Healthcare-associated infections

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Review Articles Educational s for prevention of healthcare-associated : A systematic review Nasia Safdar, MD, MS; Cybéle Abad, MD Background: Healthcare-associated s (HCAIs) are associated with considerable
Review Articles Educational s for prevention of healthcare-associated : A systematic review Nasia Safdar, MD, MS; Cybéle Abad, MD Background: Healthcare-associated s (HCAIs) are associated with considerable morbidity and mortality. Education of healthcare providers is a fundamental measure to prevent HCAI. Objective: To perform a systematic review to determine the effect of educational strategies of healthcare providers for reducing HCAI. Data Source: Multiple computerized databases for the years 1966 to November 1, 2006, supplemented by manual searches for relevant articles. Study Selection: English-language controlled studies and randomized trials that included an educational and provided data on the incidence of one or more kinds of HCAIs were included. Data Extraction: Data were extracted on study design, patient population, type of intensive care unit, details of the educational, target group for, incidence of HCAI, duration of follow-up, and costs of. Both investigators abstracted data using a standard data abstraction form; study quality was also assessed. Data Synthesis: A total of 26 studies used a number of different educational programs targeting varied study populations of healthcare providers to determine their effect on HCAI rates. Most were pre post studies and were implemented in the intensive care setting. There was a statistically significant decrease in rates after in 21 studies, with risk ratios ranging from 0 to The beneficial effect of education was apparent in teaching and nonteaching institutions and in lesser-developed countries and developed nations. Limitations: Only English language studies were included. Because of the study designs and limitations of the individual studies, a causal association between educational s and reduced HCAI rates cannot be made. Conclusions: The implementation of educational s may reduce HCAI considerably. Cluster randomized trials using validated educational s and costing methods are recommended to determine the independent effect of education on reducing HCAI and the cost-savings that may be realized with this approach. (Crit Care Med 2008; 36: ) KEY WORDS: nosocomial; ; education From the Section of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School, Madison, WI. The authors have not disclosed any potential conflicts of interest. Supported, in part, by a 2006 Vision Grant from the Society of Critical Care Medicine, Mount Prospect, IL (Dr. Safdar), and by a K12 Institutional Training Grant from the National Institutes of Health, Bethesda, MD (Dr. Safdar). For information regarding this article, Copyright 2008 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: /CCM.0B013E318165FAF3 Healthcare-associated s (HCAIs) represent a major preventable patient safety issue (1, 2). Approximately 2 million patients each year in the States acquire an HCAI, resulting in some 90,000 deaths and adding an estimated $4.5 to $5.7 billion per year to the costs of patient care (3). One fourth of HCAIs involve patients in intensive care units (4), and nearly 70% are due to microorganisms that are multi drug resistant (5), indicating an escalating public health crisis. Three types of account for 80% of all HCAIs in the intensive care unit: urinary tract (usually catheter-associated, CAUTI), bloodstream (usually associated with the use of an intravascular device [catheterrelated], CRBSI), and pneumonia (usually ventilator-associated, VAP) (4). A number of randomized controlled trials have been undertaken to determine strategies for prevention of HCAI and form the basis of recent evidence-based guidelines (6 8). Education of healthcare personnel is widely viewed as the fundamental measure in reducing HCAI. However, the specific educational s used, the target population, and the sustainability of these efforts vary widely from study to study. We undertook a systematic review to critically assess the studies that have reported the efficacy of an educational using one or more of the three major types of HCAI (CAUTI, CRBSI, and VAP) as outcomes. METHODS Search Strategy. We performed a comprehensive search of a large number of computerized databases restricted to the English language from inception to November 30, 2006 (MED- LINE, CINAHL, Cochrane Network). Search terms were related to nosocomial, healthcare-associated, ventilatorassociated pneumonia, catheter-associated urinary tract, and catheter-related bloodstream, and combinations of these terms. In addition, we perused the references from all included studies and enlisted the help of a librarian to ensure a thorough search. Inclusion Criteria. We included all randomized controlled trials, controlled beforeand-after studies, and interrupted time-series analyses. Studies that examined the effectiveness of an educational targeted at healthcare personnel for prevention of three HCAIs (CRBSI, VAP, CAUTI) were selected. The primary outcome was the incidence of one or more types of HCAI of interest. Studies that did not report incidence of as an outcome were excluded. Data Extraction and Validity Assessment. Data were extracted independently and crosschecked by both authors (NS and CA) using a Crit Care Med 2008 Vol. 36, No standard data collection form. We extracted data on setting, study design, methodologic quality, type of, outcomes reported, period of follow-up, and costs of the. Where possible, relative risks were calculated from original data for dichotomous outcomes. The study location (i.e., intensive care unit, ward, hospital-wide) and unit of analysis (i.e., number of s/ device ) were recorded. We assessed the validity of the included studies using published criteria (9 13), addressing seven major categories: question, rationale, objectives, study design,, evaluation, and results. We chose to not use a quality score assessment scale, as this may introduce bias while attempting to weigh the evidence (14). Statistical Analysis. Because of heterogeneity in the included studies, we considered a formal meta-analysis inappropriate. We reported the risk ratio from each included study. RESULTS A total of 46 studies were identified that described an educational for prevention of HCAI; 26 of these met our inclusion criteria (15 40). The remainder were excluded because rates of nosocomial were not reported (n 3), the study did not include an education (n 15), or education was not a major part of a multifaceted approach to prevention of HCAI (n 2). The details of the literature search leading to final selection are shown in Figure 1. Study Characteristics. The characteristics of the included studies are shown in Table 1. All except three studies were pre- and post observational studies, with no concurrent controls. One study was a nonrandomized trial using concurrent controls (18) Articles identified by computerized database searches (n = 31) Additional papers identified by reviewing reference lists (n = 15) Articles excluded (n= 20) Reasons for exclusion: Education was not the major part of a multifaceted approach to preventing (n=2) Rates of nosocomial were not reported (n=3) Not an educational study (n=15) Articles meeting review criteria (n = 26) Figure 1. Process of searching the literature to select studies for inclusion. and one was a cluster randomized trial (25). One study used a pre- and post design but also had concurrent controls (21). Although most study settings were limited to adults, five included the pediatric population (23, 28, 29, 31, 36). Sixteen were conducted in institutions in the States (15 18, 20, 21, 25, 28 31, 34, 35, 38 40); the remainder were conducted in Argentina (n 3) (19, 32, 37), Brazil (n 1) (27), Taiwan (n 1) (23), Pakistan (n 1) (33), Canada (n 1) (22), Thailand (n 1) (36), and Switzerland (n 2) (24, 26). Twenty studies were undertaken in intensive care units (15 17, 19 23, 26 28, 31 34, 36 40); the remaining studies were either in hospital wards (29, 30, 35), long-term care facilities (18, 25), or hospital-wide (24). Eleven studies reported rates of CRBSI (15, 16, 19 21, 27, 29, 34, 38 40), six reported rates of VAP (17, 28, 31, 33, 36, 37), and three reported rates of CAUTI (30, 32, 35). The remaining studies described rates of overall nosocomial s (18, 22 26). Of the 26 studies, two focused only on the nurses as the target population for the educational (29, 30); three involved nursing staff (2) and respiratory therapy (17, 28); eight involved nursing staff and physicians (15, 20, 26, 31, 34, 35, 38 40); and 11 either mentioned staff or healthcare workers without specifying further (18, 19, 21, 23 25, 27, 32, 33, 36, 37). One study focused solely on medical students and interns (15). The post follow-up ranged from 6 months to 2 yrs. Description of Interventions. The educational s varied according to study, but they all made use of a combination of different modalities. The most common educational tools were lectures or classes, video presentations, posters, questionnaires and fact sheets, and practical demonstrations (15, 26, 38). Six studies made use of a standardized 10- page self-study module with pretests and posttests (16, 17, 20, 31, 34, 39). Seventeen studies made use of direct feedback as part of the (15, 19, 22 25, 27, 28, 30, 32 38, 40). Other s beyond education used in the studies included protocols to remove catheters when no longer necessary, maintaining a fully stocked and easily accessible cart for catheter insertion, and emphasis on compliance with hand hygiene. The duration of each was also highly variable, ranging from a 1-day course (15) to sustained s lasting up to 8 months and even years (23). Many studies did not provide an exact duration of. Several studies simultaneously or sequentially employed other measures to prevent HCAI. Table 2 summarizes the descriptions of the educational s employed in the included studies. Efficacy of Intervention. All studies included in this review either reported the relative risk or rate ratio or provided data for its calculation. Five studies did not find a statistically significant reduction in nosocomial rates after implementation of the (18, 25, 27, 29, 38); all the other included studies found evidence for substantial efficacy of the educational. The risk ratio ranged from as low as zero to as high as 1.6. The precision estimate using confidence intervals was reported or could be calculated in 14 studies (16, 19, 20, 22, 26, 29, 30, 32 34, 37 40). Eighteen studies provided a direct statement on whether the educational translated into the desired behavior change, such as greater compliance with hand hygiene (15, 16, 18, 19, 22, 24, 26 28, 31, 32, 35 38) or better adherence to evidence-based guidelines (17, 23, 39). Durability of Intervention Effect. Sustainability of the effect was clearly reported only in three studies. The study by Berenholtz et al. (21) encompassed 4 yrs, from January 1998 to December The last was in the fourth quarter of On analyzing rates for January 2003 to April, these remained comparable with post rates at 0.54/ Crit Care Med 2008 Vol. 36, No. 3 Table 1. Studies of educational s to reduce healthcare-associated Location, Year First Author (Reference) Study Design Target Population Setting Targeted Infection Before Infections After RR (95% CI) p Value Canada, Switzerland, Switzerland, 2000 Conly (22) Kelleghan (28) Lange (29) Goetz (30) Eggimann (26) Makris (25) Pittet (24) Cluster randomized trial MICU staff MICU Overall nosocomial Nursing staff, RT RN Nursing staff 32.9 s per 100 discharges MS-ICU VAP 7 cases/100 patients Pediatric medical services/ wards Medical surgical CRBSI 4.58/1000 CAUTI wards RN, MD MICU Overall nosocomial HCW LTCF Overall nosocomial Hospital staff Hospital wide Overall nosocomial 32 cases/ s per 1000 patient 6.33/1000 patient 11.7 s per 100 discharges 3 cases/100 patients 3.83/ cases/ s per 1000 patient 4.15/1000 patient a 0.36 ( ) p () p ( ) p ( ) p ( ) p () p % 9.9% 0.59 () p Argentina, Argentina, Sherertz (15) Coopersmith (16) Zack (17) Mody (18) (19) Warren (20) Babcock (31) Berenholtz (21) Coopersmith (38) (32) Nonrandomized trial with concurrent controls Medical students, first year house staff ICU, stepdown unit CRBSI 4.5 BSI per 1000 patient RN SICU CRBSI 10.8/1000 Nursing staff, RT ICU VAP 12.6 VAPs per 1000 ventilator HCW LTCF Overall nosocomial HCW ICU CRBSI BSI per RN, MD ICU CRBSI 4.9 BSI per RN, MD, ICU VAP 8.75/1000 RT ventilator ICU staff SICU CRBSI SICU: 11.3 per ; C:5.7 per 1000 RN, MD SICU CRBSI 3.4/1000 MICU staff MICU CAUTI 21.3/ BSI per 1000 patient 3.7 BSI/ VAPs per 1000 ventilator /1000 resident b /1000 resident b BSI per 2.1 BSI per 4.74/1000 ventilator SICU: 0 per ; C:1.6 per / / () p ( ) p () 0.25 ( ) p ( ) p () 0 RR:0.28 a 0.82 ( ) p ( ) p.006 Salahuddin (33) ICU staff ICU VAP 13.2/1000 device 6.5/1000 device 0.52 ( ) p.02 Warren (34) RN, MD ICU CRBSI 9.4/ / ( ) p Crit Care Med 2008 Vol. 36, No Table 1. Continued Location, Year First Author (Reference) Study Design Target Population Setting Targeted Infection Before Infections After RR (95% CI) p Value Taiwan, Won (23) Brazil, 2005 Lobo (27) Topal (35) 2005 Thailand, Danchaivijitr 2005 Argentina, (36) (37) Pronovost (40) Warren (39) NICU staff NICU Overall nosocomial per 1000 patient ICU staff MICU CRBSI 20/1000 RN, MD General CAUTI 32/1000 medical wards per 1000 patient 11/ / () p () p () HCW ICU VAP 40.5% 24% 0.59 () HCW ICU VAP per per ( ) ventilator ventilator p.003 HCW ICU CRBSI 7.7 per 1000 HCW ICU CRBSI 11.2 per per per ( ) 0.79 ( ) p.05 RR, relative risk; CI, confidence interval; MICU, medical intensive care unit; MS-ICU, medical/surgical intensive care unit; VAP, ventilator-associated pneumonia;, not reported; RN, registered nurse; CRBSI, catheter-related bloodstream ; CAUTI, catheter-associated urinary tract ; MD, physician; HCW, healthcare worker; LTCF, long-term care facility; BSI, bloodstream ; SICU, surgical intensive care unit; RT, respiratory therapist; ICU, intensive care unit; C, control facility; NICU, neonatal intensive care unit. a Rates of CRBSI in study facility or ICU compared with control facility or ICU; b range of rates reported. Similarly, Coopersmith et al. (16) likewise observed low rates up to a year after the study ended. Pronovost et al. (40) found that the rates of CRBSI continued to decline at 16 to 18 months of follow-up after ended. Assessment of Methodologic Quality of Included Studies. The study rationale was easily identifiable in all the studies. The study design was appropriate for the study question in all, and a majority (73%) described the design in sufficient detail. However, only 43% of studies chose a similar comparison group for their study. Similarly, only 39% studied the long-term (i.e., 1 yr post) effects of their. Only one of the studies was a cluster randomized controlled trial. The setting under which the s were carried out was well described in all studies. However, detailed description of the educational methods occurred only in 60% of studies. A description of the level of the learner was also lacking in many studies. In terms of study evaluation, outcomes matched the underlying objective in 75% of the studies. The methods used for statistical testing were described in all studies; however, few of the studies performed adjustment for baseline differences in their pre- and post groups, and none reported an assessment of power or sample size calculation. Important threats to internal validity in quasi-experimental studies such as maturation, diffusion, regression to the mean, and confounding factors were not addressed in the majority of the included studies. Costs of Interventions. Only four studies provided estimates of the costs of their s (15, 17, 20, 24). Zack et al. (17) calculated that costs for implementing the education program, inclusive of salaries, benefits, and supplies, amounted to $59,200. Sherertz et al. (15) estimated that the overall cost for the al course was $74,081. Warren et al. (20) estimated that the cost of their educational program was approximately $4,000. Pittet et al. (24) retrospectively analyzed program costs, and conservatively estimated direct and indirect costs at Fr 380,000. Cost-Effectiveness of Interventions. Only a few studies provided an assessment of estimated cost savings associated with the (15 17, 21, 24, 28, 30, 34, 35, 39). The amount of estimated savings varied from study to study but were all based on the total number of s prevented by the. of the included studies undertook a prospective formal cost-effectiveness or cost-benefit analysis. For example, Goetz et al. (30) used published estimates of costs associated with nosocomial urinary tract s and, by preventing 106 s that would have occurred without the, estimated savings as much as $403,000 over the study period. Berenholtz et al. (21) used published estimates for the mean cost of CRBSI and found that their s prevented 43 CRBSIs, eight deaths, and $1,945,922 in additional costs per year. Warren et al. (34) estimated savings ranging from $103,600 to as much as $1,573,000 in 24 months by preventing 28 CRBSIs, using estimates of approximately $34,000 $56,000 per episode of CRBSI. Coopersmith et al. (16) estimates savings of $185,000 to $2.8 million by preventing 50 catheter-related s during the 18- month post period. Digiovine et al. (41) and Dimick et al. (42) used estimates from other analyses. Sherertz et al. (15) estimated saving $63,082 to $815,309 from a 28% decline in catheterrelated in the 18-month post period based on attributable costs of catheter-related from Centers for Disease Control and Prevention data and other studies. Zack et al. (17) used estimates from recent studies on VAP and calculated cost savings between $425,606 and $4.05 million 936 Crit Care Med 2008 Vol. 36, No. 3 Table 2. Description of s and costs of s in included studies First Author (Reference) Description of Intervention Assessment of Change in Behavior Targeted by Intervention Other Interventions Done Beyond Education Cost of Intervention (US) Conly (22) Kelleghan (28) Lange (29) Feedback data on handwashing practices presented during in-service rounds. Policy and procedure review and modification. Posters, instruction modules distributed. Intervention carried out twice in 4-yr period 1 hr of education focused on relationship between practice and. Interactive hands on demonstration of practices to prevent VAP In-services for nursing staff; patient families given instruction by nurses and video Compliance with handwashing improved after Handwashing, sterile procedures Multiple changes in catheter maintenance and blood draws Goetz (30) Video review of catheter care, feedback of CAUTI rates Eggimann Slideshows, in-service examinations, practical Multiple changes in catheter (26) demonstrations, detailed written guidelines insertion and maintenance Makris (25) 3-part modules/presentations 40 min each, Change in germicidal 2 3 wks apart product Pittet (24) Poster campaign to encourage hand hygiene Compliance with hand Promotion of alcohol-based hygiene improved after rubs Sherertz 1-day course: introduction to basic Use of full-size sterile drapes $74,081 (15) control principles (hand hygiene, isolation increased after precaution), 5- to 15-min didactic teaching at various stations on blood draws, IVD insertion, urinary catheter insertion Zack (17) 10-page self-study module on prevention of $59,200 VAP, before and after tests, posters, lectures. Intervention was initiated in September 2000 Warren (20) Reporting CRBSI rates to all ICU personnel; Increased proportion of $ min lectures and grand rounds to catheters were inserted into nursing and medical personnel on subclavian (preferred prevention of CRBSI; posters and fact location) during sheets distributed in ICU; 10-page, selfstudy period than in module on prevention of CRBSI in pre- period 1999 Babcock (31) Warren (34) Coopersmith (16) Mody (18) 10-page self-study mod
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