un hospital terciario]. Enfermedades Infecciosas e Microbilogía Clínica 2009;27(10):561–5. Fakih 2010 {published data only} Fakih MG, Pena ME, Shemes S, Rey J, Berriel-Cass D, Szpunar MS. Effect of establishing guidelines on appropriate urinary catheter placement. Academic Emergency Medicine 2010;17:337–40. Frankel 2005 {published data only} Frankel HL, Crede WB, Topal JE, Roumanis SA, Devlin MW, Foley AB. Use of corporate Six Sigma performanceimprovement strategies to reduce incidence of catheterrelated bloodstream infections in surgical ICU. Journal of American College of Surgeons 2005;201(3):349–58. French 1989 {published data only} French GL, Wong SL, Cheng AFB, Donna S. Repeated prevalence surveys for monitoring effectiveness of hospital infection control. Lancet 1989;8670(2):1021–3.

prevent hospital-acquired infection. Emerging Infectious Diseases 2001;7(2):295–8. Gnass 2004 {published data only} Gnass SA, Barboza L, Bilicich D, Angeloro P, Treyer W, Grenóvero S, et al.Prevention of central venous catheterrelated bloodstream infections using non-technologic strategy. Infection Control and Hospital Epidemiology 2004; 25(8):675–7. Goddard 2006 {published data only} Goddard L, Clayton S, Peto TEA, Bowler ICJW. The ’justin-case venflon’: effect of surveillance and feedback on prevalence of peripherally inserted intravascular devices. Journal of Hospital Infection 2006;64(4):401–2. Goetz 1999 {published data only} Goetz AM, Kedzuf S, Wagener M, Muder RR. Feedback to nursing staff as an intervention to reduce catheter-associated urinary tract infection. American Journal of Infection Control 1999;27(5):402–4. Gokula 2007 {published data only} Gokula MR, Smith MA, Hickner J. Emergency room staff education and use of a urinary catheter indication sheet improves appropriate use of foley catheters. American Journal of Infection Control 2007;35(9):589–93. Gowardman 2005 {published data only} Gowardman JR, Kelaher C, Whiting J, Collignon PJ. Impact of a formal removal policy for central venous catheters on duration of catheterisation. Medical Journal of Australia 2005;182(5):249–50. Gozu 2011 {published data only} Gozu A, Clay C, Younus F. Hospital-wide reduction in central line-associated bloodstream infections: a tale of two small community hospitals. Infection Control and Hospital Epidemiology 2011;32(6):619–22. Grap 2003 {published data only} Grap MJ, Strickland D, Tormey L, Keane K, Lubin S, Emerson J. Collaborative practice: development, implementation, and evaluation of a weaning protocol for patients receiving mechanical ventilation. American Journal of Critical Care 2003;12(5):454–60. Guerin 2010 {published data only} Guerin K, Wagner J, Rains K, Bessesen M. Reduction in central line-associated bloodstream infections by implementation of a post insertion care bundle. American Journal of Infection Control 2010;38(6):430–3.

García-Rodicio 2009 {published data only} García-Rodicio S, Abajo C, Godoy M, Catalá MA. Development and implementation of an audit tool for quality control of parenteral nutrition. Nutrition in Clinical Practice 2009;24(4):500–7.

Guner 2011 {published data only} Guner R, Hasanoglu I, Keske S, Tasyaran MA. Educational approach to reduce catheter-related bloodstream infections and catheter-related urinary tract infection rates in intensive care unit. Clinical microbiology and infection. Proceedings of the 21st ECCMID/27th ICC Conference; 2011. Milan, 2011:S775.

Gaynes 2001 {published data only} Gaynes R, Richards C, Edwards J, Emori TG, Horan T, Alonso-Echanove J. Feeding back surveillance data to

Gunther 2009 {published data only} Gunther SG, Schwebel C, Vésin A, Remy J, Dessertaine G, Timsit JF. Interventions to decrease tube, line, and


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drain removals in intensive care units: the FRATER study. Intensive Care Medicine 2009;35:1772–6. Gurskis 2009 {published data only} Gurskis V, Asembergiene J, Kevalas R, Miciulevicine, Pavilonis A, Valinteliene R, et al.Reduction of nosocomial infection and mortality attributable to nosocomial infections in pediatric intensive care units in Lithuania. Medicina (kaunas) 2009;45(2):203–13.

Hong 1990 {published data only} Hong SW, Ching TY, Fung JP, Seto WL. The employment of ward opinion leaders for continuing education in the hospital. Medical Teacher 1991;12(2):209–217. Horbar 2006 {published data only} Horbar JD, Rogowski J, Plsek PE, Delmore P, Edwards WH, Hocker J. Collaborative quality improvement for neonatal intensive care. Pediatrics 2001;107(1):14–22.

Gusarov 2009 {published data only} Gusarov VG. Impact of pneumonia prevention protocol on the results of treatment in patients in the acute period of stroke. Anesteziologiia i reanimantologiia 2009;May-June (3):34–7.

Horvath 2009 {published data only} Horvath B, Norville R, Lee D, Hyde A, Gregurich MA, Hockenberry M. Reducing central venous catheter-related bloodstream infection in children with cancer. Oncology Nursing Forum 2009;36(2):232–8.

Hansen 2006 {published data only} Hansen BG. Reducing nosocomial urinary tract infections through process improvement. Journal for Healthcare Quality Web Exclusive 2006;28(2):W2–9.

Huang 2004 {published data only} Huang WC, Wann SR, Shoa-Lin L, Kunin CM, Kung MH, Lin CH, et al.Catheter-associated urinary tract infections in intensive care can be reduced by prompting physicians to remove unnecessary catheters. Infection Control Hospital Epidemiology 2004;25:975–8.

Harnage 2007 {published data only} Harnage SA. Achieving zero catheter related blood stream infections: 15 months success in a community based medical center. Journal of The Association for Vascular Access 2007;12(4):218–24. Hatler 2006 {published data only} Hatler CW, Mast D, Corderella J, Mitchell G, Howard K, Aragon J, et al.Using evidence and process improvement strategies to enhance healthcare outcomes for the critically ill: a pilot project. American Journal of Critical Care 2006; 15(6):549–55. Helman 2003 {published data only} Helman DL, Sherner JH, Fitzpatrick TM, Callender ME, Shorr AF. Effect of standardized orders and provider education on head-of-bed positioning in mechanically ventilated patients. Critical Care Medicine 2003;31(9): 2285–90. Hendrix 1998 {published data only} Hendrix MS, Fieselmann JF, Bock MJ, Wakefield DS, Helms MC, Bentler SE. Outreach education to improve quality of rural ICU care. American Journal of Respiratory Critical Care Medicine 1998;158:418–23. Hiemenz 1986 {published data only} Hiemenz J, Skelton J, Pizzo PA. Perspective on the management of catheter-related infections in cancer patients. Pediatric Infectious Disease 1986;5(1):6–11. Higuera 2005 {published data only} Higuera F, Rosenthal DV, Duarte P, Ruiz J, Franco G, Safdar N. The effect of process control on the incidence of central venous catheter-associated bloodstream infections and mortality in intensive care units in Mexico. Critical Care Medicine 2005;33(9):2022–7. Holzmann-Pazgal 2012 {published data only} Holzmann-Pazgal G, Kubanda A, Davis K, Khan AM, Brumley K, Denson SE. Utilizing a line maintenance team to reduce central-line-associated bloodstream infections in a neonatal intensive care unit. Journal of Perinatology 2012; 32(4):281–6.

Hwang 2005 {published data only} Hwang JH, Choi CW, Chang YS, Choe YH, Park WS, Shin SM, et al.The efficacy of clinical strategies to reduce nosocomial sepsis in extremely low birth weight infants. Journal of Korean Medical Science 2005;20:177–81. Jain 2006 {published data only} Jain M, Miller L, Belt D, King D, Berwick DM. Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Quality on Safety in Health Care 2006;15: 235–9. Jeffreis 2009 {published data only} Jeffries HE, Mason W, Brewer M, Oakes KL, Munoz EI, Gornick W, et al.Prevention of central venous catheterassociated bloodstream infections in paediatric intensive care units: a performance improvement collaborative. Infection Control and Hospital Epidemiology 2009;30(7):645–51. Jonhson 2009 {published data only} Johnson V, Mangram A, Mitchell C, Lorenzo M, Howard D, Dunn E. Is there a benefit to multidisciplinary rounds in an open trauma intensive care unit regarding ventilatorassociated pneumonia. The American Surgeon 2009;75(12): 1171–4. Kalra 2011 {published data only} Kalra S, Nelson Y, Dave P, Wadhwa R. Student assessment of teaching effectiveness of “bundle of changes”- A paired, controlled trial. Journal of Anaesthesiology, Clinical Pharmacology 2011;27(4):506–10. Karada 2000 {published data only} Karada A, Görgülü S. Devising an intravenous fluid therapy protocol and compliance of nurses with the protocol. Journal of Intravenous Nursing 2000;23(4):232–8. Kauffmann 2011 {published data only} Kauffmann G, Davis A, Schulwolf E, Press V, Stupay K, Arora V. IBCD: Development and testing of a checklist to


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improve quality of care for hospitalized general medical patients. Journal of Hospital Medicine 2011;6(4):S117–8. Kaye 2006 {published data only} Kaye KS, Engemann JJ, Fulmer EM, Clark CC, Noga EM. Favorable impact of an infection control network on nosocomial infection rates in community hospitals. Infection Control and Hospital Epidemiology 2006;27(3): 228–32.

Lally 1997 {published data only} Lally R, Farber M, Biorn J. Successful use of a quality improvement team to reduce ventilator-associated pneumonia. Critical Care Nurse 1997;17(6):38–46. Laux 2006 {published data only} Laux L, Herbert C. Decreasing ventilator-associated pneumonia. Getting on board. Critical Care Nursing Quarterly 2006;29(3):253–8.

Kelleghan 1993 {published data only} Kelleghan SI, Salemi C, Padilla S, McCord M, Mermilliod G, Canola T, et al.An effective continuous quality improvement approach to the prevention of ventilatorassociated pneumonia. American Journal of Infection Control 1993;21(6):322–30.

Lobo 2005 {published data only} Lobo RD, Levin AS, Gomes LMB, Cursino R, Park M, Figueiredo VB, et al.Impact of an educational program and policy changes on decreasing catheter-associated bloodstream infections in a medial intensive care in Brazil. American Journal of Infection Control 2005;33:85–7.

Kellie 2012 {published data only} Kellie SP, Scott MJ, Cavallazzi R, Wiemken TL, Goss L, Parker D, et al.Procedural and educational interventions to reduce ventilator-associated pneumonia (VAP) rate and central line-associated blood stream infections (CLABSI). Chest. 2011; Vol. 140, issue 4:350A. [DOI: 10.1378/ chest.1081447]

Lobo 2010 {published data only} Lobo RD, Levin AS, Oliveira MS, Gomes LMB, Gobara S, Park M, et al.Evaluation of interventions to reduce catheterassociated bloodstream infection: Continuous tailored education versus one basic lecture. American Journal of Infection Control 2010;38(6):440–8.

Khatib 1999 {published data only} Khatib M, Jamaleddine G, Abdallah A, Ibrahim Y. Hand washing and use of gloves while managing patients receiving mechanical ventilation in the ICU. Chest 1999;116:172–5. Kidd 2007 {published data only} Kidd KM, Sinkowitz-Cochran RL, Giblin TB, Tokars JI, Cardo DM, Solomon SL. Barriers to and facilitators of implementing an intervention to reduce the incidence of catheter-associated bloodstream infections. Infection Control and Hospital Epidemiology 2007;28(1):103–4. Kilbride 2003 {published data only} Kilbride HW, Powers R, Wirtschafter DD, Sheehan MB, Charsha DS, LaCorte M. Evaluation and development of potentially better practices to prevent neonatal nosocomial bacteraemia. Pediatrics 2003;111(4 Pt 2):e504-18. Koff 2011 {published data only} Koff MD, Corwin HL, Beach ML, Surgenor SD, Loftus RW. Reduction in ventilator associated pneumonia in a mixed intensive care unit after initiation of a novel hand hygiene program. Journal of Critical Care 2011;26(5): 489–95. Kulvatunyou 2007 {published data only} Kulvatunyou N, Boonbarwornrattanakul A, Soonthornkit Y, Kocharsanee C, Lertsithichai P. Incidence of ventilatorassociated pneumonia (VAP) after the institution of an educational program on VAP prevention. Journal of the Medical Association of Thailand 2007;90(1):89–95. Lai 2003 {published data only} Lai KK, Baker SP, Fontecchio SA. Impact of a program of intensive surveillance and interventions targeting ventilated patients in the reduction of ventilated patients in the reduction of ventilator-associated pneumonia and its costeffectiveness. Infection Control and Hospital Epidemiology 2003;24(11):859–63.

Lolom 2009 {published data only} Lolom I, Deblamgy C, Capelle A, Guerinot W, Bouvet E, Barry B, et al.Effect of a long-term quality improvement program on the risk of infection related to peripheral venous catheters [Impact d’un programme prolonge d’amelioration continur de la qualitye sur le risqué infectieux lie aux catheters veineux peripheriques]. Presse Medicale 2009;38 (1):34–42. Lyerla 2010 {published data only} Lyerla F, LeRouge C, Cooke DA, Turpin D, Wilson L. A nursing clinical decision support system and potential predictors of head-of-bed position for patients receiving mechanical ventilation. American Journal of Critical Care 2010;19:39–47. Maas 1998 {published data only} Maas A, Flament P, Pardou A, Deplan A, Dramaix M, Struelens MJ. Central venous catheter-related bacteraemia in critically ill neonates: risk factors and impact of a prevention programme. Journal of Hospital Infection 1998; 40:211–24. Marelich 2000 {published data only} Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practioners and nurses. Chest 2000;118(2):459–67. Marra 2009 {published data only} Marra AR, Cal RG, Silva CV, Caserta RA, Paes AT, Moura DF Jr. Successful prevention of ventilator-associated pneumonia in an intensive care setting. American Journal of Infection Control 2009;37(8):619–25. Matocha 2011 {published data only} Matocha D. A process improvement approach to the elimination of central line associated bloodstream infections. Proceedings of the Association for Vascular Access Annual Scientific Meeting; 2011 October 3-6; San Jose, California.


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http://www.avainfo.org/website/download.asp?id=280432 (accessed 1 July 2012). Mazi 2011 {published data only} Mazi W, Abdullah D, Gasem G, Helali N, Senok A. Reduction of healthcare-associated infections after implementation of bundle programmes in a tertiary care teaching hospital in Saudi Arabia. Clinical Microbiology and Infection. Proceedings of 21st ECCMID/27th ICC Conference. Milan, 2011:S327–8.

Orsi 2005 {published data only} Orsi GB, Raponi M, Franchi C, Rocco M, Mancini C, Venditti M. Surveillance and infection control in an intensive care unit. Infection Control and Hospital Epidemiology 2005;26(3):321–5. Parras 1994 {published data only} Parras F, Ena J, Bouza E, Guerrero MC, Moreno S, Galvez T, et al.Impact of an educational program for the prevention of colonization of intravascular catheter. Infection Control and Hospital Epidemiology 1994;15(4):239–42.

Mckee 2008 {published data only} Mckee C, Berkowitz I, Cosgrove SE, Bradley K, Beers C, Peri TM, et al.Redution of catheter-associated bloodstream infections in paediatric patients: experimentation and reality. Pediatric Critical Care Medicine 2008;9(1):40–6.

Penne 2002 {published data only} Penne K. Using evidence in central catheter care. Seminars in Oncology Nursing 2002;18(1):66–70.

Mckinley 2003 {published data only} Mckinley LL, Moriarty HJ, Short TH, Johnson CC. Effect of comparative data feedback on intensive care unit infection rates in a Veterans Adminstration Hospital Network System. American Journal of Infection Control 2003;31(7):397–404.

Peredo 2010 {published data only} Peredo R, Sabatier C, Villagrá A, González J, Hernández C, Pérez F, et al.Reduction in catheter-related bloodstream infections in critically ill patients through a multiple system intervention. European Journal of Clinical Microbiology and Infectious Diseases 2010;29(9):1173–7.

McLean 2006 {published data only} McLean SE, Jesen LA, Schoeder DG, Gibney NRT, Skjoddt NM. Improving adherence to a mechanical ventilation weaning protocol for critically ill adults: outcomes after an implementation program. American Journal of Critical Care 2006;15(3):299–309.

Pérez-González 2007 {published data only} Pérez-González LF, Ruiz-González JM, Noyola DE. Nosocomial bacteremia in children: a 15-year experience at a general hospital in Mexico. Infection Control and Hospital Epidemiology 2007;28(4):418–22.

Meier 1998 {published data only} Meier PA, Fredrickson M, Catney M, Nettleman MD. Impact of a dedicated intravenous therapy team on nosocomial bloodstream infection rates. American Journal of Infection Control 1998;26:388–92. Miller 2010a {published data only} Miller RS, Norris PR, Jenkins JM, Talbot TR, Starmer JM, Hutchison AS. Systems initiatives reduce healthcareassociated infections: a study of 22,928 device days in a single trauma unit. The Journal of Trauma 2010;68(1): 23–31. Miranda 2007 {published data only} Miranda JA, Trick WE, Evans AT, Charles-Damte M, Reilly MB, Clarke P. Firm-based trial to improve central venous catheter insertion practices. Journal of Hospital Medicine 2007;2:135–42. Misset 2004 {published data only} Misset B, Timsit JF, Dumay MF, Garrouste M, Chalfine A, Flouriot I, et al.A continuous quality-improvement program reduces nosocomial infection rates in the ICU. Intensive Care Medicine 2004;30(3):395–400. Ngo 2005 {published data only} Ngo A, Murphy S. A theory-based intervention to improve nurses’ knowledge, self-efficacy, and skills to reduce PICC occlusion. Journal of Infusion Nursing 2005;28(3):173. Ong 2011 {published data only} Ong A, Dysert K, Herbert C, Laux L, Granato J, Crawford J, et al.Trends in central line-associated bloodstream infections in a trauma-surgical intensive care unit. Archives of Surgery 2011;146(3):302–7.

Pethyoung 2005 {published data only} Pethoung W, Picheansathian W, Boonchuang P, Apisarnthanarak A, Danchaivijitr S. Effectiveness of education and quality control work group focusing on nursing practices for prevention of ventilator-associated pneumonia. Journal of the Medical Association of Thailand 2005;88(Suppl 10):S110–114. Pronovost 2008 {published data only} Pronovost P. Intervention to decrease catheter-related bloodstream infections in the ICU: the Keystone Intensive Care Unit Project. American Journal of Infection Control 2008;36(10):S171.e1–5. Pronovost 2010 {published data only} Pronovost PJ, Goeschel CA, Colantuoni E, Watson S, Lubomski LH, Berenholtz SM, et al.Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ 2010;c:309: 1–6. Provonost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al.An intervention to decrease catheterrelated bloodstream infections in the ICU. New England Journal of Medicine 2006;355(26):2725–32. Puntis 1990 {published data only} Putins JWL, Holden CE, Smallman S, Finkel Y, George RH, Booth IW. Staff training: a key factor in reducing intravascular catheter sepsis. Archives of Disease in Childhood 1990;65(3):335–7. Reilly 2006 {published data only} Reilly L, Sullivan P, Ninni S, Fochesto D, Williams K, Fetherman B. Reducing foley catheter device days in an


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intensive care unit. AACN Advance Critical Care 2006;17 (3):272–83. Rello 2011 {published data only} Rello J, Chastre J, Cornaglia G, Masterton R. A European care bundle for management of ventilator-associated pneumonia. Journal of Critical Care 2011;26(1):3–10. Rosenthal 2003 {published data only} Rosenthal VD, Guzman S, Pezzotto S, Christopher JC. Effect of an infection control program using education and performance feedback on rates of intravascular deviceassociated bloodstream infections in intensive care units in Argentina. American Journal of Infection Control 2003;31: 405–9. Rosenthal 2004 {published data only} Rosenthal DV, Guzman S, Safdar N. Effect of education and performance feedback on rates of catheter-associated urinary tract infection in intensive care units in Argentina. Infection Control and Hospital Epidemiology 2004;25:47–50. Rosenthal 2006a {published data only} Rosenthal DV, Guzman, Crnich C. Impact of an infection control program on rates of ventilator-associated pneumonia in intensive care units in 2 Argentinean hospitals. American Journal of Infection Control 2006;34:58–63. Rosenthal 2008 {published data only} Rosenthal VD. Device-associated nosocomial infections in limited-resources countries: findings of the International Nosocomial Infection Control Consortium (INICC). American Journal of Infection Control 2008;36(10): S171.e7–S171.e12. Saint 2005 {published data only} Saint S, Kaufman SR, Thompson M, Rogers MAM, Chenoweth CE. A reminder reduces urinary catheterization in hospitalised patients. Journal on Quality and Patient Safety 2005;31(8):455–62. Sansivero 2011 {published data only} Sansivero G, Galloway M. Registered professional nurses placing central vascular access catheters via the internal jugular vein at the bedside: One year evaluation of a pilot program. Journal of Vascular Access 2011;12(1):84–5. Santana 2008 {published data only} Santana SL, Furtado GHC, Wey SB, Medeiros EAS. Impact of an education program on the incidence of central lineassociated bloodstream infection in 2 medical-surgical intensive care units in Brazil. Infection Control and Hospital Epidemiology 2008;29(12):1171–3. Scales 2009 {published data only} Scales DC, Dainty K, Hales B, Pinto R, Fowler RA, Adhikari NKJ. An innovative telemedicine knowledge translation program to improve quality of care in intensive care units: protocol for a cluster randomised pragmatic trial. Implementation Science 2009;4(5):1–9. [DOI: 10.1186/ 1748-5908-4-5] Scales 2011a {published data only} Scales K. Reducing infection associated with central venous access devices. Nursing Standard 2011;25(36):49–56.

Seguin 2010 {published data only} Seguin P, Laviolle B, Isslame S, Coué A, Mallédant Y. Effectiveness of simple daily sensitization of physicians to the duration of central venous and urinary tract catheterization. Intensive Care Medicine 2010;36(7):1202–6. Seto 1991 {published data only} Seto WH, Ching TY, Yuen TY, Chu YB, Seto WL. The enhancement of infection control in-service education by ward opinion leaders. American Journal of Infection Control 1991;19(2):86–91. Shapey 2009 {published data only} Shapey IM, Foster MA, Whitehouse T, Jumaa P, Bion JF. Central venous catheter-related bloodstream infections: improving post-insertion catheter care. Hospital Infection Control 2009;71(2):117–22. Sherertz 2000 {published data only} Sherertz RJ, Ely EW, Westbrook DM, Gledhill KS, Streed SA, Kiger B, et al.Education of physicians-in-training can decrease the risk for vascular catheter infection. Annals of Internal Medicine 2000;132:641–8. Smith 2011 {published data only} Smith L, Elamin E. Implementation of evidence-based guidelines in reducing catheter related bloodstream infections. Chest. Proceedings of the CHEST Conference. Honolulu, 2011. Soifer 1998 {published data only} Soifer NE, Borzak S, Edlin BR, Weinstein RA. Prevention of peripheral venous catheter complication with an intravenous therapy team. Archives of Internal Medicine 1998;158:473–7. Sutton 2005 {published data only} Sutton CD, Garcea G, Pollard C, Berry DP, Dennison AR. The introduction of a nutrition clinical nurse specialist results in a reduction in the rate of catheter sepsis. Clinical Nutrition 2005;24:220–3. Sydnor 2011 {published data only} Sydnor ERM, Perl TM. Hospital epidemiology and infection control in acute-care settings. Clinical Microbiology Reviews 2011; Vol. 24, issue 1:141–73. Timsit 2011 {published data only} Timsit J-F, Minet C, Lugosi M, Calvino-Gunther S, AraSomohano C, Bonadona A, et al.Prevention of catheterrelated infections in ICU. Journal des Anti-Infectieux 2011; 13(3):161–9. Tolentino DelosReyes 2007 {published data only} Tolentino Delos Reyes AF, Ruppert SD, Shiao SY. Evidencebased practice: use of the ventilator bundle to prevent ventilator-associated pneumonia. American Journal of Critical Care 2007;16(1):20–27. Topal 2005 {published data only} Topal J, Conklin S, Camp K, Morris V, Balcezak T, Hebert P. Prevention of nosocomial catheter-associated urinary tract infections through computerized feedback to physicians and a nurse-directed protocol. American Journal of Medical Quality 2005;20(3):121–6.


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Troeng 2011 {published data only} Troeng M. Evaluation of an educational programme in management and care of central venous access devices. Journal of Vascular Access 2011;12(1):90. Tsuchida 2007 {published data only} Tsuchida T, Makimot K, Toki M, Sakai K, Onaka E, Otono Y. The effectiveness of a nurse-initiated intervention to reduce catheter-associated bloodstream infections in an urban acute hospital: An intervention study with before and after comparison. International Journal of Nursing Studies 2007;44:1324–33. Urrea Ayala 2009 {published data only} Ayala MU, Quesada LR. Catheter-associated blood stream infections: Implementation of a new consensus protocol [La bacteriemia asociada al cateter venoso central: implementación de un nuevo protocolo de consenso]. Anales de Pediatria 2009;71(1):20–4. Verdier 2006 {published data only} Verdier R, Parer S, Jean-Pierre H, Dujols P, Picot MC. Impact of an infection control program in an intensive care unit in France. Infection Control and Hospital Epidemiology 2006;27(1):60–6. Wall 2005 {published data only} Wall Rj, Ely EW, Elasy TA, Dittus RS, Foss J, Wilkerson KS, et al.Using real time process measurements to reduce catheter related bloodstream infections in the intensive care unit. Quality and Safety in Health care 2005;14:295–302. Warren 2003 {published data only} Warren DK, Zack JE, Cox MJ, Cohen MM, Fraser VJ. An educational intervention to prevent catheter-associated bloodstream infections in a non teaching, community medical center. Critcal Care Medicine 2003;31(7):1959–63. Warren 2006 {published data only} Warren DK, Cosgrove SE, Diekema DJ, Zuccotti G, Climo MW, Bolon MK, et al.A multicenter intervention to prevent catheter-associated bloodstream infections. Infection Control and Hospital Epidemiology 2006;27:662–9. Weireter 2009 {published data only} Weireter LJ, Collins JN, Britt RC, Reed SF, Novosel TJ, Britt LD. Impact of a monitored program of care on incidence of ventilator-associated pneumonia: results of a long term performance-improvement project. Journal of American College of Surgeons 2009;208:700–5.

collaborative to reduce neonatal central line-associated blood stream infections. Journal of Perinatology 2010;30: 170–81. Worrall 2010 {published data only} Worrall CL, Anger PB, Simpson KN, Leon SM. Impact of a hospital-acquired/ventilator-associated/healthcareassociated pneumonia practice guideline on outcomes in surgical trauma patients. Journal of Trauma 2010;68:382–6. Xiao 2007 {published data only} Xiao Y, Seagull J, Bochicchio GV, Guzzo JL, Dutton RP, Sisley A, et al.Video-based training increases steriletechnique compliance during central venous catheter insertion. Critical Care Medicine 2007;35:1302–6. Yoo 2001 {published data only} Yoo S, Ha M, Choi D, Hynjoo P. Effectiveness of surveillance of central catheter-related bloodstream infection in an ICU in Korea. Infection Control and Hospital Epidemiology 2001;22(7):433–6. Youngquist 2007 {published data only} Youngquist P, Carroll M, Farber M, Macy D, Madrid P, Ronning J, et al.Implementing a ventilator bundle in a community hospital. Journal of Quality and Patient Safety 2007;33(4):219–25. Zaydfudin 2009 {published data only} Zaydfundim V, Dosset LA, Starmer JM, Arbogast PG, Feurer ID, Ray AW. Implementation of a real-time compliance dashboard to help reduce SICU ventilatorAssociated pneumonia with the ventilator bundle. Archives of Surgery 2009;144:656–62. Zingg 2009 {published data only} Zingg W, Imhof A, Maggiorini M, Stocker R, Keller E, Ruef C. Impact of a prevention strategy targeting hand hygiene and catheter care on the incidence of catheterrelated bloodstream infections. Critical Care Medicine 2009; 37(7):2167–73. Zuschneid 2003 {published data only} Zuschneid I, Schwab F, Geffers C, Ruden H, Gastmeier P. Reducing central venous catheter-associated primary bloodstream infections in intensive care units is possible: data from the German nosocomial infection surveillance system. Infection Control and Hospital Epidemiology 2003; 24:501–5.

References to studies awaiting assessment

Westwell 2008 {published data only} Westwell S. Implementing a ventilator care bundle in an adult intensive care unit. Nursing in Critical Care 2008;13 (4):203–7.

Chen 2011 {published data only} Chen YZ, Yan CY. Hematology-oncology port-A: improving nursing care quality. Hu Li Tsa Chih - Journal of Nursing 2011;58(3 Suppl):64–72.

Williams 2008 {published data only} Williams Z, Rodney C, Kelly E. A single device to increase rate of compliance in maintaining 30-degree head-of-bed elevation in ventilated patients. Critical Care Medicine 2008;36(4):115–7.

Danchaivijitr 1992 {published data only} Danchaivijitr S, Chokloikaew S, Tangtrakool T, Waitayapiches S. Does indication sheet reduce unnecessary urethral catheterization?. Journal of the Medical Association of Thailand 1992;75(Suppl 2):1–5.

Wirtschafter 2010 {published data only} Wirtschafter DD, Pettit J, Kurtin P, Dalsey M, Chance K, Morrow HW. A statewide quality improvement

Eid 2011 {published data only} Eid R, Domingues F, Barretto JKS, Marra AR, Silva CV, Paes AT, et al.Successful prevention of tracheostomy


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associated pneumonia in step-down units. American Journal of Infection Control 2011;39(6):500–5. Kaplan 2011 {published data only} Kaplan HC, Lannon C, Walsh MC, Donovan EF, Ohio Perinatal Quality Collaborative. Ohio statewide qualityimprovement collaborative to reduce late-onset sepsis in preterm infants. Pediatrics 2011;127(3):427–35. Khouli 2011 {published data only} Khouli H, Jahnes K, Shapiro J, Rose K, Mathew J, Gohil A, et al.Performance of medical residents in sterile techniques during central vein catheterization randomized trial of efficacy of simulation-based training. Chest 2011;139(1): 80–7. Latif 2012 {published data only} Latif RK, Bautista AF, Memon SB, Smith EA, Wang C, Wadhwa A, et al.Teaching aseptic technique for central venous access under ultrasound guidance: a randomized trial comparing didactic training alone to didactic plus simulation-based training. Anesthesia and Analgesia 2012; 114(3):626–33. Longmate 2011 {published data only} Longmate AG, Ellis KS, Boyle L, Maher S, Cairns CJ, Lloyd SM, et al.Elimination of central-venous-catheter-related bloodstream infections from the intensive care unit. BMJ Quality and Safety 2011;20(2):174–80. Lopez 2011 {published data only} Lopez AC. A quality improvement program combining maximal barrier precaution compliance monitoring and daily chlorhexidine gluconate baths resulting in decreased central line bloodstream infections. Dimensions of Critical Care Nursing 2011;30(5):293–8. Marra 2011 {published data only} Marra AR, Camargo TZS, Goncalves P, Sogayar AMCB, Moura Jr DF, Guastelli LR, et al.Preventing catheterassociated urinary tract infection in the zero-tolerance era. American Journal of Infection Control 2011;39:500–5. Miller 2011 {published data only} ∗ Miller MR, Niedner MF, Huskins WC, Colantuoni E, Yenokyan G, Moss M, et al.Reducing PICU central lineassociated bloodstream infections: 3-year results. Pediatrics 2011;128(5):e1077–83. Morris 2011 {published data only} Morris AC, Hay AW, Swann DG, Everingham K, McCulloch C, McNulty J, et al.Reducing ventilatorassociated pneumonia in intensive care: impact of implementing a care bundle. Critical Care Medicine 2011; 39(10):2218–24. Munhoz 2012 {published data only} Munoz-Price LS, Dezfulian C, Wyckoff M, Lenchus JD, Rosalsky M, Birnbach DJ, et al.Effectiveness of stepwise interventions targeted to decrease central catheter-associated bloodstream infections. Critical Care Medicine 2012;40(5): 1464–9. Papadimos 2008 {published data only} Papadimos TJ, Hensley SJ, Duggan JM, Khuder SA, Borst MJ, Fath JJ, et al.Implementation of the “FASTHUG”

concept decreases the incidence of ventilator-associated pneumonia in a surgical intensive care unit. Patient Safety in Surgery 2008; Vol. 2, issue 3. [DOI: 10.1186/ 1754-9493-2-3] Resende 2011 {published data only} Resende DS, Ó JM, Brito DV, Abdallah VO, Gontijo Filho PP. Reduction of catheter-associated bloodstream infections through procedures in newborn babies admitted in a university hospital intensive care unit in Brazil. Revista da Sociedade Brasileira de Medicina Tropical 2011; Vol. 44, issue 6:731–4. Scales 2011 {published data only} Scales DC, Dainty K, Hales B, Pinto R, Fowler RA, Adhikari NK, et al.A multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial. JAMA 2011;305(4):363–72. Speroff 2011 {published data only} Speroff T, Ely EW, Greevy R, Weinger MB, Talbot TR, Wall RJ, et al.Quality improvement projects targeting health care-associated infections: comparing virtual collaborative and toolkit approaches. Journal of Hospital Medicine (Online) 2011;6(5):271–8. Tong 2011 {published data only} Tong L, Zhong Y, Feng B-L, Yu Z-Y. Preventing peripheral central venous catheter-related bloodstream infections through process management. Chinese Journal of Clinical Nutrition 2011;19(1):56–8.

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O’Grady 2011 O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al.Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the prevention of intravascular catheter-related Infections. Clinical Infectious Diseases 2011;52(9):162–93. [DOI: 10.1093/cid/cir257] Phipps 2006 Phipps S, Lim YN, McClinton S, Barry C, Rane A, N’Dow J. Short term urinary catheter policies following urogenital surgery in adults. Cochrane Database of Systematic Reviews 2006, Issue 2. [DOI: 10.1002/ 14651858.CD004374.pub2] Pittet 2006 Pittet D, Allegranzi B, Sax H, Bertinato L, Concia E, Cookson B, et al.Considerations for a WHO European strategy on health-care-associated infection, surveillance, and control surveillance, and control. Lancet Infectious Diseases 2005;5(4):242–50. Pratt 2007 Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SR, et al.epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection 2007;65 (Suppl 1):S1–S64. Ramritu 2008 Ramritu P, Halton K, Cook D, Whitby M, Graves N. Catheter-related bloodstream infections in intensive care units: a systematic review with meta-analysis. Journal of Advanced Nursing 2008;62(1):3–21. Ramsay 2001 Ramsay C, Grimshaw J, Grilli R. Robust methods for analysis of interrupted time series designs for inclusion in systematic reviews. Proceedings of the 9th Annual Cochrane Colloquium; 2011 Oct; Lyon. Lyon: Cochrane Collaboration, 2001. Ramsay 2003 Ramsay CR, Matowe L, Grilli R, Grimshaw JM, Thomas RE. Interrupted time series designs in health technology assessment: lessons from two systematic reviews of behavior change strategies. International Journal of Technology Assessment in Health Care 2003;19(4):613–23.

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Ranji 2007 Ranji SR, Shetty K, Posley KA, Lewis R, Sundaram V, Galvin CM, et al.Closing the quality gap: a critical analysis of quality improvement strategies: Vol. 6 - Prevention of Healthcare-Associated Infections. Agency for Healthcare Research and Quality (US) 2007; Vol. 4, issue 7:51–6.

O’Brien 2007 O’Brien MA, Rogers S, Jamtvedt G, Oxman AD, OdgaardJensen J, Kristoffersen DT, et al.Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2007, Issue 4. [DOI: 10.1002/14651858.CD000409.pub2]

Rello 2012 Rello J, Afonso E, Lisboa T, Ricart M, Balsera B, Rovira A, et al.FADO Project Investigators. A care bundle approach for prevention of ventilator-associated pneumonia. Clinical Microbiological and Infection 2012 Feb 9 [Epub ahead of print]. [DOI: 0.1111/j.1469-0691.2012.03808.x]


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RevMan 2011 The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). 5.1. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011. Richards 1999 Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System. Critical Care Medicine 1999;27(5):887–92. Rosenthal 2006 Rosenthal VD, Maki DG, Salomao R, lvarez-Moreno CA, Mehta Y, Higuera F. Device-associated nosocomial infections in 55 intensive care units of 8 developing countries. Annals of Internal Medicine 2006;145:582–91. Rosenthal 2010 Rosenthal VD, Maki DG, Jamulitrat S, Medeiros EA, Todi SK, Gomez DY, et al.INICC Members. International Nosocomial Infection Control Consortium (INICC) report, data summary for 2003-2008, issued June 2009. American Journal of Infection Control 2010;38(2):95–104. Safdar 2002 Safdar N, Kluger DM, Maki DG. A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, non cuffed central venous catheters: implications for preventive strategies. Medicine 2002;81(6):466–79. Safdar 2005 Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and economic consequences of ventilator-associated pneumonia: A systematic review. Critical Care Medicine 2005;33(10): 2184–93. Safdar 2008 Safdar N, Abad C. Educational interventions for prevention of healthcare-associated infection: a systematic review. Critial Care Medicine 2008;36(3):933–40. Saint 2000 Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. American Journal of Infection Control 2000;28:68–75. Saint 2009 Saint S, Meddings JA, Calfee D, Kowalski CP, Krein SL. Catheter-associated urinary tract infection and the medicare rule changes. Annals of Internal Medicine 2009;150(12): 877–84. Shojania 2001 Shojania KG, Duncan BW, McDonald KM, Wachter RM, Markowitz AJ. Making health care safer: a critical analysis of patient safety practices. Evidence report technology assessment (summary) 2001;43(i-x):1–668. Shojania 2009 Shojania KG, Jennings A, Mayhew A, Ramsay CR, Eccles MP, Grimshaw J. The effects of on-screen, point of care computer reminders on processes and outcomes of care. Cochrane Database of Systematic Reviews 2009, Issue 3. [DOI: 10.1002/14651858.CD001096.pub2]

Snyders 2011 Snyders O, Khondowe O, Bell J. Oral chlorhexidine in the prevention of ventilator-associated pneumonia in critically ill adults in the ICU: A systematic review. SAJCC 2011;27 (2):48–56. Stata 2009 StataCorp. Stata Statistical Software. Release 11. College Station, TX: StataCorp LP, 2009. Stone 2005 Stone PW, Braccia D, Larson E. Systematic review of economic analyses of health care-associated infections. American Journal of Infection Control 2005;33:501–9. Tambyah 2002 Tambyah PA, Knasinski V, Maki DG. The direct costs of nosocomial catheter-associated urinary tract infection in the era of managed care. Infection Control and Hospital Epidemiology 2002;23:27–31. Tambyah 2012 Tambyah PA, Oon J. Catheter-associated urinary tract infection. Current Opinion in Infectious Diseases 2012;25 (4):365–70. [DOI: 10.1097/QCO.0b013e32835565cc] Umscheid 2011 Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infection Control and Hospital Epidemiology 2011;32(2):101–14. Weinstein 1998 Weinstein RA. Nosocomial infection update. Emerging Infectious Diseases 1998;4(3):416–20. WHO 2011 World Health Organization. Report on the burden of endemic health care-associated infection worldwide. WHO Document Production Services 2011. [: ISBN 978 92 4 150150 7] Wilson 2009 Willson M, Wilde M, Webb ML, Thompson D, Parker D, Harwood J, et al.Nursing interventions to reduce the risk of catheter-associated urinary tract infection: part 2: staff education, monitoring, and care techniques. Journal of Wound, Ostomy and Continence Nursing 2009;36(2): 137–54. Yokoe 2008a Yokoe D, Classen D. Improving patient safety through infection control: a new healthcare imperative. Infection Control and Hospital Epidemiology 2008;29:S3–S11. Yokoe 2008b Yokoe DS, Mermel LA, Anderson DJ, Arias KM, Burstin H, Calfee DP. A compendium of strategies to prevent healthcare-associated infections in acute care hospitals. Infection Control and Hospital Epidemiology 2008;29: S12–S21. Zilberberg 2009 Zilberberg MD, Shorr AF, Kollef MH. Implementing quality improvements in the intensive care unit: ventilator


36

∗

bundle as an example. Critical Care Medicine 2009;37(1): 305–9. Indicates the major publication for the study


37

CHARACTERISTICS OF STUDIES

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

Study design: ITS Data collection: Quarterly VAP rates were collected from the respective infection control officers over the course of the evidence based practice initiative using the NNIS calculation. An experienced critical care research nurse observed CPG adoption using the adaptation checklist. The same research nurse collected the patient information by a record review Definition of VAP: Based on NNIS definition (CDC 2003) Ventilators used: Not described in the paper; differences in type of ventilators, differences in mechanical ventilation, respiratory equipment, and antibiotic therapy across units and sites were not controlled for in the study, neither were weaning protocols which also may have had an impact on the duration of ventilation Targeted behaviour: Improve procedures (adoption of a CPG developed to decrease VAP rate)

Participants

Providers: Unknown number of nurses, technicians, and respiratory therapists (self learning packet); staff physicians, residents, interns, respiratory therapists, housekeeping staff (briefing) Patients: Patients (n = 106 for all five sites, only four sites included in the analysis;individual site data not reported) on continuous mechanical ventilation for greater than, or equal to, 48 hours, who did not meet the NNIS criteria for a diagnosis of VAP at the time of data collection. Excluded: patients with conditions requiring the head of the bed to be down Age (range): Mean = 50 years (17 to 91 years) Gender, number of females (%): 35 (33) APACHE II score (range): Mean = 15 (3 to 39) Enteral feeding, no. (%): 85 (83) ICU length of stay (range): Mean = 15 days (2 to 68 days) Ventilator days (range): Mean = 10 days (5 to 52 days) Years of respiratory history (range): Mean = 0 years (0 to 20 years) Patient characteristics were not presented separately for the pre- and post-intervention period (patient characteristics separated by VAP and non-VAP patients) Setting: Medical ICU, unknown no. of beds Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: Mechanical ventilator Evidence base of intervention: CPG based on review of the literature Clinical practice guideline • Head-of-bed elevation • Oral care • Ventilator tubing condensate removal • Hand hygiene • Use of gloves Type of intervention: Professional intervention


38

Abbott 2006 dataset 1

(Continued)

Format: Paper, computer, interpersonal Description of intervention: 1. Knowledge translation activities A multidisciplinary education team developed a standard of care for the ventilated patient that included: a. CPG implementation. b. Use of standing orders for the care of the ventilated patient c. Ongoing and open discussion with staff as to the usefulness of implementation strategies d. Frequent delivery of data to multidisciplinary team members and quarterly trends to organisation leaders e. Briefing of VAP prevention initiative to Joint Commission on Accreditation of Healthcare Organisations during on-site survey f. Ongoing assessment of the change process was performed to determine if factors facilitating or hindering the adoption of the VAP CPG were related to knowledge, attitude, behaviour, policy, or system 2. Educational intervention 2.1. Initial education plan a. VAP self learning packet was incorporated into the orientation for nurses, technicians, and respiratory therapists b. Infection control and preventing infection briefing was provided during the critical care course c. Briefings to staff physicians, residents, interns, respiratory therapists, housekeeping staff were provided 2.2. Ongoing educational initiatives a. Development and displaying of educational story boards to reinforce all CPG elements: educational story poster about the change process and audit data for periodic in-service programmes; reminders at the bedside to reinforce initiatives and CPGs b.One-to-one bedside teaching was conducted with reminders at the bedside with continuous interaction checks and teaching c. Weekly email reminders were sent to staff asking them to email data from hospitals after measurement began 2.3. Feedback a. Commander-senior executive-level briefed updated progress on status of VAP and reinforced care initiatives b. Updated VAP process and status were sent to Patient Care Council, Infection Control Committee, hospital level Performance Improvement Council, and other applicable committees c. Feedback on guideline adoption and VAP rate to staff Timing: a) Frequency and number of events: Not specified b) Duration of intervention: Reinforcements of CPG occurred throughout the whole study period c) Period after the intervention under which data was collected: 24 months Outcomes

Quarterly VAP rates: at 3, 6, 9 and 12 months after the intervention Outcomes that could not be reanalysed and therefore not included in this review: Adoption rates, ventilator days, length of ICU stay, length of hospital stay, and costs


39


(Continued)

Notes Risk of bias Bias

Authors’ judgement

Support for judgement

Intervention independent of other changes Unclear risk

It was not explicitly stated in the paper if the intervention was independent of other changes

Shape of the intervention effects pre-spec- Low risk ified

Although 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 Low risk into account)

Secular 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 collec- Low risk tion

Routine 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 Low risk bias) All outcomes

The primary outcome (VAP rate) was objective and based on standardised criteria

Incomplete outcome data (attrition bias) All outcomes

Unclear risk

There is missing data for quarter two in the pre-intervention period

Selective reporting (reporting bias)

Unclear risk

No mention of protocol for study, therefore we are unable to assess if all outcomes are reported

Other bias

Low risk

No other biases identified


40

Abbott 2006 dataset 2 Methods

Study design: ITS Data collection: Quarterly VAP rates were collected from the respective infection control officers for each ICU in each hospital over the course of the evidence based practice initiative using the NNIS calculation. An experienced critical care research nurse observed CPG adoption at both facilities, using the adaptation checklist. The same research nurse collected the patient information by a record review Definition of VAP: Based on NNIS definition (CDC 2003) Ventilators used: Not described in the paper; differences in type of ventilators, differences in mechanical ventilation, respiratory equipment, and antibiotic therapy across units and sites were not controlled for in the study, neither were weaning protocols which also may have had an impact on the duration of ventilation Targeted behaviour: Improve procedures (adoption of a CPG developed to decrease VAP rate)

Participants

Providers: Unknown number of nurses, technicians, and respiratory therapists (self learning packet); staff physicians, residents, interns, respiratory therapists, housekeeping staff (briefing) Patients: Patients (n = 106 for all five sites, only four sites included in the analysis; individual site data not reported) on continuous mechanical ventilation for greater than, or equal to, 48 hours, who did not meet the NNIS criteria for a diagnosis of VAP at the time of data collection. Excluded: Patients with conditions requiring the head of the bed to be down Age (range): Mean = 50 years (17 to 91 years) Gender, number of females (%): 35 (33) APACHE II score (range): Mean = 15 (3 to 39) Enteral feeding, no. (%): 85 (83) ICU length of stay (range): Mean = 15 days (2 to 68 days) Ventilator days (range): Mean = 10 days (5 to 52 days) Years of respiratory history (range): Mean = 0 years (0 to 20 years) Patient characteristics were not presented separately for the pre- and post-intervention period (patient characteristics separated by VAP and non-VAP patients) Setting: Surgical ICU Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: mechanical ventilator Evidence base of intervention: CPG based on review of the literature Clinical practice guideline • Head-of-bed elevation • Oral care • Ventilator tubing condensate removal • Hand hygiene • Use of gloves Type of intervention: Professional intervention Format: Paper, computer, interpersonal Description of intervention: 1. Knowledge translation activities A multidisciplinary education team developed a standard of care for the ventilated patient that included:


41


(Continued)

a. CPG implementation. b. Use of standing orders for the care of the ventilated patient c. Ongoing and open discussion with staff as to the usefulness of implementation strategies d. Frequent delivery of data to multidisciplinary team members and quarterly trends to organisation leaders e. Briefing of VAP prevention initiative to Joint Commission on Accreditation of Healthcare Organisations during on-site survey f. Ongoing assessment of the change process was performed to determine if factors facilitating or hindering the adoption of the VAP CPG were related to knowledge, attitude, behaviour, policy, or system 2. Educational intervention 2.1. Initial education plan a. VAP self learning packet was incorporated into the orientation for nurses, technicians, and respiratory therapists b. Infection control and preventing infection briefing was provided during the critical care course c. Briefings to staff physicians, residents, interns, respiratory therapists, housekeeping staff were provided 2.2. Ongoing educational initiatives a. Development and displaying of educational story boards to reinforce all CPG elements: educational story poster about the change process and audit data for periodic in-service programmes; reminders at the bedside to reinforce initiatives and CPGs b. One-to-one bedside teaching was conducted with reminders at the bedside with continuous interaction checks and teaching c. Weekly email reminders were sent to staff asking them to email data from hospitals after measurement began 2.3. Feedback a. Commander-senior executive-level briefed updated progress on status of VAP and reinforced care initiatives b. Updated VAP process and status were sent to Patient Care Council, Infection Control Committee, hospital level Performance Improvement Council, and other applicable committees c. Feedback on guideline adoption and VAP rate to staff 3. Other interventions a) Special oral care equipment was purchased b) Dentists and dental hygienists were employed to provide oral care for patients with mechanical ventilation Timing: a) Frequency and number of events: Not specified b) Duration of intervention: Reinforcements of CPG occurred throughout the whole study period c) Period after the intervention under which data was collected: 20 months Outcomes

Quarterly VAP rates: at 3, 6, 9 and 12 months after the intervention Outcomes that could not be reanalysed and therefore not included in this review: Adoption rates, ventilator days, length of ICU stay, length of hospital stay, and costs


42


(Continued)

Notes

Statistical analyses not reported Data were extracted from graphs and reanalysed by reviewers

Risk of bias Bias














Low risk

All data points included


Unclear risk


Other bias

Low risk



43


Study design: ITS Data collection: Quarterly VAP rates were collected from the infection control officers over the course of the evidence based practice initiative using the NNIS calculation. An experienced critical care research nurse observed CPG adoption at both facilities, using the adaptation checklist. The same research nurse collected the patient information by a record review Definition of VAP: Was based on NNIS definition (CDC 2003) Ventilators used: Not described in the paper; differences in type of ventilators, differences in mechanical ventilation, respiratory equipment, and antibiotic therapy across units and sites were not controlled for in the study, neither were weaning protocols which also may have had an impact on the duration of ventilation Targeted behaviour: Improve procedures (adoption of a CPG developed to decrease VAP rate)

Participants

Providers: Unknown number of nurses, technicians, and respiratory therapists (self learning packet); staff physicians, residents, interns, respiratory therapists, housekeeping staff (briefing) Patients: Patients (n = 106 for all five sites, only four sites included in the analysis;individual site data not reported) on continuous mechanical ventilation for greater than, or equal to, 48 hours, who did not meet the NNIS criteria for a diagnosis of VAP at the time of data collection. Excluded: patients with conditions requiring the head of the bed to be down Age (range): Mean = 50 years (17 to 91 years) Gender, number of females (%): 35 (33) APACHE II score (range): Mean = 15 (3 to 39) Enteral feeding, no. (%): 85 (83) ICU length of stay (range): Mean = 15 days (2 to 68 days) Ventilator days (range): Mean = 10 days (5 to 52 days) Years of respiratory history (range): Mean = 0 years (0 to 20 years) Patient characteristics were not presented separately for the pre- and post-intervention period (patient characteristics separated by VAP and non-VAP patients) Setting: Trauma ICU; unknown number of beds Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: Mechanical ventilator Evidence base of intervention: CPG based on review of the literature Clinical practice guideline • Head-of-bed elevation • Oral care • Ventilator tubing condensate removal • Hand hygiene • Use of gloves Type of intervention: Professional intervention Format: Paper, computer, interpersonal Description of intervention: 1. Knowledge translation activities A multidisciplinary education team developed a standard of care for the ventilated patient that included:


44


(Continued)

a. CPG implementation. b. Use of standing orders for the care of the ventilated patients c. Ongoing and open discussion with staff as to the usefulness of implementation strategies d. Frequent delivery of data to multidisciplinary team members and quarterly trends to organisation leaders e. Briefing of VAP prevention initiative to Joint Commission on Accreditation of Healthcare Organisations during on-site survey f. Ongoing assessment of the change process was performed to determine if factors facilitating or hindering the adoption of the VAP CPG were related to knowledge, attitude, behaviour, policy, or system 2. Educational intervention 2.1. Initial education plan a. VAP self learning packet was incorporated into the orientation for nurses, technicians, and respiratory therapists b. Infection control and preventing infection briefing was provided during the critical care course c. Briefings to staff physicians, residents, interns, respiratory therapists, housekeeping staff were provided 2.2. Ongoing educational initiatives a. Development and displaying of educational story boards to reinforce all CPG elements: educational story poster about the change process and audit data for periodic in-service programmes; reminders at the bedside to reinforce initiatives and CPGs b.One-to-one bedside teaching was conducted with reminders at the bedside with continuous interaction checks and teaching c. Weekly email reminders were sent to staff asking them to email data from hospitals after measurement began 2.3. Feedback a. Commander-senior executive-level briefed updated progress on status of VAP and reinforced care initiatives b. Updated VAP process and status were sent to Patient Care Council, Infection Control Committee, hospital level Performance Improvement Council, and other applicable committees c. Feedback on guideline adoption and VAP rate to staff Timing: a) Frequency and number of events: Not specified b) Duration of intervention: Reinforcements of CPG occurred throughout the whole study period c) Period after the intervention under which data was collected: 20 months Outcomes

Quarterly VAP rates: at 3, 6, 9 and 12 months after the intervention Outcomes that could not be reanalysed and therefore not included in this review : Adoption rates, ventilator days, length of ICU stay, length of hospital stay, and costs

Notes


Risk of bias Interventions to improve professional adherence to guidelines for prevention of device-related infections (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

45


(Continued)

Bias














Low risk

All data points included


Unclear risk


Other bias

Low risk



46


Study design: ITS Data collection: Quarterly VAP rates were collected from the infection control officers over the course of the evidence based practice initiative using the NNIS calculation. An experienced critical care research nurse observed CPG adoption at both facilities, using the adaptation checklist. The same research nurse collected the patient information by a record review Definition of VAP: Based on NNIS definition (CDC 2003) Ventilators used: Not described in the paper; differences in type of ventilators, differences in mechanical ventilation, respiratory equipment, and antibiotic therapy across units and sites were not controlled for in the study, neither were weaning protocols which also may have had an impact on the duration of ventilation Targeted behaviour: Improve procedures (adoption of a CPG developed to decrease VAP rate)

Participants

Providers: Unknown number of nurses, technicians, and respiratory therapists (self learning packet); staff physicians, residents, interns, respiratory therapists, housekeeping staff (briefing) Patients: Patients (n = 106 for all five sites, only four sites included in the analysis;individual site data not reported) on continuous mechanical ventilation for greater than, or equal to, 48 hours, who did not meet the NNIS criteria for a diagnosis of VAP at the time of data collection. Excluded: patients with conditions requiring the head of the bed to be down Age (range): Mean = 50 years (17 to 91 years) Gender, number of females (%): 35 (33) APACHE II score (range): Mean = 15 (3 to 39) Enteral feeding, no. (%): 85 (83) ICU length of stay (range): Mean = 15 days (2 to 68 days) Ventilator days (range): Mean = 10 days (5 to 52 days) Years of respiratory history (range): Mean = 0 years (0 to 20 years) Patient characteristics were not presented separately for the pre- and post-intervention period (patient characteristics separated by VAP and non-VAP patients) Setting: One trauma ICU; unknown number of beds Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: Mechanical ventilator Evidence base of intervention: CPG based on review of the literature Clinical practice guideline • Head-of-bed elevation • Oral care • Ventilator tubing condensate removal • Hand hygiene • Use of gloves Type of intervention: professional intervention Format: paper, computer, interpersonal Description of intervention: 1. Knowledge translation activities A multidisciplinary education team developed a standard of care for the ventilated patient that included:


47


(Continued)

a. CPG implementation. b. Use of standing orders for the care of the ventilated patient c. Ongoing and open discussion with staff as to the usefulness of implementation strategies d. Frequent delivery of data to multidisciplinary team members and quarterly trends to organisation leaders e. Briefing of VAP prevention initiative to Joint Commission on Accreditation of Healthcare Organisations during on-site survey f. Ongoing assessment of the change process was performed to determine if factors facilitating or hindering the adoption of the VAP CPG were related to knowledge, attitude, behaviour, policy, or system 2. Educational intervention 2.1. Initial education plan a. VAP self learning packet was incorporated into the orientation for nurses, technicians, and respiratory therapists b. Infection control and preventing infection briefing was provided during the critical care course c. Briefings to staff physicians, residents, interns, respiratory therapists, housekeeping staff were provided 2.2. Ongoing educational initiatives a. Development and displaying of educational story boards to reinforce all CPG elements: educational story poster about the change process and audit data for periodic in-service programmes; reminders at the bedside to reinforce initiatives and CPGs b.One-to-one bedside teaching was conducted with reminders at the bedside with continuous interaction checks and teaching c. Weekly email reminders were sent to staff asking them to email data from hospitals after measurement began 2.3. Feedback a. Commander-senior executive-level briefed updated progress on status of VAP and reinforced care initiatives b. Updated VAP process and status were sent to Patient Care Council, Infection Control Committee, hospital level Performance Improvement Council, and other applicable committees c. Feedback on guideline adoption and VAP rate to staff Timing: a) Frequency and number of events: not specified b) Duration of intervention: reinforcements of CPG occurred throughout the whole study period c) Period after the intervention under which data was collected: 16 months Outcomes

Quarterly VAP rates: at 3, 6 and 9 months after the intervention Outcomes that could not be reanalysed and therefore not included in this review : Adoption rates, ventilator days, length of ICU stay, length of hospital stay, and costs

Notes



48


(Continued)

Bias














Unclear risk

The authors did not describe how they addressed the missing data for the last quarter in the post-intervention period


Unclear risk


Other bias

Unclear risk



49

Beathard 2003 Methods

Study design: ITS with historical controls (the same population and under the same conditions, except for the prophylaxis protocol) Data collection: Monthly review of medical charts of patients receiving haemodialysis via a TDC Definition of catheter related bacteraemia: Defined as bacteraemia in a patient with a TDC with no other etiologic explanation for the infection Catheters used: Cuffed tunnelled dialysis catheters. All central lines were inserted in an operating room Targeted behaviour: Improve procedures (to improve care provided to patient with TDC to protect the hub from contamination)

Participants

Providers: All dialysis facility staff; no provider characteristics reported Patients: Patients (n = 700) with TDC; Pre-intervention period: n = 298; Post-intervention period: n = 402 patients; no patient characteristics reported Setting: One haemodialysis facility at one hospital; unclear no. of beds Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: TDC Evidence base of intervention: Infection prophylaxis protocol based on National Kidney Foundation’s Kidney Disease Outcomes and Quality Initiative Clinical Practice Guidelines for Vascular Access Clinical practice guideline: • Individually wrap both of the catheter hubs with gauze saturated with povidoneiodine 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


50

Beathard 2003

(Continued)

b) Duration of intervention: Repeated education and spot checks for compliance with the protocol occurred throughout the study period c) Period after the start of the intervention during which data was collected: 24 months Outcomes

CLABSI rates at 3, 6 ,9 ,12, 18 and 21 months after the intervention Outcomes that could not be reanalysed and therefore not included in this review: Compliance rates

Notes

The study ignored secular (trend) changes and performed a simple t-test of the preversus post-intervention periods. Data were extracted from graph and reanalysed by reviewers

Risk of bias Bias



Intervention independent of other changes Low risk

See p.104, Col 1, Para 3 Quote: “Except for the institution of the study protocol, all conditions of care and use of the TDC were the same for the control and study periods”






Routine 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


The primary outcome (CLABSI rate) was objective and based on a standard definition


51

Beathard 2003

(Continued)


Unclear risk

No information in the text


Unclear risk


Ching 1990 Methods

Study design: RCT Data collection: Three prevalence surveys, 10 days apart, were conducted to assess patient-care practices for urinary catheter care in all 27 wards. Five weeks after the education programme, two more prevalence surveys were conducted. These surveys were unannounced and were conducted 10 days apart Definitions: Incorrect urinary catheter practices were defined by three factors: improper securing of catheters, the presence of kinking of catheters and the use of urine bags without a drainage spigot Type of catheters: Indwelling urinary catheters Targeted behaviour: Improve procedures (decrease incorrect practices for urinary catheter care)

Participants

Providers: n = 939 nurses; Intervention group: n = 838 nurses (28%) from 24 wards; Control group:n = 101 nurses (29%) from 3 wards Rank: Student nurses: Intervention: n = 239; Control: n = 31 Registered nurses: Intervention: n = 462; Control: n = 56 Enrolled nurses: Intervention: n = 34; Control: n = 6 Officers: Intervention: n = 103; Control: n = 8 Gender: number male/female. Intervention: n = 90/748; Control: 14/87 Years postgraduate: 0 (students): Intervention: n = 239; Control: n = 31 1 to 7 years: Intervention: n = 433; Control: n = 48 8 to 14 years: Intervention: n = 129; Control: n = 15 >14 years: Intervention: n = 37; Control: n = 7 The nurses in the intervention and control groups were similar with respect to gender, number of years postgraduate and rank The number of nurses (%) who attended the in-service lecture: Intervention: 238 (28); Control: 29 (29) Patients: Unknown number of in-patients; no patient characteristics provided Setting: 27 public wards in a 1000 bed university teaching hospital Country: Hong Kong

Interventions

Infection-associated invasive medical device addressed by intervention: Indwelling urinary catheter Evidence base of recommendation: Guideline for urinary catheter care was drafted by the infection control team, and adapted from guidelines by Wong and Hooton 1981 and Kurun 1987 Clinical practice guideline:


52

Ching 1990

(Continued)

• Urinary catheter is to be properly secured • Urinary catheter and collection tube must be kept from kinking • The urine bags are to be emptied by the draining spigot into a collecting container Before introducing the new guideline, the usual practice was to use urine bags with no draining spigot and the bag was changed daily. There was no official guideline or urinary catheter care in the hospital before the intervention Type of intervention: Professional intervention Format: Interpersonal Description of intervention: 1-Knowledge translation activities The nursing administration of the hospital selected the infection control liaison nurse for the education programme. In consultation with their nursing officers, a nursing officer II was appointed as the infection control liaison nurse for each of the 24 wards in the test group, and a registered nurse was appointed as the assistant. The new guideline was presented and controversial points were discussed 2-Educational intervention: Intervention group: All infection control liaison nurse and their assistants were requested to attend a 3-hour training session by the infection control team. The infection control liaison nurse and their assistants were released from normal duties for half a day to conduct demonstration tutorials for all nurses in their wards. The format of these tutorials was similar to the lecture, but they were conducted for small groups of six to 10 nurses within their own ward area. All nurses in the ward were required to attend. Their attendance was recorded and submitted to the infection control liaison nurse. A 30-minute lecture on the new guideline was given by the nurse Control group : Also the control group received the 30-minute lecture on the new guideline given by the nurse Timing: a) Frequency and number of events: Two events (one that only the intervention group received) b) Duration of intervention: One 30 minutes lecture and a half day tutorial c) Period after the start of the intervention during which outcomes were reported: Five weeks Outcomes

Incorrect practices on urinary catheter care Outcomes that could not be reanalysed and therefore not included in this review: none

Notes Risk of bias Bias


Random sequence generation (selection Unclear risk bias)

Support for judgement It was not clear how the random draw was executed, and it was therefore unclear if the sequence generation was unpredictable Quote: “The control groups consisted of three


53

Ching 1990

(Continued)

wards (surgical, medical and gynaecology), selected by a random draw, and the remaining 24 wards were the test group” Allocation concealment (selection bias)

Unclear risk

Unclear if the concealment of allocation was adequate

Protection against contamination

Low risk

It is unlikely that the control group received the intervention

Baseline characteristics

Low risk

Baseline characteristics of health professionals were reported and did not differ between groups

Baseline outcomes measurements

Low risk

Incorrect practices were measured prior to the intervention and no significant differences were found between intervention and control group

Blinding of outcome assessment (detection Unclear risk bias) All outcomes

It 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


Low risk

There 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


Low risk

There was no evidence of selective reporting, since results for all outcomes listed in the methods section were presented

Other bias

High risk

The analysis did not allow for clustering


54

Cocanour 2006 Methods

Study design: ITS Data collection: The Infection Control Practitioner reviewed the patients charts, cultures, and radiology results several times per week and monitored the patients for development of nosocomial infections Definition of VAP: Based on the NNIS definition Type of ventilators/respiratory equipment: Not specified in the paper Targeted behaviour: Improve procedures (appropriate management of mechanically ventilated patients to prevent VAP)

Participants

Providers: ICU team (unclear number of PGY-2 and PGY-1 surgery residents, PGY-3 and PGY-1 anaesthesia residents, surgical and anaesthesia critical care fellows and a critical care board certified surgeon or anaesthesiologist attending); no provider characteristics reported Patients: Unclear number of (primarily) trauma patients on mechanical ventilator (approximately 10% to 15% were general surgery and other surgical subspecialty patients) . Cardiovascular, neurosurgery, burn, and transplant patients were not admitted to this unit; no patient characteristics reported Setting: 20 beds shock trauma ICU at a 690 bed tertiary university affiliated Texas hospital Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: Mechanical ventilator Evidence base of recommendation: The intervention was based on CDC guidelines for prevention of nosocomial pneumonia Clinical practice guideline: The ventilator bundle incorporated the CDC Guidelines for Prevention of Nosocomial pneumonia and included • Head of bed elevation • Peptic ulcer prophylaxis • Endotracheal tube suctioning • Handwashing • Getting the patient out of bed • Oral care • Glove and nonpermeable apron use • Use of sleeved Yankauers • Changing nasogastric irrigation fluids daily • Chlorhexidine baths twice weekly • Strict glucose control Type of intervention: Professional intervention Format: Unclear, defined only as a performance improvement project Description of intervention: 1-Knowledge translation activities The STICU Infection Control Guidelines were published and made available to the STICU faculty and staff. A core group of leaders in the hospital and shock trauma ICU was assembled that included the hospital’s director of performance improvement, the short term ICU medical director, the infection control practitioner assigned to the shock trauma ICU, the shock trauma ICU Pharmacist, the shock trauma ICU respiratory supervisor, the shock trauma ICU nursing director, shock trauma ICU nurse manager,


55

Cocanour 2006

(Continued)

and senior nursing leaders from both the day and night shift, who were all involved with either or both of the improvement projects 2-Educational intervention: No information 3-Feedback on infection rate Data on shock trauma ICU infection rate was reported to the shock trauma ICU personnel, shock trauma ICU attendings, and the hospital’s performance improvement committee and Infection Control Committee on a monthly basis Timing: a) Frequency and number of events: Not specified b) Duration of intervention: June 2002 to September 2002 (4 months) c) Period after the intervention during which outcomes were measured: 4 months Outcomes

• VAP rate three months after the intervention Outcomes that could not be reanalysed and therefore not included in this review: VAP rate after the second intervention (audit and feedback on the VAP bundle); compliance rates, total cost of shock trauma ICU and the patients’ costs

Notes

The study ignored secular (trend) changes and performed a simple t-test of the preversus post-intervention periods Data were extracted from graph and reanalysed by reviewer

Risk of bias Bias



Intervention independent of other changes High risk

See p.123, Col 1, Para 3 Quote: “In addition to the ventilator bundle implementation, tight glucose control was a separate performance improvement project” This project started in March 2002, during the baseline period for the VAP bundle intervention. Two separate improvement projects (not further described) took place at the time of the intervention, and the ventilator bundle was part of one of them


Allthough 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




56

Cocanour 2006

(Continued)


Routine collection of objective outcome data: Infection Control Practitioner reviewed their charts, cultures, and radiology results several times per week


The primary outcome (VAP rate) was objective and based on a standard definition


Unclear risk



Low risk


Other bias

High risk

Risk of performance bias due to a decreased turnover of shock trauma ICU registered nurses and utilisation of agency nurses during the intervention

Coopersmith 2002 Methods

Study design: ITS Data collection: All patients admitted to the ICU were followed prospectively for CLABSIs by an infection control team Definition of CLABSIs: CLABSIs were classified as primary or secondary based upon CDC NNIS definition. Primary bloodstream infection (bacteraemia) was defined as 1) recognised pathogen isolated from blood culture not related to infection at another site or 2) fever 38.5°C, chills or hypotension, and either of the following: a) common skin contaminant isolated from two blood cultures drawn on separate occasions, within 24 hrs, unrelated to infection at another site, or b) common skin contaminant isolated from a blood culture from a patient with an intravascular device and the physician institutes appropriate antimicrobial therapy. Secondary bacteraemia was defined as bloodstream infection, which develops as a result of a documented infection with the same microorganism at another body site Catheters used: A small number (estimated to be between 1% and 2%) of Chlorhexidine and Silver sulphadiazine-impregnated catheters were inserted when patients were clinically judged to need four CVC lumens for access purposes. Quadruple-lumen,antibiotic-impregnated catheters were used in both the pre- and post-intervention time periods, but their accessibility was specifically limited after the implementation of the education module. Peripherally inserted central lines were excluded from analysis Targeted behaviour: improve procedures (CVC insertion and care to decrease the rate of primary CLABSIs)

Participants

Providers: 52 healthcare professionals (49 nurses, 1 attending physician, and 2 critical care fellows); no characteristics of healthcare professionals provided


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Coopersmith 2002

(Continued)

Patients: All patients (4283) admitted to the ICU; pre-intervention period: 2188 patients; Post-intervention period: 2095 patients Age: not reported Gender: Percentage females; Pre-intervention: 40.2; Post-intervention: 44.7 APACHE score: not reported Ventilated patients, month: Pre-intervention: 68.3; Post-intervention: 66.3 Length of mechanical ventilation, days: Pre-intervention: 2.5; Post-intervention: 2.8 Patient characteristics were similar during both time periods Setting: One 18 bed surgical/burn/traumaI ICU at an urban teaching hospital; Patient census, month: Pre-intervention: 121.6; Post-intervention: 115.6 Occupancy, %: Pre-intervention: 85.8; Post-intervention: 83.7 Length of stay, days 3: Pre-intervention: 3.7; Post-intervention: 4.0 CVCs placed, month Pre-intervention: 40.2; Post-intervention: 40.4 Country: USA Targeted behaviour: improved CVC insertion and care Interventions

Infection-associated invasive medical device addressed by intervention: Central line catheters Evidence base of recommendation: Based on local policy and CDC guideline The clinical practice guideline addressed: • Handwashing and aseptic technique • Methods for detecting potential clinical signs and symptoms of local infection • Technique for sending catheter-tip culture • Routine catheter site care • Replacing administration sets and fluids • Cleaning and changing injection ports and luer-lock caps • How to handle parenteral fluids and multidose vials, and procedure for drawing blood cultures The guideline for catheter maintenance included: • Changing injection caps and intravenous tubing for fluids and medications every 72 hrs (or immediately if blood accumulated in or around the cap or its integrity was compromised) • Changing transparent line dressings every 7 days • Changing gauze dressings every 48 hrs • Immediate replacement of dressings that were either soiled or no longer occlusive Type of intervention: Format: Paper, interpersonal, Description of intervention: 1-Knowledge translation activities a. A multidisciplinary task force (a physician and infection control practitioners) compared hospital policy with CDC recommendations on insertion and care of CVCs b. Registered nurses in the ICU completed a 17-question survey about their own CVC care practice, and filled out a 13-question observation survey documenting physician practice they witnessed during CVC insertion c. Based upon this information, the task force designed an education module to improve practices related to CVC insertion and care 2-Educational intervention a. The educational programme consisted of a 10-page self study module on risk factors and practice modifications involved in catheter-related infections as well as a verbal in-


58

Coopersmith 2002

(Continued)

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

Notes

The study ignored secular (trend) changes and performed a simple t-test of the preversus post-intervention periods. Data were extracted from graph and reanalysed by reviewers

Risk of bias Bias










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Coopersmith 2002

(Continued)


Routine 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




Unclear risk



Unclear risk


Other bias

High risk

Different type of catheters were used before (antimicrobic coated) and after the intervention (not coated)

Kaye 2000 Methods

Study design: ITS Data collection: Not reported Definition of VAP: Pneumonia was defined in accordance with NNIS Manual criteria. The patient must have rales or dullness to percussion or a chest radiograph with new or progressive infiltrates, consolidation, cavitation, or pleural effusion. Further, the patient must meet at least one of the following requirements: new onset of purulent sputum or change in character of sputum; organisms collected from blood cultures; isolated pathogen from transtracheal aspirate, bronchial brushing, or biopsy; isolation of virus or detection of viral antigen in respiratory secretions; or histopathologic findings of pneumonia. Nosocomial pneumonia was determined to be VAP if onset of infection was within 48 hours of ventilator use Type of ventilator/respiratory equipment: Not described Targeted behaviour: Improve procedures (changes of all aspect of care of patient requiring mechanical ventilation)

Participants

Providers: Unclear number of nurses, respiratory therapists, and other medical staff; no provider characteristics provided Patients: Unclear number of patients requiring mechanical ventilation; no patient characteristics provided Setting: 4 medical-surgical ICUs at a university hospital; unclear no of beds Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: mechanical ventilator Evidence base of intervention: guideline development based on literature review The Clinical practice guideline included:


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Kaye 2000

(Continued)

• 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

Notes

The study has ignored secular (trend) changes and performed a simple t-test of the preversus post-intervention periods. Data extracted from graph and reanalysed by reviewers


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Kaye 2000

(Continued)

Risk of bias Bias









Intervention unlikely to affect data collec- High risk tion

No 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




Unclear risk



Low risk

All relevant outcomes in the methods section are reported in the result section

Miller 2010 Methods

Study design: ITS Data collection: PICU teams monthly collected and submitted the data Definition of CLABSI: Based on the CDCs criteria used for CLABSI Type of catheters: Polyurethane or Teflon CVC catheters Targeted behaviour: Improve procedures (appropriate insertion and management of central line catheters)

Participants

Providers: Unclear number and type of health care professionals; no provider characteristics reported Patients: Unclear number of patients with a CLABSI; no patient characteristics reported


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Miller 2010

(Continued)

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

Infection-associated invasive medical device addressed by intervention: Central line catheters Evidence base of recommendation: 1. The insertion bundle: Included evidence based procedures recommended by the CDC that have been proven to be effective in adult patients or in a single institutional PICU 2. The maintenance bundle: Created by using some of the pertinent CDC guidelines; however, consensus of mostly expert paediatric physicians and nurses were involved in the development of this effort Clinical practice guideline: Insertion bundle: • Wash hands before the procedure • For all children aged 2 months, Chlorhexidine gluconate should be used to scrub the insertion site for 30 seconds for all areas except the groin, which should be scrubbed for 2 minutes. Scrubbing should be followed by 30 to 60 seconds of air drying • No iodine skin prep or ointment should be used at the insertion site • Prepackage or fill the insertion cart, tray, or box including full sterile barriers • Create an insertion checklist, which empowers staff to stop a non-emergent procedure if it does not follow sterile insertion practices • Use only polyurethane or Teflon catheters • Conduct insertion training for all care providers, including slides and videos Maintenance bundle: • Assess daily whether catheter is needed • Catheter-site care: iodine ointment should not be used; use a Chlorhexidine gluconate scrub to sites for dressing changes (30-seconds scrub, 30-seconds air-dry) • Change gauze dressing every 2 days unless they are soiled, dampened, or loosened • Change clear dressings every 7 days unless they are soiled, dampened, or loosened • Use a prepackaged dressing-change kit or supply area • Catheter hub, cap, and tubing care: replace administration sets, including add-on devices, no more frequently than every 72 hours unless they are soiled or suspected to be infected • Replace tubing that is used to administer blood, blood products, or lipids within 24 hours of initiating infusion • Change caps no more often than every 72 hour (or according to manufacturer recommendations); however, caps should be replaced when the administration set is changed • The prepackaged cap-change kit, or supply area elements to be designated by the local institution Type of intervention: Professional intervention Format: Computer, interpersonal 1. Knowledge translation activities


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Miller 2010

(Continued)

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

Notes

The 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 Bias










Routine collection of objective outcome data: The number of CLABSI cases and the monthly total of central line days per PICU were collected by trained, hospitalbased, infection control practitioners in accordance with CDC definitions


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Miller 2010

(Continued)




Low risk

The effects of the missing data, 2 sensitivity analyses models by imputing data for each missing data point were ran


Unclear risk


Parra 2010 Methods

Study design: ITS Data collection: A designated nurse in each ICU recorded and reported monthly to a Committee for Infection Control and Antibiotics Policy member the numbers of confirmed episodes of CLABSI and CVC-days Definition of CLABSI: Infectious Diseases Society of America and CDC criteria was used to define CLABSI. A CLABSI was considered to be ICU-related if it occurred at least 48 hours after admission to or up to 48 hours after discharge from the ICU Type of catheters: Not described in the paper Targeted behaviour: Improve procedures (care provided to patients with central line catheters to prevent CLABSI)

Participants

Providers: Healthcare workers (n = 155): n = 125 nurses (including 22 students) and n = 30 physicians (including 10 residents); no characteristics of health professionals provided Patients: Unclear number of patients with a central line catheter who developed CLABSI; no patient characteristics reported Setting: 3 adult ICUs (medical, general post-surgery, and cardiac post-surgery; 60 beds in total) at a university hospital Country: Spain

Interventions

Infection-associated invasive medical device addressed by intervention: Central line catheters Evidence base of recommendation: Based on guidelines for the prevention of intravascular catheter-related infection from Infectious Diseases Society of America CDC: Clinical practice guideline: • Use of a full sterile sheet when preparing the CVC insertion site • Choose the subclavian vein as the preferred site of insertion • Use closed needleless catheter connection systems • Desinfect of clean skin with 2% Chlorhexidine gluconate solution before CVC insertion CVC site dressing regimens • Aseptic technique during CVC care and maintenance (handwashing and use of gloves) • Optimal frequency of CVC dressing replacement • Use of parenteral nutrition through a multilumen CVC


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Parra 2010

(Continued)

Management of suspected CLABSI (change avoiding guide wire technique) Replacement of administration sets,needleless systems, and parenteral fluids Type of intervention: Professional intervention Format: Interpersonal, paper Description of intervention: 1-Knowledge translation activities: Not reported 2-Educational intervention: A short lecture (15 minutes) on 10 main points of the IDSA-CDC guidelines for the prevention of intravascular catheter-related infections was given to all ICU workers (physicians, residents, nurses, and students) on all shifts. The lecture was preceded (a few minutes before) and followed (6 months after) by identical multiple-choice questionnaires to assess healthcare worker knowledge of the 10 selected points. Each test took an average of 15 to 20 minutes to complete Timing: a) Frequency and number of events: One b) Duration of intervention: 15 minutes c) Period after the start of the intervention during which outcomes were reported: 26 months Outcomes

CLABSI rate at 3, 6, 9, 12, 18 and 24 months after the start of the intervention Outcomes that could not be reanalysed and therefore not included in this review: none

Notes

The study ignored secular (trend) changes and performed a simple t-test of the preversus post-intervention periods. Data were extracted from graphs and reanalysed by reviewers

Risk of bias Bias




See p.964, Col 2, Para 3 Quote: “No other interventions potentially affecting the incidence of CLABSI were performed: there were no changes in hospital policy on prevention of CLABSI or in the availability of supplies used (type of central venous catheter [CVC], connectors,antiseptics, or other supplies used in CVC insertion and care). No changes in CLABSI diagnosis procedures were introduced in the microbiology laboratory. The staff members responsible for data collection did not change during the study period”


Although 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


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Parra 2010

(Continued)

review authors the risk of bias was low Appropriate analysis (secular trends taken Low risk into account)



Routine collection of data: The staff members responsible for data collection did not change during the study period




Unclear risk

Not stated in the paper


Unclear risk


Salahuddin 2004 Methods

Study design: ITS Data collection: Infection control nurses collected and reported VAP rate Definitions: VAP was defined using the CDC criteria of: new or progressive chest radiographic infiltrates persisting for 72 hours and two or more of the following: temperature > 38.8 C or < 35.5 C, leucocytosis > 10 X 109 /L or < 3 X 109 /L, positive endotracheal secretion culture (> 104 cfu/mL) Type of ventilators/respiratory equipment:Not described Targeted behaviour: I mprove procedures (appropriate management of mechanically ventilated patients to prevent VAPs)

Participants

Providers: Certified intensives, anaesthetist and clinical, resident house staff, critical care nurses and technicians; provider characteristics not reported Patients: Patients on continuous mechanical ventilation for > 48 hours (n = 677); Pre-intervention period: n = 333 patients; Post-Intervention period: n = 344 patients Medicine patients: Pre-intervention period: 212 (64%); Post-intervention period: 247 (72%) Surgical patients: Pre-intervention period: 121 (36%); Post-intervention period: 97 (28%) Most common diagnosis: Sepsis: Pre-intervention period: 52 (16%); Post-intervention period: 64 (19%), P = 0. 302 Pneumonia: Pre-intervention period: 33 (10%); Post-intervention period: 28 (8%), P = 0.421 Neurosurgical: Pre-intervention period: 24 (7%); Post-intervention period: 24 (7%), P = 0.907


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Salahuddin 2004

(Continued)

COPD: Pre-intervention period: 20 (6%); Post-intervention period: 22 (6%), P = 0.834 Quarterly ventilator day: Pre-intervention period: 789 (731 to 832); Post-intervention period: 728 (711 to 739), P = 0.061 non-invasive positive pressure ventilation: Pre-intervention period: 42 (13%); Post-intervention period: 53 (15%), P = 0.295 Setting: One 10 bed Medical and Surgical ICU at a 495 bed, primary and tertiary care teaching hospital Country: Pakistan Interventions

Infection-associated invasive medical device addressed by intervention: Mechanical ventilator Evidence base of recommendation: Two physicians and the ICU head nurse reviewed the results of a literature search of articles on prevention of VAP. A preventive practice guideline was devised based on this search Clinical practice guideline: • Handwashing between all patient contacts on entering and exiting the ICU • Protective gown and glove use for specific groups of patients as recommended by the CDC and Prevention guidelines • Place mechanically ventilated patients in a semirecumbent position by maintaining the head of the bed at approximately • Avoid gastric over-distension; monitor gastric residual volumes before administering scheduled enteral feedings (maximum gastric residual 150 to 200 mL) • Use non-invasive positive pressure ventilation to avoid endotracheal intubation • Use non-invasive positive pressure ventilation to facilitate early extubation, to minimise the duration of endotracheal intubation • Use orogastric tubes whenever possible; as nasogastric tubes may increase the incidence of nosocomial sinusitis • Provide adequate sedation to avoid accidental extubation; sedation score scale maintained between 3 to 5 • Prevent accidental extubation by securing the endotracheal tube at the bedside and using soft restraints according to hospital policy; whenever necessary to avoid selfextubation • 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:


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Salahuddin 2004

(Continued)

12 months Outcomes

VAP rates at 3, 6 and 9 months after start of the intervention Outcomes that could not be reanalysed and therefore not included in this review: none

Notes

The study ignored secular (trend) changes and performed a simple t-test of the preversus post-intervention periods. Data extracted from graphs and reanalysed by reviewers

Risk of bias Bias



Random sequence generation (selection Low risk bias) Allocation concealment (selection bias)

Low risk








Routine collection of data: The hospital infection control team regularly surveyed all ICU patients for occurrence of VAP




Unclear risk

Not reported in the text


Unclear risk



69

Salahuddin 2004

Other bias

(Continued)

Unclear risk

The comparatively larger proportion medicine patients, and lower number of surgical patients (not tested for statistical significance) in the post-intervention group, may have biased the results

Sannoh 2010 Methods

Study design: ITS Data collection: Infection control nurse did the surveillance of the CVC infection using standard definitions Definition of CLABSI: A positive blood culture with a catheter in situ for at least 48 hours without any other source of infection Type of catheters: umbilical artery catheters, (VYGON Corporation,Montgomeryville, PA) and umbilical vein catheters had a stop cork (Smith Medical MD, Inc,St. Paul, MN) , with either a Luer Lock and an attached syringe for blood draws (Becton Dickinson, Franklin Lakes, New Jersey) or a Smartsite needless connector (Alaris,CareFusion, San Diego, California) for continuous or intermittent infusions, and peripherally inserted CVC catheters No of catheters: Pre-intervention period: 36 Broviac catheters, 76 PICCs, 60 umbilical artery catheters and umbilical vein catheters, and 70 umbilical vein catheters;; Post-intervention period: 41 Broviac catheters, 93 peripherally inserted CVC catheters, 77 umbilical artery catheters and umbilical vein catheters, and 97 umbilical vein catheters Targeted behaviour: Improve procedures (appropriate management of neonates with CVC to reduce CLABSI)

Participants

Providers: Nurses; about 90% of the neonatal ICU nurses; no characteristics of healthcare professionals provided; CVC insertion and maintenance are performed primarily by nurses Patients: Neonates with a CVC in place for more than 24 hours; n = 373; Pre-intervention period: n = 163; Post-intervention period: n = 210; patient demographic and clinical characteristics were similar in the two periods Birth weight, g: Pre-intervention period: 1769 ± 1136; 1275 [499 to 5418]; Post-intervention period: 1751 ± 1079; 1365 [305 to 4495] Birth weight, 1000 g: pre-intervention period: 40% (65); Post-intervention period: 38% (79) Gestational age, weeks: pre-intervention period: 31 ± 5; 29 [23 to 42]; Post-intervention period: 31 ± 6; 30 [21 to 41] Female sex: Pre-intervention period: 46% (75); Post-intervention period: 46% (96) Ventilator-days: Pre-intervention period: 14 ± 19; 6 [1 to 113]: Post-intervention period: 16 ± 21; 6 [1 to 164] Length of stay, days: Pre-intervention period: Time 1: 46 days; Time 2: 6 days; Time 3: 38 days; Mean 37 (range 1 to 194 days); Post-intervention period: Time 1:43 days; Time 2: 6 days; Time 3: 38 days; Mean: 30 days, (range 2 to 273 days) Mortality : Pre-intervention period: 13% (22); Post-intervention period: 15% (31) Country: USA Setting: 50-bed regional neonatal intensive care referral unit


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Sannoh 2010

(Continued)

Interventions

Infection-associated invasive medical device addressed by intervention: central line catheters Evidence base of recommendation: based on CDC recommendations Clinical practice guideline: Catheter hub care policy and new catheter dressing policy: • During catheter hub access, the surface area of the needleless port and the outer surface of the stop cork or Luer-lock threads of the catheter hub must be scrubbed in a circular motion with friction using 2% Chlorhexidine in 70% isopropyl alcohol for 10 seconds and allowed to dry for 30 seconds • It is mandatory: standard hand hygiene, the use of clean gloves and the establishment of sterile fields with 4” 3 4” gauze under the catheter port and the syringes used to access the hub with medications and flushing solution • Change dressings only when soiled, instead of routine weekly changes Type of intervention: Professional intervention Format: Interpersonal, audio-visual, paper Description of intervention: 1. Knowledge translation activities Not reported 2. Educational intervention 1. One month of in-service was provided to the health care team in multiple sessions. Each session consisted of a 15-minute DVD demonstrating the 9 steps of catheter hub care to the health care team in small groups 2. The DVD was available on the neonatal ICU Web site for the health care team to view at any time 3 Reminders:Catheter hub care checklists were placed at every bedside 4. CVC care cart: Placed in each room to facilitate ready access to cleaning materials 5. Hand hygiene campaigns: Implemented throughout the study period Timing: a) Frequency and number of events: In-service consisting of one 15-minute DVD session b) Duration of intervention: One month c) Period after the start of the intervention during which outcomes were reported: 12 months for CLABSI and device utilisation rates

Outcomes

• CLABSI rate at 3, 6, 9 and 12 months after the start of the intervention • Device utilisation rate at 3, 6, 9 and 12 months after the start of the intervention Outcomes that could not be reanalysed and therefore not included in this review: • CLABSI rate by catheter type and birth weight category • adherence score • cost savings secondary to the decrease in CLABSI

Notes

The study ignored secular (trend) changes and performed a simple t-test of the preversus post-intervention periods. Data extracted from graphic and reanalysed by reviewers

Risk of bias Bias




71

Sannoh 2010

(Continued)


See p.425, Col 2, Para 2 Quote: “Hand hygiene campaigns that had been implemented were reinforced throughout the study period”






Routine collection of data: Surveillance for CVC infection was done by an infection control nurse, using standard definitions




Unclear risk

Not specified in the text


Unclear risk


Other bias

Low risk

No 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)


72

Sona 2009 Methods

Study design: ITS Data collection: All patients admitted to the ICUs were prospectively surveyed for the occurrence of VAP by members of the Hospital Infection Control Team Definition of VAP: Based on NNIS criteria Type of ventilators: Not described Targeted behaviour: Improve procedures (oral care of patients with mechanical ventilator to reduce VAP)

Participants

Providers: Attending and fellow medical staffs and incoming residents (unclear number); 80-member registered nursing staff; no characteristics of healthcare professionals provided Patients: All patients admitted to the surgical ICU that required mechanical ventilation n = 1648; Pre-intervention period: n= 777; Post-intervention period n = 871 patients Age (years): Pre-intervention: 56.2 (17 to 95); Post-intervention: 57.1 (14 to 99), P = 0. 58 Ventilator days: Pre-intervention: 4606; Post-intervention: 4158, P < 0.001 Ventilator days per patient: Pre-intervention: 5.9 4.8, P < .01 APACHE II score: Pre-intervention: 17.7 (2 to 41); Post-intervention: 18.1 (3 to 48), P = 0.36 ICU length of stay (days): Pre-intervention: 8.9 (0.3 to 70.4); Post-intervention: 9.8 (. 02 to 62.1), P = 0.15 Hospital length of stay of patients (days): Pre-intervention: 26.4 (1 to 144); Post-intervention: 23.5 (1 to 193), P = 0.09 Setting: One 24-bed surgical ICU in 1344-bed tertiary care, university-affiliated teaching hospital (surgical ICU admits all non-cardiothoracic and non-neurosurgical critical care surgical and trauma patients in the hospital) Unit admissions: Pre-intervention period: n = 1520; Post-intervention period:n = 1747 Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: Mechanical ventilator Evidence base of recommendation: The hospital policy was based on literature reviews of evidence Clinical practice guideline: • Mechanical cleaning of the teeth or gums to remove plaque and application of an oral antimicrobial • Brush teeth for 1 to 2 minutes using floor stock brush and paste containing the active ingredient sodium mono fluoro phosphate 0.7% every 12 hours • Rinse the mouth with tap water with an irrigating syringe and suction with an oral suction handle • For patients without teeth, clean the gums with toothpaste on a foam sponge, and then rinse with water and suction as above • Immediately following water rinse, apply 15 mL of Chlorohexidine to all oral surfaces using a foam sponge, suction all excess solution from the mouth • No further oral swabbing or liquids are allowed for 30 minutes after the procedure. Document the full oral care protocol every 12 hours on the medication administration record Type of intervention: Professional intervention Format: Interpersonal, paper,


73

Sona 2009

(Continued)

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, biweekly reviews of compliance b) Duration of intervention: Not clear c) Period after the start of the intervention during which outcomes were reported: 12 months Outcomes

VAP rate (and cost) at 3, 6 and 12 months after start of intervention (reanalysed by reviewers) Outcomes that could not be reanalysed and therefore not included in this review: protocol compliance, organism profile

Notes

The study ignored secular (trend) changes and performed a simple t-test of the preversus post-intervention periods and therefore the data were extracted from graphs and reanalysed by reviewers

Risk of bias Bias



Support for judgement See p.56, Col 1, Para 3 Quote: “The previously implemented interventions to reduce VAP were maintained in the same fashion as they had been done in the


74

Sona 2009

(Continued)

previous 5 years. No other interventions or studies were implemented between study periods” Shape of the intervention effects pre-spec- Low risk ified





Routine 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




Low risk


Unclear risk


Other bias

Unclear risk

Few patient characteristics were reported, and it is unclear if the pre- and post-intervention group are comparable


75

Warren 2004 Methods

Study design: ITS Data collection: Data were prospectively recorded by one of the investigators Definition of CLABSI: CLABSI was defined as primary bacteraemia in the presence of a CVC. Secondary bacteraemia was defined as bloodstream infection that develops as a result of a documented infection with the same microorganism at another body site (CDC definition) Type of catheters: The intravascular catheters (e.g., CVCs, dialysis catheters, pulmonary artery catheters) employed throughout the hospital during this study period were standard catheters without antimicrobial or antiseptic coatings. Arterial catheters were not surveyed as part of this investigation Targeted behaviour: Improve procedures (care of patients with CVC to reduce CLABSI)

Participants

Providers: Unclear number of nurses and physicians; no provider characteristics presented Patients: All patients admitted to the medical ICU with CVC (unclear number of patients); no patient characteristics provided Country: USA Setting: One medical 19-bed ICU at a university affiliated urban teaching hospital

Interventions

Infection-associated invasive medical device addressed by intervention: Central line catheters Evidence base of intervention: ICU infection control committee revised the policies and procedures for CVC insertion and site maintenance Clinical practice guideline: • Wash hands thoroughly or use an alcohol-based waterless disinfectant before and after patient contact • DIsinfect hands and wear sterile gloves when touching or changing the dressing on the catheter • Femoral catheters should be avoided • When placed in an emergency situation, the femoral catheter should be discontinued as soon as feasible • The person placing the catheter must wear sterile gown, sterile gloves, a mask, and a cap • Excessive hair around insertion site can be removed with scissors or clippers only • The insertion site and an area of at least 15 cm in diameter around the site shall be cleared with the appropriate skin antiseptic • Drape the insertion site using full sterile drape • Use sterile technique to apply transparent dressing to insertion site • Do not apply antimicrobial ointment to the insertion site unless the CVC is a dialysis catheter • Avoid changing catheters over a guide wire • Change transparent membrane dressing no more than every 7 d or when dressing becomes damp, loosened, or soiled • Follow hospital protocol for changing IV fluid administration sets and cleaning of injection ports with appropriate antiseptic prior to accessing Type of intervention: Professional intervention Format: Interpersonal, paper, computer Description of intervention: 1. Knowledge translation activities


76

Warren 2004

(Continued)

Monthly meetings of ICU infection control were held to educate the leadership of the unit on the problem of catheter-associated bloodstream infection; to review in detail the optimal practices for catheter insertion and maintenance in the unit, to describe the components of the education programme and their local implementation; to foster team building; to develop a strategy for the education of resident and attending physicians, and to have a feedback mechanism for potential problems encountered during the implementation phase of the study. Additional meetings were held by members of the ICU infection control committee to revise the policies and procedures for CVC insertion and site maintenance 2. Educational intervention The educational programme included: a self-study module on risk factors and practice modifications involved in CLABSI; a 45 min lecture; posters, and fact sheets were distributed at each patient computer terminal located directly outside the patient room 3. Reminders Fact sheets, and posters were displayed throughout the ICU describing the programme, and photographic guidelines were available at each bedside computer station illustrating the correct procedure for the insertion of CVCs and their subsequent maintenance to included dressing of the insertion site 4. Promotional campaign Regular administration of lapel buttons to a staff member promoting the education programme was launched 5. Feedback: Monthly up-date of the CLABSI rates was posted in the ICU in multiple locations Timing: a) Frequency and number of events: Not reported b) Duration of intervention: Not clear c) Period after the start of the intervention during which outcomes were reported: 24 months Outcomes

CLABSI rate at 3, 6, 9,12, 18 and 21 months after the start of the intervention (reanalysed by review authors) Outcomes that could not be reanalysed and therefore not included in this review: Costs

Notes


Risk of bias Bias



Support for judgement See p.1613, Col 1, Para 4 Quote: “Patient-care policies and protocols in the medical ICUs remained unchanged during the study period except for the prevention of ventilator-associated pneumonia. A new policy for the prevention of ventilator-associated pneumonia was introduced in Octo-


77

Warren 2004

(Continued)

ber 2000 and maintained throughout the duration of the study” Shape of the intervention effects pre-spec- Low risk ified





Routine 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




Unclear risk



Unclear risk


Other bias

Low risk

No evidence of other risk of bias. The patients in the pre- and post-intervention groups were comparable


78

Zack 2002 Methods

Study design: ITS Data collection: All patients admitted to the ICUs were prospectively surveyed for the occurrence of VAP by members of the Hospital Infection Control Team Definition of VAP: VAP was defined by the occurrence of a new and persistent radiographic infiltrate in conjunction with one of the following: positive pleural/blood cultures for the same organism as that recovered in the tracheal aspirate or sputum; radiographic cavitation; histopathological evidence of pneumonia; or two of the following: fever, leukocytosis, and purulent tracheal aspirate or sputum. Persistence of an infiltrate was defined as having the infiltrate present radio graphically for 72 hrs. Fever was defined as an increase in the core temperature of 1°C or higher and a core temperature 38. 3°C. Leukocytosis was defined as a 25% increase in the circulating leukocytes from the baseline and a value 10x 109/L. Tracheal aspirates were considered purulent if abundant neutrophils were present per high-power field by using Gram’s stain (i.e.> 25 neutrophils per high-power field). VAP complicating community-acquired pneumonia was considered to be present if a new infiltrate developed 48 hrs after the start of mechanical ventilation and empirical antibiotic treatment for community-acquired pneumonia were also required to be stable or improving in their radiographic appearance for 48 hrs before the development of the new infiltrates Type of ventilator/respiratory equipment: Not described Targeted behaviour: Improve procedures (care of patients with mechanical ventilator to reduce VAP)

Participants

Providers: Respiratory care practitioners (n = 114) and ICU nurses (n = 146; 64.9%); no provider characteristics provided Patients: Unclear number of patients requiring mechanical ventilation and who developed VAP; no patient characteristics provided Setting: Five ICUs at a 1000-bed primary and tertiary care urban teaching hospital (medical: 19 beds, surgical/trauma/burns: 18 beds, medical/surgical: 12 beds, surgical cardiothoracic: 17 beds, neurology and neurosurgical: 20 beds) Country: USA

Interventions

Infection-associated invasive medical device addressed by intervention: Mechanical ventilator Evidence base of recommendation: The hospital policy was derived in large part from two literature reviews (authored by one of the task force members). The task force also compared the new hospital policy to the CDC recommendations for the prevention of VAP Clinical practice guideline: • Place mechanically ventilated patients in a semirecumbent position by maintaining the head of the bed at approximately 30° or greater above the horizontal plane as tolerated by the patient • Intubate the trachea orally whenever possible to minimize the risk of nosocomial sinusitis; avoid nasotracheal intubation because of the association between nosocomial sinusitis and VAP • Use oral-gastric tubes rather than nasogastric tubes; nasogastric tubes may increase the possibility of nosocomial sinusitis. • Extubate patients and remove orogastric tubes as soon as clinically indicated • Prevent accidental extubation; adequately secure the endotracheal tube to the patient and/or restrain the patient per hospital policy, if necessary, to prevent accidental


79

Zack 2002

(Continued)

self-extubation • Provide adequate sedation to prevent unexpected extubation • Avoid gastric overdistention; monitor gastric residual volumes before administering scheduled enteral feedings (gastric residual maximum 150 to 200 mL) • Provide oral hygiene at least once daily • Drain condensate from ventilator circuits regularly with gloved hands; open ventilator circuit and carefully drain condensate into an open container, being careful not to touch the circuit tip to the container; reconnect tubing carefully to avoid contamination; empty container contents into hopper immediately; do not empty fluid into the trash can or onto the floor • Use in-line valved t-adapters or holding chambers for aerosolized medication delivery • Use non-invasive mechanical ventilation via face mask when appropriate to minimize the need for tracheal intubation • Avoid overuse of antibiotics • Provide daily chlorhexidine oral rinse (only for patients undergoing cardiac surgery) • Provide immunisations for influenza and Streptococcus pneumonia Type of intervention: Professional intervention Format: Interpersonal, paper Description of intervention: 1. Knowledge translation activities A multidisciplinary task force designed an education module to improve practices related to the prevention of VAP 2. Educational intervention: Self study module, in-service education provided by one of the infection control personnel at scheduled meeting times, and for respiratory care practitioners two one hour lectures on the pathogenesis and prevention of VAP 3. Reminders: Four to six sheets and one poster taken directly from the study module were posted throughout the ICUsat the initiation of the intervention 4. Feedback: Monthly updates on the VAP rates with comparisons to the NNIS data from the CDC were presented at monthly ICUand respiratory care services staff meetings during both pre- and post-intervention periods Timing: a) Frequency and number of events: Educational module one month, in services at staff meeting, monthly updates on ICU VAP b) Duration of intervention: Unclear c) Period after the start of the intervention during which outcomes were reported: 12 months Outcomes

VAP rate at 3, 6, 9 and 12 months after start of the intervention (reanalysed by review authors) Outcomes that could not be reanalysed and therefore not included in this review: Cost saving

Notes



80

Zack 2002

(Continued)

Bias










Routine 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




Unclear risk



Unclear risk


Other bias

Unclear risk

It was unclear if the pre- and post-intervention groups were comparable

Abbreviations APACHE II score: acute physiology and chronic health evaluation score CDC: Centers for Disease Control and Prevention CLABSI: central line-associated bloodstream infection CVC: central venous catheter DVD: digital video disc ICU: intensive care unit ITS: interrupted time series NNIS: National Nosocomial Infections Surveillance system Interventions to improve professional adherence to guidelines for prevention of device-related infections (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

81

PGY: post-graduate year PICU: paediatric intensive care unit RCT: randomised controlled trial TDC: tunnelled dialysis catheter USA: United States of America VAP: ventilator-associated pneumonia

Characteristics of excluded studies [ordered by study ID]

Study

Reason for exclusion

Abramczyk 2011

Uncontrolled before-after study that could not be reanalysed as a time series study

Apisarnthanarak 2007

Controlled before-after study with two control groups but only one intervention group

Apisarnthanarak 2008

Uncontrolled before-after study with no proper baseline measurement

Babcock 2004


Barsuk 2009

Controlled before-after study with only one control group and one intervention group

Baxter 2005


Berenholtz 2004a


Berenholtz 2004b


Berg 1995


Berhe 2006


Bird 2010


Bizarro 2010


Björnestam 2000

Uncontrolled before-after study that could not be reanalysed as time series study

Bruminhent 2010


Brunelle 2003


Burns 2003


Camp 2009


Casey 2003

Case-control study


82

(Continued)

Castello 2011

Uncontrolled before-study that could not be reanalysed as a time series study

Cherry-Bukowiec 2011

The aim of the intervention was not to improve adherence with infection control guidelines

Chrdle 2012

Surveillance study with no proper baseline measurement

Christenson 2006


Cohen 1991


Cohran 1996


Collingnon 2007


Cools 1987


Coopersmith 2004

Uncontrolled before-after study that could not be reanalysed as a time series study. Study derived from Coopersmith 2002

Cornia 2003

No-randomised crossover study

Costello 2008


Crouzet 2007


Cruden 2000


Danchaivijitr 2005


Dawson 2011

Narrative review

Dinç 2000


Dries 2004


Du Bose 2008


Duane 2009


East 2005


Eggimann 2000


Espiau 2011


Esteve 2009



83

(Continued)

Fakih 2010


Frankel 2005


French 1989

Surveillance study

García-Rodicio 2009


Gaynes 2001

Surveillance study

Gnass 2004

Surveillance study

Goddard 2006

Surveillance study

Goetz 1999


Gokula 2007


Gowardman 2005


Gozu 2011


Grap 2003


Guerin 2010


Guner 2011

Inappropriately analysed time series study. No full-text and no graph which could have permitted reanalysis

Gunther 2009


Gurskis 2009


Gusarov 2009

Retrospective one site before-after study

Hansen 2006


Harnage 2007


Hatler 2006


Helman 2003


Hendrix 1998

Study that did not report the rates of nosocomial infections separately of other nosocomial events

Hiemenz 1986

Descriptive study


84

(Continued)

Higuera 2005


Holzmann-Pazgal 2012

Inappropriately analysed (one site) time series study. The graph provided does not permit reanalysis (i.e. it does not present the infection rate)

Hong 1990


Horbar 2006

Controlled before-after study with only one control group

Horvath 2009


Huang 2004


Hwang 2005


Jain 2006


Jeffreis 2009


Jonhson 2009


Kalra 2011

Knowledge the only outcome

Karada 2000


Kauffmann 2011

Inappropriately 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 2006


Kelleghan 1993


Kellie 2012


Khatib 1999


Kidd 2007

Qualitative study

Kilbride 2003

Descriptive study

Koff 2011


Kulvatunyou 2007


Lai 2003



85

(Continued)

Lally 1997


Laux 2006

Uncontrolled before-after study with no interpretable outcomes

Lobo 2005


Lobo 2010

Controlled before-after study with one control group

Lolom 2009


Lyerla 2010


Maas 1998

Uncontrolled before-after study with only one data point before the intervention

Marelich 2000

Intervention was not directed at health professionals

Marra 2009


Matocha 2011


Mazi 2011

Inappropriately analyses time series study. Protocol only. No full-text. No graphs which could have permitted reanalysis

Mckee 2008


Mckinley 2003

Intervention aimed to improve surveillance

McLean 2006


Meier 1998


Miller 2010a


Miranda 2007

Controlled clinical trial that reported the comparative data of self reported practice during catheter insertion

Misset 2004


Ngo 2005


Ong 2011


Orsi 2005


Parras 1994


Penne 2002



86

(Continued)

Peredo 2010

Uncontrolled before-after study with missing data points

Pethyoung 2005


Pronovost 2008


Pronovost 2010

Surveillance study derived from Provonost 2006

Puntis 1990


Pérez-González 2007


Reilly 2006


Rello 2011

Descriptive study

Rosenthal 2003


Rosenthal 2004


Rosenthal 2006a


Rosenthal 2008

Surveillance study

Saint 2005

Controlled before-after study with only one control and one intervention site

Sansivero 2011

The aim of the intervention was not to improve adherence with infection control guidelines

Santana 2008


Scales 2009

Protocol for a randomized trial

Scales 2011a

Overview paper

Seguin 2010


Seto 1991


Shapey 2009

Surveillance study

Sherertz 2000


Smith 2011

Retrospective chart review

Soifer 1998

Controlled clinical trial with no clear separation between the groups

Sutton 2005



87

(Continued)

Sydnor 2011

Overview paper

Timsit 2011

Review paper

Tolentino DelosReyes 2007


Topal 2005


Troeng 2011

Observational study. No full-text available. No graph which could have permitted reanalysis

Tsuchida 2007


Urrea Ayala 2009


Verdier 2006


Wall 2005


Warren 2003


Warren 2006


Weireter 2009


Westwell 2008


Williams 2008


Wirtschafter 2010


Worrall 2010


Xiao 2007

Not a randomized trial

Yoo 2001


Youngquist 2007


Zaydfudin 2009


Zingg 2009


Zuschneid 2003


Abbreviations CBA: controlled before-after Interventions to improve professional adherence to guidelines for prevention of device-related infections (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

88

CCT: clinical controlled trial RCT: randomised controlled trial

Characteristics of studies awaiting assessment [ordered by study ID] Chen 2011 Methods

ITS study

Participants

Hospitalised haematology-oncology patients with port A

Interventions

The 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

Outcomes

Haematology-oncology port-A related infections

Notes

One haematology-oncology clinic in Taiwan, abstract in English but full-text paper in Taiwanese

Danchaivijitr 1992 Methods

RCT

Participants

Patients assessed for need of urethral catheterisation

Interventions

Indication sheet

Outcomes

Rates of catheterisation; rates of catheterisation without proper indication

Notes

Thirteen hospitals in Thailand

Eid 2011 Methods

ITS study

Participants

Patients with tracheostomies

Interventions

Procedures to prevent ventilator-associated pneumonia and monitoring and educational sessions

Outcomes

Rate of pneumonia

Notes

Two step down units in one hospital


89

Kaplan 2011 Methods

ITS study

Participants

Infants born at 22 to 29 weeks’ gestation

Interventions

The Institute for Healthcare Improvement Breakthrough Series quality-improvement model

Outcomes

Compliance with catheter insertion component; compliance with evidence based indwelling catheter care; infection rate

Notes

Twenty-four Ohio NICUs in the USA

Khouli 2011 Methods

RCT

Participants

Medical residents

Interventions

Simulation-based plus video training or video training alone

Outcomes

Performance scores and rates of catheter-related bloodstream infections

Notes Latif 2012 Methods

RCT

Participants

Interns and student nurse anaesthetists

Interventions

Simulation training of aseptic techniques

Outcomes

Scores in aseptic techniques

Notes Longmate 2011 Methods

ITS study

Participants

ICU patients with a CVC

Interventions

Establishment of infection surveillance and introduction of bundles of care processes relating to insertion and maintenance of CVCs. The changes were supported by educational interventions

Outcomes

CLABSI rate

Notes

One ICU in the UK


90

Lopez 2011 Methods

ITS study

Participants

ICU patients with a CVC

Interventions

An ongoing compliance-tracking programme for maximal barrier precautions was instituted, and caregivers were reeducated on the importance of central-line-bundle prevention efforts. A quality improvement intervention of daily CHG baths for all ICU patients was introduced

Outcomes

CLABSI rate

Notes

One medical-surgical ICU in a regional medical centre in Greece

Marra 2011 Methods

ITS study

Participants

all ICU and step-down units patients requiring urinary catheters

Interventions

Implementation 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

Outcomes

CAUTI rate

Notes

One medical-surgical ICU and in two step-down units , in Brasil or USA

Miller 2011 Methods

Non-randomised, factorial design

Participants

Staff at 29 paediatric ICUs

Interventions

Bundles and monitoring of behaviours

Outcomes

CLABSI rates

Notes Morris 2011 Methods

A before-after study conducted within the context of an existing, independent, infection surveillance programme

Participants

All patients admitted to intensive care for 48 hrs or more during the periods before and after intervention

Interventions

A 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


91

Morris 2011

(Continued)

Outcomes

Compliance with head-of-bed elevation and chlorhexidine, “wake and wean” elements, and overall bundle compliance; VAP rate

Notes

One mixed medical-surgical teaching hospital ICU in Scotland

Munhoz 2012 Methods

ITS study

Participants

All consecutive central catheter-associated bloodstream infection cases as determined by the Infection Control Department

Interventions

Daily nursing rounds aimed at assuring compliance with an intensive care unit goal-oriented checklist

Outcomes

Central catheter-associated bloodstream infections

Notes Papadimos 2008 Methods

ITS study

Participants

Patients on mechanical ventilation

Interventions

Aggressive 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)

Outcomes

VAP rate

Notes

One surgical ICU in the USA

Resende 2011 Methods

ITS study

Participants

Neonates with a CVC

Interventions

An intervention designed to reduce CLABSI with five evidence based procedures was conducted (stepwise introduction of evidence based intervention and intensive and continuous education)

Outcomes

CLABSI rate

Notes

One neonatal in Brazil


92

Scales 2011 Methods

Cluster RCT

Participants

15 ICUs

Interventions

A 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

Outcomes

The 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

Notes

Fifteen community hospital ICUs in Ontario, Canada

Speroff 2011 Methods

Cluster RCT

Participants

ICUs of 60 hospitals

Interventions

Virtual collaborative intervention; versus a toolkit-only approach

Outcomes

CLABSI and VAP rates

Notes

Sixty hospital ICUs in the USA

Tong 2011 Methods

ITS study

Participants

Unclear - full-text not available

Interventions

A standard process management policy for management of infections

Outcomes

Peripheral central venous CLABSI

Notes

Article in Chinese, translation not available at time of review submission

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


93

DATA AND ANALYSES

Comparison 1. Ventilator-associated pneumonia (VAP) analysis

Outcome or subgroup title 1 VAP change in pre- and post-intervention slope at 3 to 6 months 2 VAP 3 months level 3 VAP 6 months level 4 VAP 9 months level 5 VAP 12 months level

No. of studies

No. of participants

Statistical method

Effect size

8

Effect Size (Random, 95% CI)

Totals not selected

8 8 8 5

Effect size (Random, 95% CI) Effect size (Random, 95% CI) Effect size (Random, 95% CI) Effect size (Random, 95% CI)

Totals not selected Totals not selected Totals not selected Totals not selected

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

Outcome or subgroup title 1 CLABSI change in pre- and post-intervention slope at 4 to 8 months 2 CLABSI 3 months level 3 CLABSI 6 months level 4 CLABSI 9 months level 5 CLABSI 12 months level 6 CLABSI 18 months level 7 CLABSI 21 months level

No. of studies

No. of participants

Statistical method

Effect size

6

Effect size (Random, 95% CI)

Totals not selected

6 6 6 5 4 2

Effect size (Random, 95% CI) Effect size (Random, 95% CI) Effect size (Random, 95% CI) Effect size (Random, 95% CI) Effect size (Random, 95% CI) Effect size (Random, 95% CI)

Totals not selected Totals not selected Totals not selected Totals not selected Totals not selected Totals not selected


94

Analysis 1.1. Comparison 1 Ventilator-associated pneumonia (VAP) analysis, Outcome 1 VAP change in pre- and post-intervention slope at 3 to 6 months. Review:

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

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

Study or subgroup

Effect Size (SE)

Effect Size

Effect Size

IV,Random,95% CI

IV,Random,95% CI


-0.3193 (0.9016)

-0.32 [ -2.09, 1.45 ]


0.5214 (0.7651)

0.52 [ -0.98, 2.02 ]


0.005 (1.4925)

0.01 [ -2.92, 2.93 ]


0.5368 (0.8595)

0.54 [ -1.15, 2.22 ]

Kaye 2000

-0.7603 (0.9873)

-0.76 [ -2.70, 1.17 ]

Salahuddin 2004

-3.9509 (0.9152)

-3.95 [ -5.74, -2.16 ]

Sona 2009

1.4846 (0.0793)

1.48 [ 1.33, 1.64 ]

Zack 2002

-5.1748 (0.8738)

-5.17 [ -6.89, -3.46 ]

-10

-5

Intervention

0

5

10

Standard care


95

Analysis 1.2. Comparison 1 Ventilator-associated pneumonia (VAP) analysis, Outcome 2 VAP 3 months level. Review:


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

Study or subgroup

Effect size (SE)

Effect size

Effect size

IV,Random,95% CI

IV,Random,95% CI


0.4157 (0.2851)

0.42 [ -0.14, 0.97 ]


-1.1477 (0.2527)

-1.15 [ -1.64, -0.65 ]


-1.185 (0.61)

-1.19 [ -2.38, 0.01 ]


0.1438 (0.5251)

0.14 [ -0.89, 1.17 ]

Kaye 2000

-0.7968 (0.6079)

-0.80 [ -1.99, 0.39 ]

Salahuddin 2004

-0.1429 (0.5045)

-0.14 [ -1.13, 0.85 ]

Sona 2009

0.6652 (0.0352)

0.67 [ 0.60, 0.73 ]

Zack 2002

0.0291 (0.3204)

0.03 [ -0.60, 0.66 ]

-4

-2

Intervention

0

2

4

Standard care


96




Study or subgroup

Effect size (SE)

Effect size

Effect size

IV,Random,95% CI

IV,Random,95% CI


0.0964 (0.9177)

0.10 [ -1.70, 1.90 ]


-1.774 (0.5374)

-1.77 [ -2.83, -0.72 ]


-1.18 (1.3525)

-1.18 [ -3.83, 1.47 ]


0.6755 (0.7321)

0.68 [ -0.76, 2.11 ]

Kaye 2000

-1.5556 (0.8714)

-1.56 [ -3.26, 0.15 ]

Salahuddin 2004

-3.9021 (0.8128)

-3.90 [ -5.50, -2.31 ]

Sona 2009

2.1498 (0.1013)

2.15 [ 1.95, 2.35 ]

Zack 2002

-5.1456 (0.9903)

-5.15 [ -7.09, -3.20 ]

-10

-5

Intervention

0

5

10

Standard care


97




Study or subgroup

Effect size (SE)

Effect size

Effect size

IV,Random,95% CI

IV,Random,95% CI


0.512 (1.0181)

0.51 [ -1.48, 2.51 ]


-2.9199 (0.5765)

-2.92 [ -4.05, -1.79 ]


-2.365 (1.4725)

-2.37 [ -5.25, 0.52 ]


0.8186 (0.9418)

0.82 [ -1.03, 2.66 ]

Kaye 2000

-2.3524 (1.1317)

-2.35 [ -4.57, -0.13 ]

Salahuddin 2004

-4.0383 (1.0085)

-4.04 [ -6.01, -2.06 ]

Sona 2009

2.8194 (0.1322)

2.82 [ 2.56, 3.08 ]

Zack 2002

-5.1165 (1.1845)

-5.12 [ -7.44, -2.79 ]

-10

-5

Intervention

0

5

10

Standard care


98




Study or subgroup

Effect size (SE)

Effect size

Effect size

IV,Random,95% CI

IV,Random,95% CI


0.9277 (1.1787)

0.93 [ -1.38, 3.24 ]


-4.0676 (0.71)

-4.07 [ -5.46, -2.68 ]


-3.5525 (1.805)

-3.55 [ -7.09, -0.01 ]

Sona 2009

3.4846 (0.1586)

3.48 [ 3.17, 3.80 ]

Zack 2002

-5.0874 (1.4272)

-5.09 [ -7.88, -2.29 ]

-10

-5

0

Intervention

5

10

Standard care

Analysis 2.1. Comparison 2 Central line-associated blood stream infections (CLABSIs) analysis, Outcome 1 CLABSI change in pre- and post-intervention slope at 4 to 8 months. Review:


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

Study or subgroup

Effect size (SE)

Effect size

Effect size

IV,Random,95% CI

IV,Random,95% CI

Beathard 2003

0.4643 (0.1286)

0.46 [ 0.21, 0.72 ]

Coopersmith 2002

0.1211 (0.1842)

0.12 [ -0.24, 0.48 ]

Miller 2010

0.1052 (0.3684)

0.11 [ -0.62, 0.83 ]

Parra 2010

1 (0.28)

1.00 [ 0.45, 1.55 ]

Sannoh 2010

-0.4222 (0.1556)

-0.42 [ -0.73, -0.12 ]

Warren 2004

0.0657 (0.1696)

0.07 [ -0.27, 0.40 ]

-4

-2

Intervention

0

2

4

Standard care


99

Analysis 2.2. Comparison 2 Central line-associated blood stream infections (CLABSIs) analysis, Outcome 2 CLABSI 3 months level. Review:


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

Study or subgroup

Effect size (SE)

Effect size

Effect size

IV,Random,95% CI Beathard 2003

IV,Random,95% CI

-2.3143 (0.4)

-2.31 [ -3.10, -1.53 ]

Coopersmith 2002

-1.8579 (0.6947)

-1.86 [ -3.22, -0.50 ]

Miller 2010

-1.6316 (0.5789)

-1.63 [ -2.77, -0.50 ]

Parra 2010

0.0533 (0.8267)

0.05 [ -1.57, 1.67 ]

Sannoh 2010

1.2852 (0.3778)

1.29 [ 0.54, 2.03 ]

Warren 2004

0.1246 (0.7751)

0.12 [ -1.39, 1.64 ]

-10

-5

Intervention

0

5

10

Standard care


100




Study or subgroup

Effect size (SE)

Effect size

Effect size

IV,Random,95% CI

IV,Random,95% CI

Beathard 2003

-1.8571 (0.4929)

-1.86 [ -2.82, -0.89 ]

Coopersmith 2002

-1.7368 (0.7421)

-1.74 [ -3.19, -0.28 ]

Miller 2010

-1.5132 (0.5132)

-1.51 [ -2.52, -0.51 ]

Parra 2010

1.0533 (1.0267)

1.05 [ -0.96, 3.07 ]

Sannoh 2010

0.8629 (0.4852)

0.86 [ -0.09, 1.81 ]

Warren 2004

0.1903 (0.7716)

0.19 [ -1.32, 1.70 ]

-10

-5

Intervention

0

5

10

Standard care


101




Study or subgroup

Effect size (SE)

Effect size

Effect size

IV,Random,95% CI Beathard 2003

IV,Random,95% CI

-1.3929 (0.6)

-1.39 [ -2.57, -0.22 ]

Coopersmith 2002

-1.6105 (0.8263)

-1.61 [ -3.23, 0.01 ]

Miller 2010

-1.4079 (0.6842)

-1.41 [ -2.75, -0.07 ]

Parra 2010

2.0533 (1.2533)

2.05 [ -0.40, 4.51 ]

Sannoh 2010

0.4407 (0.6148)

0.44 [ -0.76, 1.65 ]

Warren 2004

0.2561 (0.8062)

0.26 [ -1.32, 1.84 ]

-10

-5

0

Intervention

5

10

Standard care




Study or subgroup

Effect size (SE)

Effect size

Effect size

IV,Random,95% CI

IV,Random,95% CI

Beathard 2003

-0.9286 (0.7214)

-0.93 [ -2.34, 0.49 ]

Coopersmith 2002

-1.4895 (0.9368)

-1.49 [ -3.33, 0.35 ]

Parra 2010

3.0667 (1.4933)

3.07 [ 0.14, 5.99 ]

Sannoh 2010

0.0185 (0.7518)

0.02 [ -1.46, 1.49 ]

Warren 2004

0.3218 (0.872)

0.32 [ -1.39, 2.03 ]

-10

-5

Intervention

0

5

10

Standard care


102




Study or subgroup

Effect size (SE)

Effect size

Effect size

IV,Random,95% CI

IV,Random,95% CI

Beathard 2003

-0.0071 (0.9643)

-0.01 [ -1.90, 1.88 ]

Coopersmith 2002

-1.2421 (1.2158)

-1.24 [ -3.63, 1.14 ]

Parra 2010

5.0667 (2.0133)

5.07 [ 1.12, 9.01 ]

Warren 2004

0.4533 (1.0761)

0.45 [ -1.66, 2.56 ]

-20

-10

Intervention

0

10

20

Standard care


103




Study or subgroup

Effect size (SE)

Effect size

Effect size

IV,Random,95% CI

IV,Random,95% CI

Beathard 2003

0.45 (1.0857)

0.45 [ -1.68, 2.58 ]

Parra 2010

6.08 (2.2667)

6.08 [ 1.64, 10.52 ]

-10

-5

Intervention

0

5

10

Standard care

ADDITIONAL TABLES Table 1. Adjusted VAP rates

Author/ year

Pre-interChange in level (SE); P value, 95% CI vention VAP rate (SD) 3 months

Abbott 7.13 (4.98) 2006 dataset 1

6 months

9 months

Pre-interChange in Autovention trend (SE); correlation trend (SE); P value P value 12 months

1.59 (4.49); 0.47 (4.57); 2.55 (5.07); 4.62 (5.87); -1.26 (0.81) 2.1 (1.4); P -0.15 P = 0.733; - P = 0.920; - P = 0.631; - P = 0.457; - ; P = 0.164 = 0.189 12.2 to 9.03 10.3 to 11.3 9.43 to 14.5 9.27 to 18.5

Abbott 15.60 (5.62) -3.51 (3.44) -9.97 (3.02) 2006 dataset ; P = 0.336; ; P = 0.011; 2 -11.4 to 4.4 -16.9 to -2. 99

-16.41 (3.2) ; P = 0.001; -23.89 to -8. 94

-22.86 (3. 1.32 (0.42); 99); P < 0. P = 0.014; 0. 000; -32.06 35 to 2.29 to -13.66

-6.45 (1.42) -0.57 ; P = 0.002; -9.72 to -3. 18

Abbott 14.78 (4.00) 0.017 (5.97) 2006 dataset ; P = 0.998; 3 13.74 to 13. 78

-9.46 (5.89) ; P = 0.147; -23.06 to 4. 13

0.38 (0.76); 14.21 (7.22) P = 0.630; ; P = 0.085; 1.37 to 2.13 -30.85 to 2. 44

-4.74 (2.43) -0.22 ; P = 0.087; -10.36 to 0. 88

-4.72 (5.41) ; P = 0.408; -17.19 to 7. 75

Abbott 25.11 (5.98) 3.2 (5.14); P 4.07 (4.4); P 4.92 (5.66); 2006 dataset = 0.552; -8. = 0.386; -6. P = 0.413; 4 94 to 15.35 34 to 14.47 8.47 to 18. 31

NA

-1.47 (0.62) 0.86 (3.14); -0.17 ; P = 0.048; P = 0.793; -2.93 to -0. 6.57 to 8.28 02


104

Table 1. Adjusted VAP rates

(Continued)

Kaye 2000

12.14 (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

NA

1.38 (0.69); -5.02 (3.83) 0.02 P = 0.083; - ; P = 0.226; 0.23 to 2.98 -13.84 to 3. 81

Salahuddin 2004

12.70 (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

NA

0.32 (0.41); -0.32 (1.13) -0.69 P = 0.478; - ; P = 0.791; 0.82 to 1.47 3.45 to 2.81

Sona 2009

5.34 (2.27)

Zack 2002

12.48 (1.03) -5.33 (0.9); P = 0.004; 7.83 to -2. 82

3.37 (0.18); 4.88 (0.23) 6.39 (0.29); 7.91 (0.36); -2.27 (0.07) 1.51 (0.07); -1.33 P = 0.003; 2. ;P = 0.002; P = 0.002; 5. P = 0.002; 6. ; P = 0.001; P = 0.003; 1. 58 to 4.16 3.88 to 5.89; 12 to 7.67 34 to 9.48 -2.58 to -1. 18 to 1.84 95 -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) -0.38 (0.26) 0.03 (0.33); -0.73 ; P = 0.023; ; P = 0.219; - P = 0.934; -9.32 to -1. 1.10 to 0.34 0.90 to 0.96 16

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/ year

CLABSI Change in level (SE); P value, 95% CI rate preintervention level (SD) 3 months 6 months 9 months 12 months

Beathard 2003

6.18 (1. -3.24 (0. 40) 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

18 months

21 months

-0.012 (1. 35); P = 0.993; -3. 2 to 3.17

0.63 (1. 52); P = 0.689; 2.96 to 4. 23

Preintervention trend (SE); P value

Change Autoin trend correla(SE); P tion value

-0.67 (0. 18); P = 0.007; -1. 1 to -0.25

0.64 (0. -0.68 18); P = 0. 009; 0.21 to 1.08


105

Table 2. Adjusted CLABSI rates

(Continued)

Coopersmith 2002

10.79 (1. -3.53 (1. 90) 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

Miller 2010

5.76 (0. -1. 76) 24 (0.44); P= 0.016; -2.20 to 0.28

-1.15 (0. 39); P = 0.013; -2. 01 to -0. 29

Parra 2010

3.97 (0. 0.04 75) (0.62); P = 0.954; 1.44 to 1. 51

Sannoh 2010

Warren 2006

-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. -0.67 34); P = 0.519; 0.56 to 1. 03

-1.07 (0. NA 52); P = 0.063; -2. 20 to 0. 07

NA

NA

-0.18 (0. 04); P = 0.001; -0. 26 to -0. 095

0.084 (0. 0.21 28); P = 0.756; -0. 52 to 0. 69

0.79 (0. 77); P = 0.339; 1.03 to 2. 61

1.54 (0. 94); P = 0.144; 0.68 to 3. 76

2.30 (1. 12); P = 0.080; 0.36 to 4. 95

3.80 (1. 50); P = 0. 039; 0.24 to 7.36

4.56 (1. 70); P = 0. 032; 0.53 to 8.58

-0.59 (0. 20); P = 0.021; -1. 06 to -0. 12

0.75 (0. -0.24 21); P = 0. 008; 0.26 to 1.24

14.83 (2. 3.47 (1. 70) 02); P = 0. 042; 0.24 to 6.70

2.33 (1. 30); P = 0.172; 1.82 to 6. 49

1.19 (1. 65); P = 0.523; 4.08 to 6. 46

0.06 (2. 03); P = 0.980; 6.42 to 6. 52

NA

NA

-2.37 (0. 41); P = 0.010; -3. 68 to - 1. 06

-1.14 (0. -0.75 42); P = 0.074; -2. 48 to 0. 20

9.08 (2. 0.36 89) (2.24); P = 0.874; 4.51 to 5. 24

0.55 (2. 22); P = 0.809; 4.30 to 5. 40

0.74 (2. 32); P = 0.756; 4.32 to 5. 80

0.93 (2. 52); P = 0.718; 4.56 to 6. 42

1.30 (3. 10); P = 0.681; 5.46 to 8. 08

NA

-0.61 (0. 28); P = 0.050; -1. 23 to -0. 0007

0.19 (0. -0.23 49); P = 0.708; 0.89 to 1. 26

Abbreviations CI: confidence interval CLABSI: central line-associated blood stream infection NA: not available SD: standard deviation SE: standard error


106

Table 3. Interventions aimed at improving professional adherence to guidelines for prevention of VAP

Author/ year

Type of in- ClinKnowledge tervention; ical practice translation duration guideline activities

DisEducatribution of tional educational meeting material

Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4

More than one active intervention; 3 months education period

•

•

•

Cocanour 2006

More than one active intervention; unclear duration

•

•

•

No

Kaye 2000


•

•

•

•

Salahuddin 2004

More than one active intervention; weekly repeated throughout the study period

•

•

No

Sona 2009

More than one active intervention; all staff educated within

•

•

No

Audit and Reminders, feedback posters or visual aids

Other interventions

•

Champion leaders; dedicated oral care personnel performing oral care in one of the included ICUs

No

VAP bundle instituted as part of a performance improvement project

•

No

Bugline newsletter; handwashing campaign; equipment and supply purchases; patient and family education

•

•

•

•

•

•

•


A preprinted order set in every admission packet

107

Table 3. Interventions aimed at improving professional adherence to guidelines for prevention of VAP

(Continued)

2 months Zack 2002


•

•

•

•

•

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/ Type of in- Clinical year tervention; practice duration guideline

Knowledge translation activities

Distribution of educational material

Beathard 2003

More than one active intervention; repeated throughout the study

•

No

No

Coopersmith 2002

More than one active intervention, unclear duration

•

•

Miller 2010


•

Parra 2010

One short active intervention; 15 minutes

Sannoh 2010

One short active intervention; 15

Educational meetings

Audit and feedback

Reminders, posters, visual aids

Other interventions

•

No

No

Nurse educator made spot checks for compliance

•

•

•

•

•

No

•

•

No

No

•

No

•

•

No

•

•

No

•

No


Quality improvement strategy, champion leaders

CVC care cart available, 108

Table 4. Interventions aimed at improving professional adherence to guidelines for prevention of CLABSIs

minute DVD

Warren 2004

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

(Continued)

reinforced previously implemented hand hygiene campaign •

•

•

•

•

Promotional campaign for educational programme

•

Abbreviations CVC: central venous catheter DVD: digital video disc

Table 5. VAP prevention recommendations

VAP prevention Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4a Head of bed ele-

Cocanour 2006b Kaye 2000c

Salahuddin 2004d Sona 2009e

Zack 2002f

•

No

•

No

•

No

No

No

No

No

No

No

No

No

vation 30 Not implementing ventilator circuit changes unless clinically indicated

No

Continuous suctioning of subglottic secretions

No


109

(Continued)

Table 5. VAP prevention recommendations

Daily ‘sedation vacation’ and assessment of readiness for weaning

No

No

Oral care (with Chlorhexidine 0.12% every 8 hours)

•

No

Intra-cuff pressure control

No

Hand hygiene using alcohol based antiseptics

No

No

No

•

•

No

No

•

No

No

•

•

•

No

No

a Oral

care, but unclear if Chlorhexidine was used. Unclear if alcohol-based antiseptics were used for hand hygiene. care, with Chlorhexidine baths twice weekly. Unclear if alcohol-based antiseptics were used for hand hygiene. c Unclear if alcohol-based antiseptics were used for hand hygiene. d Oral 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. e Oral care using Chlorhexidine twice daily. f Oral care, but with Chlorhexidine only for patients undergoing cardiac surgery. Abbreviations VAP: ventilator-associated pneumonia b Oral

Table 6. CLABSI prevention recommendations

CLABSI prevention The use of maximal sterile barriers during catheter insertion

Coopersmith 2002 a Miller 2010b

No

The use of Aseptic technique Chlorhexidine skin and routine catheter preparation with al- site caref cohol for skin antisepsis

Parra 2010c

Sannoh 2010d

•

No

No

•

•

No

Warren 2004e

•

Aseptic technique and appropriate skin antisepsisg


110

Table 6. CLABSI prevention recommendations

(Continued)

Avoidance of routine placement of CVCs

No

No

No

No

No

Avoidance of using the femoral site in adults

No

N/A

•

N/A

•

Timely dressing changes using aseptic techniques

•

•

•

Daily audits to assess if each central line is still needed

No

•

No

•

No

No

a

Catheter insertion not covered by guidance. and maintenance bundle, both specific to PICUs. c Includes both insertion and maintenance guidance. d Includes only hub care and dressing policy. e Includes both insertion and maintenance guidance. f Unclear what is included in ‘routine catheter care’ and if it includes the use of Chlorhexidine. g Unclear if this includes the use of Chlorhexidine. Abbreviations CLABSI: central line-associated blood stream infection CVC: central venous catheter N/A: not applicable b Insertion

Table 7. Adherence with infection control recommendations

Study

Assessment of ad- Time-points for as- Assessor(s)/ herence with infec- sessment assessment tion control recommendations

Pre-intervention adherence

Post-intervention adherence

Abbott 2006 dataset 1; Abbott 2006 dataset 2; Abbott 2006 dataset 3; Abbott 2006 dataset 4a

Adoption measurements consisted of observations of infection control practices in accordance with the CPG and were measured using the adoption checklist

Head-of-bed elevation: mean = 77% (range 51 to 100) Oral care: mean = 22% (range 12 to 28) Empty condensate: mean = 94% (range 79 to 100)

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)

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

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

Before/after patient Before/after patient


111


(Continued)

care was observed during hours of the day with the highest rates of patient care activity in 2hour blocks of time

Beathard 2003

Compliance rates with two infection control policies were assessed through patient interviews

The patient interviews were performed at unclear time points

contact handwashing: mean = 8%/36% (range 4 to 11/17 to 33) Gloves: mean = 74% (range 60 to 97) A nurse educator None reported performed an unknown number of interviews

contact handwashing: mean = 14%/36% (range 11 to 19/28 to 54) Gloves: mean = 90% (range 79 to 97) Compliance with catheter exit sites being treated with Povidone-iodine ointment for the first 10 to 14 days after placement: 75% Compliance with all catheter exit sites being covered with sterile gauze dressing (non-occlusive) for the entire duration of the catheter placement: 98%

Ching 1990

Before 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 spigot

One 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

It is not clear who assessed the urinary catheter care practices

Before education, the percentage of incorrect practices in the test groups was 63%, and 68% in the control group


After education, the percentage of incorrect practices in the test group was 36% and 48% in the control group

112


(Continued)

prevalence surveys were conducted. Again, these surveys were unannounced and were conducted 10 days apart Miller 2010

Data were collected by using insertion bundle and maintenance-bundle compliance as the two process measures

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

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

None reported

Insertion-bundle compliance: 84% Maintenancebundle compliance: 82%

Sannoh 2010

The level of staff adherence with catheter hub care policy was determined before and after the DVD educational presentation

Before the presentation, 24 nurses were observed at random performing the catheter hub care protocol; after the presentation, 26 nurses were observed

Adherence to each of the 9 points of the catheter hub care protocol was scored as either “yes” or “no” by independent observers well versed in the protocol

Catheter hub care protocol adherence score (mean ± standard deviation): 14 ± 4

Catheter hub care protocol adherence score (mean ± standard deviation): 23 ± 0.7

Sona 2009

Staff compliance with the oral care protocol during the 12-month intervention period

Two unit based CNSs audited the compliance rates via bi-weekly review of the medication administration record and verification of oral care supplies

Compliance was de- None reported fined 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 room

Compliance with the oral care protocol: averaged 81% (range 70% to 90%)

a Individual

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


113

ICU: intensive care unit PICU: paediatric intensive care unit

APPENDICES Appendix 1. MEDLINE strategy 2012 Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) 1 Prosthesis-Related Infections/ or Pneumonia, Ventilator-Associated/ (7997) 2 exp Catheterization/ or Intubation, Intratracheal/ or Ventilators, Mechanical/ or Respiration, Artificial/ or Device Removal/ or Ventilator Weaning/ or Catheters, Indwelling/ (249901) 3 (((mechanical or device or artificial or assist$ or wean$) adj2 ventilat$) or (artificial adj respirat$) or catheter$).ti,ab. (168505) 4 indwelling device?.ti,ab. (134) 5 exp “Prostheses and Implants”/ (342700) 6 or/2-5 [Indwelling devices] (645252) 7 exp Sepsis/ or exp Urinary Tract Infections/ or Respiratory Tract Infections/ or Prosthesis-Related Infections/ or exp Pneumonia/ or Equipment Contamination/ (219377) 8 exp Cross Infection/ or exp Infection Control/ or Infection Control Practitioners/ (80299) 9 sepsi?.tw. or Septicaemi$.ti,ab. or ventilator-associated pneumonia.tw. or (bacteremia or fungemia).tw. or nosocomial$.ti,ab. or infection?.ti,ab,hw. (1260719) 10 or/7-9 [Infection] (1344593) 11 6 and 10 [Devices & INfection] (60636) 12 guidelines as topic/ or practice guidelines as topic/ (95299) 13 Guideline Adherence/ (16335) 14 exp Critical Pathways/ (3940) 15 (guideline? not (guideline? adj2 author?)).ti,ab. (152274) 16 ((pathway? or protocol? or algorithm?) adj2 (clinical or treatment? or diagnos$ or management or infection? or infectious? or antibiotic?)).ti,ab. (31515) 17 critical pathway?.ti,ab. (1000) 18 guidance.ti,ab. (48961) 19 (quality adj2 (improv$ or manag$ or care or healthcare)).ti,ab. (79532) 20 (guideline? adj2 (impact or effect$)).ti,ab. (1090) 21 or/12-20 [Guideline Adherence etc] (359808) 22 intervention?.ti. or (intervention? adj6 (clinician? or collaborat$ or community or complex or DESIGN$ or doctor? or educational or family doctor? or family physician? or family practitioner? or financial or GP or general practice? or hospital? or impact? or improv$ or individuali?e? or individuali?ing or interdisciplin$ or multicomponent or multi-component or multidisciplin$ or multi-disciplin$ or multifacet$ or multi-facet$ or multimodal$ or multi-modal$ or personali?e? or personali?ing or pharmacies or pharmacist? or pharmacy or physician? or practitioner? or prescrib$ or prescription? or primary care or professional$ or provider? or regulatory or regulatory or tailor$ or target$ or team$ or usual care)).ab. (127021) 23 (pre-intervention? or preintervention? or “pre intervention?” or post-intervention? or postintervention? or “post intervention?”).ti,ab. [added 2.4] (7278) 24 (hospital$ or patient?).hw. and (study or studies or care or health$ or practitioner? or provider? or physician? or nurse? or nursing or doctor?).ti,hw. (646037) 25 demonstration project?.ti,ab. (1750) 26 (pre-post or “pre test$” or pretest$ or posttest$ or “post test$” or (pre adj5 post)).ti,ab. (52486) 27 (pre-workshop or post-workshop or (before adj3 workshop) or (after adj3 workshop)).ti,ab. (468) Interventions to improve professional adherence to guidelines for prevention of device-related infections (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

114

28 trial.ti. or ((study adj3 aim?) or “our study”).ab. (494529) 29 (before adj10 (after or during)).ti,ab. (314647) 30 (“quasi-experiment$” or quasiexperiment$ or “quasi random$” or quasirandom$ or “quasi control$” or quasicontrol$ or ((quasi$ or experimental) adj3 (method$ or study or trial or design$))).ti,ab,hw. [ML] (87590) 31 (“time series” adj2 interrupt$).ti,ab,hw. [ML] (707) 32 (time points adj3 (over or multiple or three or four or five or six or seven or eight or nine or ten or eleven or twelve or month$ or hour? or day? or “more than”)).ab. (6857) 33 pilot.ti. (32046) 34 Pilot projects/ [ML] (70498) 35 (clinical trial or controlled clinical trial or multicenter study).pt. [ML] (577853) 36 (multicentre or multicenter or multi-centre or multi-center).ti. (23887) 37 random$.ti,ab. or controlled.ti. (634227) 38 (control adj3 (area or cohort? or compare? or condition or design or group? or intervention? or participant? or study)).ab. not (controlled clinical trial or randomized controlled trial).pt. [ML] (344998) 39 “comment on”.cm. or review.ti,pt. or randomized controlled trial.pt. [ML] (2590340) 40 review.ti. [EM] (216723) 41 (rat or rats or cow or cows or chicken? or horse or horses or mice or mouse or bovine or animal?).ti. (1256436) 42 exp animals/ not humans.sh. [ML] (3710539) 43 (animal$ not human$).sh,hw. [EM] (3616759) 44 *experimental design/ or *pilot study/ or quasi experimental study/ [EM] (17908) 45 (“quasi-experiment$” or quasiexperiment$ or “quasi random$” or quasirandom$ or “quasi control$” or quasicontrol$ or ((quasi$ or experimental) adj3 (method$ or study or trial or design$))).ti,ab. [EM] (87590) 46 (“time series” adj2 interrupt$).ti,ab. [EM] (707) 47 (or/22-38) not (or/39,41-42) [EPOC Methods Filter ML 2.4] (1827470) 48 (or/22-29,32-33,36-37,44-46) not (or/40,43) [EPOC Methods Filter EM 1.9-2.4] (1848292) 49 (randomized controlled trial or controlled clinical trial).pt. or randomized.ab. or placebo.ab. or clinical trials as topic.sh. or randomly.ab. or trial.ti. (782977) 50 exp animals/ not humans.sh. (3710539) 51 49 not 50 [Cochrane RCT Filter 6.4.d Sens/Precision Maximizing] (724020) 52 (or/1,11) and 21 [Results before filters] (3296) 53 52 and 51 [RCT Results] (251) 54 (52 and 47) not 53 [EPOC FIlter Results] (768)

Appendix 2. EMBASE strategy 2012 Embase Classic + Embase OvidSP 1 ventilator associated pneumonia/ or device infection/ or catheter infection/ or prosthesis infection/ or shunt infection/ (18241) 2 ((ventilator? adj2 (infection? or pneumonia)) or (cather$ adj3 infection?)).ti,ab. (3731) 3 or/1-2 [Device infections] (19565) 4 Indwelling Catheter/ or *Endotracheal Intubation/ or *Ventilator/ or *Artificial Ventilation/ or exp *Device Removal/ or (((mechanical or device or artificial or assist$ or wean$) adj2 ventilat$) or (artificial adj respirat$) or catheter$).ti,ab. or indwelling device? .ti,ab. [Indwelling Devices] (274585) 5 exp Urinary Tract Infection/ or Sepsis/ or exp Respiratory Tract Infection/ or Septicemia/ or bacteremia/ or exp Fungemia/ or exp Pneumonia/ or Equipment Contamination/ or hospital infection/ (646745) 6 exp *infection/ (1845246) 7 (sepsis or septic?emi$ or ventilator-associated pneumonia or (bacteremia or fungemia) or nosocomial$).ti,ab. or infection?.ti,ab,hw. (1739175) 8 or/5-7 [Infection] (2760649) Interventions to improve professional adherence to guidelines for prevention of device-related infections (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

115

9 (guideline? adj4 (adher$ or antibiotic? or applicat$ or apply$ or clinical or complian$ or concord$ or deploy$ or diagnos$ or effect$ or efficacy or evidence or experiment$ or impact or implement$ or infectious? or infection? or introduc$ or management or pilot$ or study or treatment? or trial? or utili?ation or utili?ing or utili?e?)).ti,ab. (76667) 10 (protocol? adj3 (adher$ or antibiotic? or applicat$ or apply$ or clinical or complian$ or concord$ or deploy$ or diagnos$ or effect$ or efficacy or evidence or experiment$ or impact or implement$ or infectious? or infection? or introduc$ or management or pilot$ or study or treatment? or trial? or utili?ation or utili?ing or utili?e?)).ti,ab. (58463) 11 practice guideline/ and (adher$ or antibiotic? or applicat$ or apply$ or clinical or complian$ or concord$ or deploy$ or diagnos$ or effect$ or efficacy or evidence or experiment$ or impact or implement$ or infectious? or infection? or introduc$ or management or pilot$ or study or treatment? or trial? or utili?ation or utili?ing or utili?e?).ti,ab. (126210) 12 (pathway? or guidance or algorithm? or (quality adj2 (improv$ or manag$ or care or healthcare))).ti,ab. (955438) 13 or/9-12 [GL/Protocol adherence implementation] (1153989) 14 secondary prevention/ or prevention/ or infection prevention/ or primary prevention/ or “prevention and control”/ (234982) 15 (prevention adj2 (primary or secondary or infection or control)).ti,ab. (50736) 16 or/14-15 [prevention] (268125) 17 controlled clinical trial/ or controlled study/ or randomized controlled trial/ [EM] (3840771) 18 (book or conference paper or editorial or letter or review).pt. not randomized controlled trial/ [Per BMJ Clinical Evidence filter] (3736305) 19 (random sampl$ or random digit$ or random effect$ or random survey or random regression).ti,ab. not randomized controlled trial/ [Per BMJ Clinical Evidence filter] (44243) 20 (animal$ not human$).sh,hw. (3704209) 21 17 not (or/18-20) [Trial filter per BMJ CLinical Evidence] (2513402) 22 intervention?.ti. or (intervention? adj6 (clinician? or collaborat$ or community or complex or DESIGN$ or doctor? or educational or family doctor? or family physician? or family practitioner? or financial or GP or general practice? or hospital? or impact? or improv$ or individuali?e? or individuali?ing or interdisciplin$ or multicomponent or multi-component or multidisciplin$ or multi-disciplin$ or multifacet$ or multi-facet$ or multimodal$ or multi-modal$ or personali?e? or personali?ing or pharmacies or pharmacist? or pharmacy or physician? or practitioner? or prescrib$ or prescription? or primary care or professional$ or provider? or regulatory or regulatory or tailor$ or target$ or team$ or usual care)).ab. (163414) 23 (pre-intervention? or preintervention? or “pre intervention?” or post-intervention? or postintervention? or “post intervention? ”).ti,ab. [added 2.4] (9234) 24 (hospital$ or patient?).hw. and (study or studies or care or health$ or practitioner? or provider? or physician? or nurse? or nursing or doctor?).ti,hw. (1355594) 25 demonstration project?.ti,ab. (2173) 26 (pre-post or “pre test$” or pretest$ or posttest$ or “post test$” or (pre adj5 post)).ti,ab. (73862) 27 (pre-workshop or post-workshop or (before adj3 workshop) or (after adj3 workshop)).ti,ab. (620) 28 trial.ti. or ((study adj3 aim?) or “our study”).ab. (670264) 29 (before adj10 (after or during)).ti,ab. (420683) 30 (“quasi-experiment$” or quasiexperiment$ or “quasi random$” or quasirandom$ or “quasi control$” or quasicontrol$ or ((quasi$ or experimental) adj3 (method$ or study or trial or design$))).ti,ab,hw. [ML] (202537) 31 (“time series” adj2 interrupt$).ti,ab,hw. [ML] (836) 32 (time points adj3 (over or multiple or three or four or five or six or seven or eight or nine or ten or eleven or twelve or month$ or hour? or day? or “more than”)).ab. (8961) 33 pilot.ti. (41495) 34 Pilot projects/ [ML] (55857) 35 (clinical trial or controlled clinical trial or multicenter study).pt. [ML] (0) 36 (multicentre or multicenter or multi-centre or multi-center).ti. (32227) 37 random$.ti,ab. or controlled.ti. (796262) 38 (control adj3 (area or cohort? or compare? or condition or design or group? or intervention? or participant? or study)).ab. not (controlled clinical trial or randomized controlled trial).pt. [ML] (524066) 39 “comment on”.cm. or review.ti,pt. or randomized controlled trial.pt. [ML] (2008120) 40 review.ti. [EM] (274694) 41 (rat or rats or cow or cows or chicken? or horse or horses or mice or mouse or bovine or animal?).ti. (1560050) 42 exp animals/ not humans.sh. [ML] (1778563) 43 (animal$ not human$).sh,hw. [EM] (3704209) Interventions to improve professional adherence to guidelines for prevention of device-related infections (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

116

44 *experimental design/ or *pilot study/ or quasi experimental study/ [EM] (4494) 45 (“quasi-experiment$” or quasiexperiment$ or “quasi random$” or quasirandom$ or “quasi control$” or quasicontrol$ or ((quasi$ or experimental) adj3 (method$ or study or trial or design$))).ti,ab. [EM] (115657) 46 (“time series” adj2 interrupt$).ti,ab. [EM] (836) 47 (or/22-38) not (or/39,41-42) [EPOC Methods Filter ML 2.4] (3034482) 48 (or/22-29,32-33,36-37,44-46) not (or/40,43) [EPOC Methods Filter EM 1.9-2.4] (2810625) 49 3 and 13 [Indwelling Device Infections & GL] (2086) 50 (3 and 16) not 49 [Indwelling device Infections & Prev Control] (1355) 51 (4 and 8 and 9) not (or/49-50) [Devices & Infection & GL] (489) 52 (4 and 8 and 16) not (or/49-51) [Device & Infection & Prevention] (1436) 53 (or/49-52) and 21 [RCT Results] (771) 54 ((or/49-52) and 47) not 53 [EPOC Filter Results] (1656)

Appendix 3. CENTRAL strategy 2012 EBM Reviews - Cochrane Central Register of Controlled Trials OvidSP 1 ((prosthes$ or ventilat$ or device or catheter?) adj3 infection?).ti,ab,tw,kw. (585) 2 (Catheteri?ation or (Intubation adj Intratracheal) or (Ventilator? adj2 Mechanical) or (Device? adj2 Remov$) or (ventilator? adj2 Wean$) or Catheter?).ti,ab,tw,kw. (8662) 3 (((mechanical or device or artificial or assist$ or wean$) adj2 ventilat$) or (artificial adj respirat$)).ti,ab,tw,kw. (3106) 4 indwelling device?.ti,ab,tw,kw. (3) 5 or/2-4 [Devices] (11457) 6 (sepsis or septic?em$ or bacteremia or fungemia or nosocomial$ or Hospital acquired or (equipment adj2 contamination) or infection? or (ventilator? adj2 pneumonia)).ti,ab,tw,kw. (31098) 7 ((pathway? or protocol? or algorithm?) adj2 (clinical or treatment? or diagnos$ or management or infection? or infectious? or antibiotic? )).ti,ab,tw,kw. (3234) 8 critical pathway?.ti,ab. (22) 9 guidance.ti,ab. (1327) 10 (quality adj2 (improv$ or manag$ or care or healthcare)).ti,ab. (6101) 11 (guideline? adj4 (adher$ or antibiotic? or applicat$ or apply$ or clinical or complian$ or concord$ or deploy$ or diagnos$ or effect$ or efficacy or evidence or experiment$ or impact or implement$ or infectious? or infection? or introduc$ or management or pilot$ or study or treatment? or trial? or utili?ation or utili?ing or utili?e?)).ti,ab,kw,tw. (2553) 12 (protocol? adj3 (adher$ or antibiotic? or applicat$ or apply$ or clinical or complian$ or concord$ or deploy$ or diagnos$ or effect$ or efficacy or evidence or experiment$ or impact or implement$ or infectious? or infection? or introduc$ or management or pilot$ or study or treatment? or trial? or utili?ation or utili?ing or utili?e?)).ti,ab,tw,hw. (8955) 13 (pathway? or guidance or algorithm? or (quality adj2 (improv$ or manag$ or care or healthcare))).ti,ab,tw,kw. (12635) 14 or/7-13 [GL] (23241) 15 and/5-6,14 (124) 16 1 or 15 (665) 17 exp Catheter-Related Infections/ (51) 18 Prosthesis-Related Infections/ or Pneumonia, Ventilator-Associated/ (188) 19 exp Catheterization/ or Intubation, Intratracheal/ or Ventilators, Mechanical/ or Respiration, Artificial/ or Device Removal/ or Ventilator Weaning/ or Catheters, Indwelling/ (12546) 20 (((mechanical or device or artificial or assist$ or wean$) adj2 ventilat$) or (artificial adj respirat$) or catheter$).ti,ab. (11043) 21 indwelling device?.ti,ab. (3) 22 exp “Prostheses and Implants”/ (9839) 23 or/19-22 [Indwelling devices] (27481) 24 exp Sepsis/ or exp Urinary Tract Infections/ or Respiratory Tract Infections/ or Prosthesis-Related Infections/ or exp Pneumonia/ or Equipment Contamination/ (7213) 25 exp Cross Infection/ or exp Infection Control/ or Infection Control Practitioners/ (1515) Interventions to improve professional adherence to guidelines for prevention of device-related infections (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

117

26 sepsi?.tw. or Septicaemi$.ti,ab. or ventilator-associated pneumonia.tw. or (bacteremia or fungemia).tw. or nosocomial$.ti,ab. or infection?.ti,ab,hw. (39376) 27 or/24-26 [Infection] (40954) 28 23 and 27 [Devices & INfection] (2935) 29 guidelines as topic/ or practice guidelines as topic/ (1001) 30 Guideline Adherence/ (420) 31 exp Critical Pathways/ (96) 32 (guideline? not (guideline? adj2 author?)).ti,ab. (4784) 33 ((pathway? or protocol? or algorithm?) adj2 (clinical or treatment? or diagnos$ or management or infection? or infectious? or antibiotic?)).ti,ab. (2904) 34 critical pathway?.ti,ab. (22) 35 guidance.ti,ab. (1327) 36 (quality adj2 (improv$ or manag$ or care or healthcare)).ti,ab. (6101) 37 (guideline? adj2 (impact or effect$)).ti,ab. (220) 38 or/29-37 [Guideline Adherence etc] (14875) 39 (or/18,28) and 38 [Results before filters] (115) 40 16 or 39 [Results] (698) 41 limit 40 to yr=“2008 -Current” (132) 42 40 not 41 (566)

Appendix 4. CINAHL strategy 2012

#

CINAHL EbscoHost, May 3, 2012

Results

S58

S57 NOT S56 [EPOC Filter Results]

284

S57

S55 AND S54

408

S56

S55 AND S29 [RCT Filter Results]

151

S55

S5 AND S13 AND S22

1049

S54

S30 or S31 or S32 or S33 or S34 or S35 or S36 or S37 or S38 360238 or S39 or S40 or S41 or S42 or S43 or S44 or S45 or S46 or S47 or S48 or S49 or S50 or S51 or S52 or S53

S53

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


118

(Continued)

(time points n3 month*) or (time points n3 hour*) or (time points n3 day*) or (time points n3 “more than”) ) S52

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

S51

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

S50

TI random* OR controlled

S49

TI ( trial or (study n3 aim) or “our study” ) or AB ( (study n3 68810 aim) or “our study” )

S48

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

S47

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

S46

(intervention n6 clinician*) or (intervention n6 community) 34670 or (intervention n6 complex) or (intervention n6 design*) or (intervention n6 doctor*) or (intervention n6 educational) or (intervention n6 family doctor*) or (intervention n6 family physician*) or (intervention n6 family practitioner*) or (intervention n6 financial) or (intervention n6 GP) or (intervention n6 general practice*) Or (intervention n6 hospital*) or (intervention n6 impact*) Or (intervention n6 improv*) or (intervention n6 individualize*) Or (intervention n6 individualise*) or (intervention n6 individualizing) or (intervention n6 individualising) or (intervention n6 interdisciplin*) or (intervention n6 multicomponent) or (intervention n6 multi-component) or (intervention n6 multidisciplin*) or (intervention n6 multi-disciplin*) or (intervention n6 multifacet*) or (intervention n6 multi-facet*) or (intervention n6 multimodal*) or (intervention n6 multi-modal*) or (intervention n6 personalize*) or(intervention n6 personalise*) or (intervention n6 personalizing) or (intervention n6 personalising) or (interven-

28277


119

(Continued)

tion n6 pharmaci*) or (intervention n6 pharmacist*) or (intervention n6 pharmacy) or (intervention n6 physician*) or (intervention n6 practitioner*) Or (intervention n6 prescrib*) or (intervention n6 prescription*) or (intervention n6 primary care) or (intervention n6 professional*) or (intervention* n6 provider*) or (intervention* n6 regulatory) or (intervention n6 regulatory) or (intervention n6 tailor*) or (intervention n6 target*) or (intervention n6 team*) or (intervention n6 usual care) S45

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

S44

TI pilot

9671

S43

(MH “Pilot Studies”)

25112

S42

AB “before-and-after”

14578

S41

AB time series

1486

S40

TI time series

205

S39

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

S38

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

S37

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


120

(Continued)

S36

TI pre w7 post or AB pre w7 post

7539

S35

MH “Multiple Time Series” or MH “Time Series”

1132

S34

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

S33

MH Experimental Studies or Community Trials or Commu- 29222 nity Trials or Pretest-Posttest Design + or Quasi-Experimental Studies + Pilot Studies or Policy Studies + Multicenter Studies

S32

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

S31

TI ( intervention* or multiintervention* or multi-interven- 125184 tion* or postintervention* or post-intervention* or preintervention* or pre-intervention* ) or AB ( intervention* or multiintervention* or multi-intervention* or postintervention* or post-intervention* or preintervention* or pre-intervention* )

S30

(MH “Quasi-Experimental Studies”)

5005

S29

S23 or S24 or S25 or S26 or S27 or S28

157058

S28

TI ( “control* N1 clinical” or “control* N1 group*” or “con- 69400 trol* N1 trial*” or “control* N1 study” or “control* N1 studies” or “control* N1 design*” or “control* N1 method*” ) or AB ( “control* N1 clinical” or “control* N1 group*” or “control* N1 trial*” or “control* N1 study” or “control* N1 studies” or “control* N1 design*” or “control* N1 method*” )

S27

TI controlled or AB controlled

53215

S26

TI random* or AB random*

92562

S25

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

S24

(MM “Clinical Trials+”)

S23

TI ( (multicent* n2 design*) or (multicent* n2 study) or (mul- 6596 ticent* n2 studies) or (multicent* n2 trial*) ) or AB ( (multicent* n2 design*) or (multicent* n2 study) or (multicent* n2 studies) or (multicent* n2 trial*) )

7190


121

(Continued)

S22

S14 or S15 or S16 or S17 or S18 or S19 or S20 or S21

124638

S21

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

S20

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

S19

TI guidance OR AB guidance

11022

S18

TI critical pathway* OR AB critical pathway*

606

S17

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

S16

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

S15

(MH “Critical Path”)

S14

(MH “Practice Guidelines”) OR (MH “Guideline Adher- 46728 ence”) OR (MH “Education, Continuing+”) OR (MH “Education, Interdisciplinary”)

S13

S6 or S7 or S8 or S9 or S10 or S11 or S12

S12

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

S11

TI nosocomial* OR AB nosocomial*

4000

S10

TX (bacteremia or fungemia)

3130

S9

TX ventilator-associated pneumonia

1633

S8

TI Septicaemi* OR AB Septicaemi*

240

S7

TX sepsi*

7853

S6

(MH “Urinary Tract Infections+”) OR (MH “Sepsis+”) OR 208416 (MH “Respiratory Tract Infections+”) OR (MH “Equipment Contamination”) OR (MH “Prosthesis-Related Infections”) OR (MH “Cross Infection”) OR (MH “Infection Control+”) OR (MH “Infection Control Practitioners”) OR (MH “Inten-

2747

286503


122

(Continued)

sive Care Units+”) OR (MH “Critical Care”) OR (MH “Preventive Health Care+”) S5

S1 or S2 or S3 or S4

30461

S4

TI indwelling device* OR AB indwelling device*

68

S3

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

S2

(MH “Intubation, Intratracheal”) OR (MH “Ventilators, Me- 14682 chanical”) OR (MH “Ventilator Weaning”) OR (MH “Respiration, Artificial”) OR (MH “Device Removal”)

S1

(MH “Catheters and Tubes+”)

8366

Appendix 5. Cochrane Library strategies EBM Reviews - Cochrane Database of Systematic Reviews 2005 to May 2012, EBM Reviews - Database of Abstracts of Reviews of Effects 2nd Quarter 2012, EBM Reviews - Health Technology Assessment 2nd Quarter 2012, EBM Reviews - NHS Economic Evaluation Database 2nd Quarter 2012. OvidSP Date: June 18, 2012

#

Searches

Results

1

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

2

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

8544

3

1 and 2 [reducing/prefeventing device infections]

82

4

catheter$.ti,kw. or catheteri$.ab. or ventilator?.ti,ab,kw. or ven- 707 tilated.ti,ab,kw

5

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

6

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

152

7

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

4

8

or/4-7 [Devices]

840


123

(Continued)

9

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

10

(prevent$ or reduc$).ti.

11

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

12

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

139

13

guidance.ti,ab.

151

14

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

15

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

16

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

17

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

18

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

19

or/10-18 [Prevention or Guideline Adherence]

6634

20

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

115

21

3 not 20

26

22

20 or 21 [Results]

141

23

from 22 keep 1-52 [CDSR]

52

4390


124

(Continued)

24

from 22 keep 53-105 [DARE]

53

25

from 22 keep 106-119 [HTA]

14

26

from 22 keep 120-141 [NHS Econ]

22

Appendix 6. EPOC Register strategies June 2012: 59 results all years. ALL FIELDS: (cather* or ventilat* or device* or intubat*) AND infection* or bacterem* or bacterial* or nosocomial or hospital acquired OR ALL FIELDS: Ventilat* and pneumon* and reduc* OR ALL FIELDS: Ventilat* and pneumon* and prevent* OR TITLE: intravenous* and infect* March 2007: 51 citations in Register; 41 results from ’pending’ (e.g. unclassified) file catheter* (intuba* or ventilator*) (device* and infection*) (“infection control*”) and (device* or catheter*)

Appendix 7. MEDLINE strategy (2008)

MEDLINE 1950-week 1, May 2008, OvidSP The strategy below shows results per line from the search in May 2008; this strategy was also run in June 2007, and December 2010 1

exp Catheterization/ (146741)

2

Intubation, Intratracheal/ (23022)

3

Ventilators, Mechanical/ (7038)

4

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

5

Respiration, Artificial/ (29575)

6

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

7

Device Removal/ (3273)

8

Ventilator Weaning/ (1981)


125

(Continued)

9

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

10

Catheters, Indwelling/ (12908)

11

catheter$.tw. (115877)

12

or/1-11 (278648)

13

exp Urinary Tract Infections/ (33272)

14

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

15

uti?.tw. (3557)

16

exp Sepsis/ (67938)

17

sepsis.tw. (41962)

18

Respiratory Tract Infections/ (25533)

19

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

20

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

21

exp Pneumonia/ (58557)

22

ventilator-associated pneumonia.tw. (1322)

23

Equipment Contamination/ (7047)

24

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

25

Prosthesis-Related Infections/ (4608)

26

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

27

exp Cross Infection/ (34977)

28

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

29

exp Infection Control/ (40292)

30

Infection Control Practitioners/mt, st (52)

31

exp Intensive Care Units/mt, st (2170)

32

Intensive Care/mt, st (2710)


126

(Continued)

33

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

34

Primary Prevention/mt (3283)

35

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

36

or/13-35 (301298)

37

12 and 36 (22427)

38

exp *education, continuing/ (24929)

39

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

40

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

41

*pamphlets/ (1097)

42

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

43

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

44

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

45

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

46

*advance directives/ (2306)

47

outreach.tw. (4346)

48

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

49

facilitator?.tw. (7388)

50

academic detailing.tw. (194)

51

consensus conference?.tw. (2770)

52

*guideline adherence/ (4659)

53

practice guideline?.tw. (7259)

54

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

55

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

56

*reminder systems/ (667)


127

(Continued)

57

reminder?.tw. (3860)

58

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

59

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

60

algorithm?.tw. (57512)

61

*feedback/ or feedback.tw. (48086)

62

chart review$.tw. (11686)

63

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

64

compliance.tw. (52614)

65

marketing.tw. (10550)

66

or/38-65 (276296)

67

exp *reimbursement mechanisms/ (13279)

68

fee for service.tw. (2399)

69

*capitation fee/ (1921)

70

*“deductibles and coinsurance”/ (441)

71

cost shar$.tw. (698)

72

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

73

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

74

*hospital charges/ (666)

75

formular?.tw. (2021)

76

fundhold?.tw. (1)

77

*medicaid/ (8042)

78

*medicare/ (14410)

79

blue cross.tw. (940)

80

or/67-79 (40409)


128

(Continued)

81

*nurse clinicians/ (4829)

82

*nurse midwives/ (4089)

83

*nurse practitioners/ (8520)

84

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

85

*pharmacists/ (4541)

86

clinical pharmacist?.tw. (760)

87

paramedic?.tw. (2114)

88

*patient care team/ (15600)

89

exp *patient care planning/ (18188)

90

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

91

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

92

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

93

(case adj1 management).tw. (5252)

94

exp *ambulatory care facilities/ (19922)

95

*ambulatory care/ (12474)

96

or/81-95 (108522)

97

*home care services/ (16296)

98

*hospices/ (2826)

99

*nursing homes/ (16664)

100

*office visits/ (1535)

101

*house calls/ (984)

102

*day care/ (2631)

103

*aftercare/ (2317)

104

*community health nursing/ (13195)


129

(Continued)

105

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

106

domiciliary.tw. (1813)

107

(home adj1 treat$).tw. (1022)

108

day surgery.tw. (1449)

109

*medical records/ (14449)

110

*medical records systems, computerized/ (9375)

111

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

112

*peer review/ (2663)

113

*utilization review/ (2450)

114

exp *health services misuse/ (2243)

115

or/97-114 (101100)

116

*physician’s practice patterns/ (14552)

117

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

118

Quality of Health Care/st (2421)

119

quality assurance.tw. (13405)

120

process assessment/ [health care] (2144)

121

*program evaluation/ (4568)

122

*length of stay/ (4985)

123

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

124

discharge planning.tw. (1640)

125

offset.tw. (10923)

126

triage.tw. (4905)

127

exp *“Referral and Consultation”/ and “consultation”/ (14446)

128

*drug therapy, computer assisted/ (740)


130

(Continued)

129

near patient testing.tw. (145)

130

*medical history taking/ (3557)

131

*telephone/ (3335)

132

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

133

*health maintenance organizations/ (9211)

134

managed care.tw. (14207)

135

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

136

or/116-133 (94857)

137

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

138

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

139

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

140

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

141

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

142

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

143

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

144

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

145

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

146

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

147

clinical strateg$.tw. (854)

148

or/137-147 (56284)

149

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

150

randomized controlled trial.pt. (256632)

151

random$.tw. (410722)

152

control$.tw. (1663443)


131

(Continued)

153

intervention$.tw. (289010)

154

evaluat$.tw. (1326665)

155

or/150-154 (3125018)

156

37 and 149 and 155 (775)

157

animal/ (4262655)

158

human/ (10397158)

159

157 not (157 and 158) (3213354)

160

156 not 159 (748) [Results 2008 Search]

Note: June 15, 2007 search of MEDLINE yielded 788 citations Note: December 2010 search yielded 119 citations

Appendix 8. EMBASE strategy (2008)

EMBASE , Ovid 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

exp *Catheterization/ (13924) exp *Catheter/ (11837) Endotracheal Intubation/ (14953) Ventilator/ (4648) ((mechanical or device or artificial or assist$) adj ventilat$).tw. (18558) Artificial Ventilation/ (33746) ((mechanical or device or artificial or assist$) adj respirat$).tw. (732) exp Device Removal/ (3859) ((ventilat$ or respirat$) adj wean$).tw. (181) Indwelling Catheter/ (2308) catheter$.tw. (93621) or/1-11 (154596) exp Urinary Tract Infection/ (30417) (urinary adj2 infection?).tw. (19088) uti?.tw. (3625) Sepsis/ (39055) sepsis.tw. (36556) exp Respiratory Tract Infection/ (101210) (respiratory adj2 infection?).tw. (18771) Septicemia/ (8533) Bacteremia/ (13756)


132

(Continued)

22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70

exp Fungemia/ (1401) (bacter?emia or fung?emia or septic?emia).tw. (21890) exp Pneumonia/ (79311) ventilator-associated pneumonia.tw. (1368) Equipment Contamination/ (6442) (equipment adj contaminat$).tw. (17) exp Device Infection/ (8254) ((prosthesis or prosthetic or device or shunt or catheter) adj2 infection?).tw. (3964) Hospital Infection/ (21189) ((cross or nosocomial or hospital) adj infection?).tw. (8406) *Intensive Care Unit/ (5810) *Intensive Care/ (10997) ((hospital or health or healthcare or device) adj (associated infection? or acquired infection?)).tw. (1275) (infection adj (prevention or control$)).tw. (5778) Primary Prevention/ (9261) (prevention adj control$).tw. (111) or/13-37 (305098) 12 and 38 (23053) (education$ adj2 (program$ or intervention? or meeting? or session? or strateg$ or workshop? or visit?)).tw. (17748) (behavio?r$ adj2 intervention?).tw. (3482) (leaflet? or booklet? or poster or posters).tw. (10663) ((written or printed or oral) adj information).tw. (822) (information$ adj2 campaign).tw. (194) (education$ adj1 (method? or material?)).tw. (2087) outreach.tw. (3060) ((opinion or education$ or influential) adj1 leader?).tw. (373) facilitator?.tw. (5879) academic detailing.tw. (178) consensus conference?.tw. (2609) practice guideline?.tw. (5904) (guideline? adj2 (introduc$ or issu$ or impact or effect? or disseminat$ or distribut$)).tw. (1669) ((introduc$ or impact or effect? or implement$ or computer$ or compli$) adj2 protocol?).tw. (1396) ((introduc$ or impact or effect? or implement$ or computer$ or compli$) adj2 algorithm?).tw. (2383) clinical pathway?.tw. (792) critical pathway?.tw. (506) ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 training program$).tw. (265) reminder?.tw. (2910) (recall adj2 system$).tw. (132) (prompter? or prompting).tw. (2112) advance directive?.tw. (1068) *feedback/ or feedback.tw. (39570) chart review$.tw. (10632) ((effect? or impact or records or chart?) adj2 audit).tw. (340) compliance.tw. (47746) marketing.tw. (7533) ((cost or clinical or medical) adj information).tw. (8358) *medical education/ (28293) *medical audit/ (3189) continuing education/ (15167)


133

(Continued)

71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119

postgraduate education/ (8158) or/40-71 (217365) fee for service.tw. (1583) cost shar$.tw. (464) (copayment? or co payment?).tw. (551) (prepay$ or prepaid or prospective payment?).tw. (1838) formular?.tw. (2026) fundhold?.tw. (1) blue cross.tw. (378) voucher?.tw. (350) (free adj2 care).tw. (338) exp *health insurance/ (14417) *health care costs/ (10170) *health care financing/ (2642) *medical fee/ (1154) *prospective payment/ (886) or/73-86 (31665) (nurse adj (rehabilitator? or clinician? or practitioner? or midwi$)).tw. (2014) ((nurse or midwi$ or practitioner) adj managed).tw. (110) clinical pharmacist?.tw. (838) paramedic?.tw. (1513) exp *paramedical personnel/ (16498) *general practitioner/ (5722) *physician/ (7492) (team? adj2 (care or treatment or assessment or consultation)).tw. (4001) (integrat$ adj2 (care or service?)).tw. (2594) (care adj2 (coordinat$ or program$ or continuity)).tw. (6813) (case adj1 management).tw. (3152) *patient care/ (10088) (chang$ adj1 location?).tw. (164) domiciliary.tw. (1169) (home adj1 (treat$ or visit?)).tw. (2652) day surgery.tw. (1155) exp *primary health care/ (12562) *ambulatory surgery/ (1993) *nursing home/ (4739) *day hospital/ (798) *outpatient care/ (1861) *terminal care/ (2291) *group practice/ (628) *general practice/ (9798) *rural health care/ (1962) *community mental health center/ (212) information system/ (11104) *medical record/ (4163) (information adj2 (management or system?)).tw. (10167) *peer review/ (1193) *professional standards review organization/ (108) exp *clinical practice/ (8582)


134

(Continued)

120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163

quality assurance.tw. (10181) exp *health care delivery/ (120061) *health care quality/ (11229) *professional practice/ (5108) (early adj1 discharg$).tw. (1167) discharge planning.tw. (614) offset.tw. (9499) triage.tw. (3803) near patient testing.tw. (149) *patient referral/ (2337) (physician patient adj (interaction? or relationship?)).tw. (928) managed care.tw. (7643) *health care organization/ (8506) *health maintenance organization/ (1635) *health care system/ (7777) *health care access/ (2904) (hospital? adj1 merg$).tw. (92) (computer$ adj2 (dosage or dosing or diagnosis therapy or decision?)).tw. (586) (computer$ adj2 (diagnosis or therapy)).tw. (1164) gatekeep$.tw. (1224) or/88-139 (281781) ((standard or usual or routine or regular or traditional or conventional or pattern) adj2 care).tw. (14093) (program$ adj2 (reduc$ or increas$ or decreas$ or chang$ or improv$ or modify$ or monitor$ or care)).tw. (17346) (program$ adj1 (health or care or intervention?)).tw. (11327) ((effect or impact or introduc$) adj2 (legislation or regulations or policy)).tw. (660) ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 treatment program$).tw. (216) ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 care program$).tw. (58) ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 screening program$).tw. (285) ((effect? or impact or evaluat$ or introduc$ or compar$) adj2 prevent$ program$).tw. (201) or/141-148 (39344) 72 or 87 or 140 or 149 (518522) Randomized controlled trial/ (157553) random$.tw. (369378) control$.tw. (1411518) intervention$.tw. (253334) (time adj series).tw. (6502) (pre test or pretest or posttest or post test).tw. (7004) evaluat$.tw. (1130889) effect$.tw. (2578193) compar$.tw. (1913563) or/151-159 (4958905) 39 and 150 and 160 (3058) Nonhuman/ (3062352) 161 not 162 (2802)


135

Appendix 9. CINAHL strategy (2008-2010)

CINAHL, 1982- , Ovid (Search date May 2008, Week 3). This strategy was used in 2010 1

exp Catheterization/ (11920)

2

Intubation, Intratracheal/ (2653)

3

Ventilators, Mechanical/ (756)

4

Respiration, Artificial/ (4898)

5

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

6

Device Removal/ (230)

7

Ventilator Weaning/ (938)

8

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

9

Catheters, Indwelling/ (730)

10

catheter$.tw. (8454)

11

or/1-10 (26367)

12

exp Urinary Tract Infections/ (2587)

13

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

14

uti?.tw. (616)

15

exp Sepsis/ (4837)

16

sepsis.tw. (2952)

17

exp Respiratory Tract Infections/ (18383)

18

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

19

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

20

ventilator-associated pneumonia.tw. (536)

21

Equipment Contamination/ (1371)


136

(Continued)

22

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

23

Prosthesis-Related Infections/ (247)

24

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

25

Cross Infection/ (9054)

26

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

27

exp Infection Control/mt, st (5577)

28

Infection Control Practitioners/mt, st (29)

29

exp Intensive Care Units/mt, st (247)

30

Intensive Care/mt, st (512)

31

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

32

exp Preventive Health Care/ (81492)

33

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

34

or/12-33 (118362)

35

11 and 34 (4032)

36

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

37

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

38

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

39

*pamphlets/ (489)

40

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

41

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

42

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

43

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

44

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

45

outreach.tw. (2220)


137

(Continued)

46

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

47

facilitator?.tw. (1710)

48

academic detailing.tw. (61)

49

consensus conference?.tw. (487)

50

practice guideline?.tw. (3156)

51

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

52

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

53

*reminder systems/ (323)

54

reminder?.tw. (1147)

55

(recall adj2 system$).tw. (42)

56

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

57

algorithm?.tw. (3060)

58

*feedback/ or feedback.tw. (5011)

59

chart review$.tw. (2368)

60

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

61

compliance.tw. (9179)

62

marketing.tw. (2896)

63

or/36-62 (56142)

64

exp *reimbursement mechanisms/ (2794)

65

fee for service.tw. (539)

66

exp *“fees and charges”/ (2277)

67

cost shar$.tw. (152)

68

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

69

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


138

(Continued)

70

exp *managed care programs/ (7198)

71

formular?.tw. (548)

72

fundhold?.tw. (0)

73

*medicaid/ (2317)

74

*medicare/ (6243)

75

blue cross.tw. (138)

76

or/64-75 (19538)

77

exp *advanced practice nurses/ (10832)

78

*nurse consultants/ (644)

79

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

80

*pharmacists/ (1098)

81

clinical pharmacist?.tw. (111)

82

paramedic?.tw. (1178)

83

*multidisciplinary care team/ (3740)

84

exp *protocols/ (4314)

85

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

86

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

87

*health care delivery, integrated/ (1227)

88

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

89

exp *continuity of patient care/ (2553)

90

*case managers/ (616)

91

(case adj1 management).tw. (4069)

92

or/77-91 (39592)

93

exp *ambulatory care facilities/ (3294)


139

(Continued)

94

*ambulatory care/ (2219)

95

exp *home health care/ (15754)

96

*hospices/ (651)

97

exp *nursing homes/ (5396)

98

*office visits/ (437)

99

*office nursing/ (1760)

100

*home visits/ (766)

101

*day care/ (697)

102

*after care/ (1125)

103

exp *community health nursing/ (10668)

104

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

105

domiciliary.tw. (278)

106

(home adj1 treat$).tw. (179)

107

day surgery.tw. (757)

108

or/93-107 (41445)

109

*medical records/ (2311)

110

exp *decision making, computer assisted/ (2098)

111

*computerized patient record/ (2135)

112

*nursing records/ (1278)

113

*problem oriented records/ (18)

114

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

115

*health service misuse/ (203)

116

exp *quality assessment/ (10454)

117

quality assurance.tw. (2411)


140

(Continued)

118

*length of stay/ (1220)

119

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

120

discharge planning.tw. (1159)

121

offset.tw. (847)

122

triage.tw. (2314)

123

exp *“Referral and Consultation”/ (3182)

124

gatekeep$.tw. (401)

125

*drug therapy, computer assisted/ (108)

126

near patient test$.tw. (39)

127

exp *patient history taking/ (1281)

128

*telephone/ (1148)

129

exp *telehealth/ (2947)

130

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

131

*health maintenance organizations/ (1721)

132

managed care.tw. (6246)

133

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

134

or/109-133 (45787)

135

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

136

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

137

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

138

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

139

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

140

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


141

(Continued)

141

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

142

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

143

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

144

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

145

or/135-144 (17011)

146

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

147

clinical trials/ (47777)

148

control$.tw. (108869)

149

random$.tw. (54495)

150

comparative studies/ (44393)

151

experiment$.tw. (19102)

152

(time adj series).tw. (729)

153

impact.tw. (44419)

154

intervention$.tw. (75152)

155

evaluat$.tw. (109418)

156

effect?.tw. (116001)

157

exp pretest-posttest design/ (11525)

158

exp quasi-experimental studies/ (4066)

159

or/147-158 (382805)

160

35 and 146 and 159 (364)


142

WHAT’S NEW Last assessed as up-to-date: 16 July 2012.

Date

Event

Description

12 March 2013

Amended

Punctuation corrected

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

Date

Event

Description

25 August 2008

Amended

Converted to new review format

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

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

SOURCES OF SUPPORT Internal sources • Ottawa Hospital Research Institute, Ottawa Hospital, Canada. • Marilia Medical School, Brazil.


143

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

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

INDEX TERMS Medical Subject Headings (MeSH) Catheter-Related Infections [∗ prevention & control]; Catheterization, Central Venous [adverse effects; standards]; Guideline Adherence [∗ standards; statistics & numerical data]; Health Personnel [∗ standards]; Pneumonia, Ventilator-Associated [∗ prevention & control]; Urinary Catheterization [adverse effects; standards]; Urinary Tract Infections [∗ prevention & control]

MeSH check words Humans


144