Clinical Practice Improvement Initiatives
2009; Elsevier BV; Volume: 136; Issue: 2 Linguagem: Inglês
10.1378/chest.09-0637
ISSN1931-3543
Autores Tópico(s)Patient Safety and Medication Errors
ResumoIn this issue of CHEST (see page 426), Levin et al1Levin P Shatz O Svini S et al.Contamination of portable x-ray equipment with resistant bacteria in the intensive care unit.Chest. 2009; 136: 426-432Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar describe their experience with an infection control program aimed at technicians employing portable radiology equipment in the ICU setting. These investigators showed that an intervention aimed at improving infection control measures using an alcohol hand rub and changing gloves before and after each contact with the patient or radiology equipment significantly reduced colonization of the radiology equipment with Gram-negative bacteria (reduction 39 to 0%; p < 0.001). Additionally, these authors demonstrated that Acinetobacter baumannii colonization of portable radiology equipment, originating from a patient, occurred during the observation period. Of equal clinical importance was the finding that the infection control program deteriorated significantly during a third observation period conducted 5 months after completion of the intervention period. This deterioration was related to a decrease in compliance with the measures contained within the infection control program. This study highlights the importance of monitoring practice improvement changes following the intervention phase where the involvement and compliance of the participants is generally at its highest level. The high level of compliance during the intervention phase is usually due to the knowledge that individuals' compliance with the intervention and clinical outcomes are being prospectively monitored. The failure to survey and report the long-term compliance and outcomes associated with practice improvement changes, especially infection control practices, is a common shortcoming of investigations describing the clinical benefits of such interventions.2Kollef M SMART approaches for reducing nosocomial infections in the ICU.Chest. 2008; 134: 447-456Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar At Barnes-Jewish Hospital (BJH), we have reported3Zack JE Garrison T Trovillion E et al.Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia.Crit Care Med. 2002; 30: 2407-2412Crossref PubMed Scopus (240) Google Scholar, 4Babcock HM Zack JE Garrison T et al.An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects.Chest. 2004; 125: 2224-2231Abstract Full Text Full Text PDF PubMed Scopus (178) Google Scholar, 5McMullen KM Zack J Coopersmith CM et al.Use of hypochlorite solution to decrease rates of Clostridium difficile-associated diarrhea.Infect Control Hosp Epidemiol. 2007; 28: 205-207Crossref PubMed Scopus (54) Google Scholar, 6Lawrence SJ Puzniak LA Shadel BN et al.Clostridium difficile in the intensive care unit: epidemiology, costs, and colonization pressure.Infect Control Hosp Epidemiol. 2007; 28: 123-130Crossref PubMed Scopus (128) Google Scholar, 7Warren DK Zack JE Mayfield JL et al.The effect of an education program on the incidence of central venous catheter-associated bloodstream infection in a medical ICU.Chest. 2004; 126: 1612-1618Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar, 8Warren DK Guth RM Coopersmith CM et al.Epidemiology of methicillin-resistant Staphylococcus aureus colonization in a surgical intensive care unit.Infect Control Hosp Epidemiol. 2006; 27: 1032-1040Crossref PubMed Scopus (66) Google Scholar, 9Merz LR Warren DK Kollef MH et al.The impact of an antibiotic cycling program on empirical therapy for gram-negative infections.Chest. 2006; 130: 1672-1678Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar the effects of infection control programs aimed at the prevention of nosocomial infections, including ventilator-associated pneumonia, Clostridium difficile-associated diarrhea, catheter-associated bloodstream infections, wound infections, and antimicrobial resistance. As part of overall quality improvement at BJH, prospective surveillance and reporting of nosocomial infections occurs, including regular reports of individual ICU infection rates to the hospital Critical Care Committee. This provides a “report card” to clinicians and the hospital administration on the compliance and effectiveness of these programs. “Zero” rates of nosocomial infections have not been reported and are generally not achievable. However, prospective monitoring of nosocomial infections allows spikes in the infection rates to be identified, which require directed investigation and intervention. Such an approach to the implementation of infection control programs ensures that the early successes of these interventions are maintained and possibly improved on. Prospective and ongoing monitoring of process improvement programs also allows the effects of new interventions or practices to be evaluated. Schuerer et al10Schuerer DJ Zack JE Thomas J et al.Effect of chlorhexidine/silver sulfadiazine-impregnated central venous catheters in an intensive care unit with a low blood stream infection rate after implementation of an educational program: a before-after trial.Surg Infect. 2007; 8: 445-454Crossref PubMed Scopus (31) Google Scholar assessed the impact of routinely using antiseptic-coated central venous catheters in the surgical ICU of BJH. The ongoing nosocomial infection surveillance program was employed to monitor the impact of this intervention on bloodstream infection rates in the ICU. Although bloodstream infections were reduced during the implementation phase of this study, the impact of the antiseptic-coated catheters was not significantly different compared with the standard infection control practices employed for the prevention of bloodstream infections; thus, routine use of these catheters was not recommended.10Schuerer DJ Zack JE Thomas J et al.Effect of chlorhexidine/silver sulfadiazine-impregnated central venous catheters in an intensive care unit with a low blood stream infection rate after implementation of an educational program: a before-after trial.Surg Infect. 2007; 8: 445-454Crossref PubMed Scopus (31) Google Scholar, 11Coopersmith CM Rebmann TL Zack JE et al.Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit.Crit Care Med. 2002; 30: 59-64Crossref PubMed Scopus (239) Google Scholar, 12Coopersmith CM Zack JE Ward MR et al.The impact of bedside behavior on catheter-related bacteremia in the intensive care unit.Arch Surg. 2004; 139: 131-136Crossref PubMed Scopus (69) Google Scholar Additionally, these investigators found12Coopersmith CM Zack JE Ward MR et al.The impact of bedside behavior on catheter-related bacteremia in the intensive care unit.Arch Surg. 2004; 139: 131-136Crossref PubMed Scopus (69) Google Scholar that deterioration occurred in clinicians' overall compliance with the bloodstream infection prevention program. A behavioral intervention improved all identified deficiencies in the infection control program, leading to a nonsignificant decrease in catheter-associated bloodstream infections. Prospective surveillance of infection control practices can also identify new changes in infection rates or clinical outcomes requiring intervention. Puzniak et al13Puzniak LA Leet T Mayfield J et al.To gown or not to gown: the effect on acquisition of vancomycin-resistant enterococci.Clin Infect Dis. 2002; 35: 18-25Crossref PubMed Scopus (99) Google Scholar showed that colonization with vancomycin-resistant enterococci in the ICU setting increased significantly after protective gowns were removed from routine use due to budgetary reductions in the ICUs of BJH. Within 2 months, the rates of colonization with vancomycin-resistant enterococci increased significantly and were associated with greater rates of infection and antibiotic use for this pathogen.13Puzniak LA Leet T Mayfield J et al.To gown or not to gown: the effect on acquisition of vancomycin-resistant enterococci.Clin Infect Dis. 2002; 35: 18-25Crossref PubMed Scopus (99) Google Scholar, 14Puzniak LA Gillespie KN Leet T et al.A cost benefit analysis of gown use in controlling vancomycin-resistant Enterococcus transmission: is it worth the price.Infect Control Hosp Epidemiol. 2004; 25: 418-424Crossref PubMed Scopus (57) Google Scholar Subsequent reintroduction of the gowns returned patient colonization rates with vancomycin-resistant enterococci back to baseline levels, which were maintained over time and resulted in cost savings.14Puzniak LA Gillespie KN Leet T et al.A cost benefit analysis of gown use in controlling vancomycin-resistant Enterococcus transmission: is it worth the price.Infect Control Hosp Epidemiol. 2004; 25: 418-424Crossref PubMed Scopus (57) Google Scholar Clinicians should also be familiar with the main reasons for deterioration in the compliance with and effectiveness of infection control programs. Foremost among these is the relationship between changing clinical workloads and adherence to the elements of these programs, especially in the ICU setting. Pittet et al15Pittet D Mourouga P Perneger TV Compliance with handwashing in a teaching hospital: infection control program.Ann Intern Med. 1999; 130: 126-130Crossref PubMed Scopus (768) Google Scholar showed that compliance with hand washing in the ICU is directly related to the workloads of nurses. Additionally, physician adherence to hand hygiene appears to also be associated with work constraints, as well as knowledge and cognitive factors, suggesting multifaceted factors for noncompliance.16Pittet D Simon A Hugonnet S et al.Hand hygiene among physicians: performance, beliefs, and perceptions.Ann Intern Med. 2004; 141: 1-8Crossref PubMed Scopus (517) Google Scholar Needleman et al17Needleman J Buerhaus P Mattke S et al.Nurse-staffing levels and the quality of care in hospitals.N Engl J Med. 2002; 346: 1715-1722Crossref PubMed Scopus (1683) Google Scholar studied 799 US hospitals to assess the relationship between nursing workload and patient outcomes. Optimal staffing models employing registered nurses were estimated to reduce nosocomial urinary tract infections by 9% and nosocomial pneumonia by 6%. In addition to workloads, the expertise or experience of health-care providers appears to be an important determinant of the effectiveness of infection control programs. Alonso-Echanove et al18Alonso-Echanove J Edwards JR Richards MJ et al.Effect of nurse staffing and antimicrobial-impregnated central venous catheters on the risk for bloodstream infections in intensive care units.Infect Control Hosp Epidemiol. 2003; 24: 916-925Crossref PubMed Scopus (140) Google Scholar found that critically ill patients cared for by float nurses had a significantly greater risk of catheter-associated bloodstream infection compared to patients cared for by nurses assigned to the ICU for the majority of the duration of the patient's central venous catheter placement. Finally, studies from the Center for Disease Control and Prevention19Robert J Fridkin SK Blumberg HM et al.The influence of the composition of the nursing staff on primary bloodstream infection rates in a surgical intensive care unit.Infect Control Hosp Epidemiol. 2000; 21: 12-17Crossref PubMed Scopus (176) Google Scholar, 20Fridkin SK Pear SM Williamson TH et al.The role of understaffing in central venous catheter-associated bloodstream infections.Infect Control Hosp Epidemiol. 1996; 17: 150-158Crossref PubMed Scopus (391) Google Scholar have also linked the composition of nursing staffing to the occurrence of bloodstream infections, including outbreaks of nosocomial infection. In addition to nosocomial infections, other health-care-associated adverse events have been associated with inadequate staffing in the hospital and ICU settings. Thorens et al21Thorens JB Kaelin RM Jolliet P et al.Influence of the quality of nursing on the duration of weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease.Crit Care Med. 1995; 23: 1807-1915Crossref PubMed Scopus (159) Google Scholar showed that delayed weaning from mechanical ventilation occurred as nursing workloads were increased. Recognition of this problem and the implementation of more balanced nurse/patient work ratios resulted in significant reductions in the duration of weaning. Similarly, needlestick injuries and near misses have been associated with increased nursing workloads, as have medication errors.22Clarke SP Rockett JL Sloane DM et al.Organizational climate, staffing, and safety equipment as predictors of needlestick injuries and near-misses in hospital nurses.Am J Infect Control. 2002; 30: 207-216Abstract Full Text Full Text PDF PubMed Scopus (192) Google Scholar, 23Blegen MA Goode CJ Reed L Nurse staffing and patient outcomes.Nurs Res. 1998; 47: 43-50Crossref PubMed Scopus (342) Google Scholar Although the science supporting this hypothesis is not exact, the overall evidence24Hugonnet S Harbarth S Sax H et al.Nursing resources: a major determinant of nosocomial infection?.Curr Opin Infect Dis. 2004; 17: 329-333Crossref PubMed Scopus (123) Google Scholar suggests that understaffing is an important element that can result in nonadherence to infection control practices as well as other practice improvement interventions. Differences in workloads for nurses on general hospital wards compared to ICUs and emergency departments may also explain some of the outcome differences observed between these hospital areas after the implementation of bundled order sets for the management of severe sepsis.25Thiel SW Asghar MF Micek ST et al.Hospital-wide impact of a standardized order set for the management of bacteremic severe sepsis.Crit Care Med. 2009; 37: 819-824Crossref PubMed Scopus (90) Google Scholar, 26Gao F Melody T Daniels D et al.The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study.Crit Care. 2005; 9: R764-R770Crossref PubMed Google Scholar Ongoing monitoring of compliance with infection control programs appears to be a critical element to ensure their long-term success. Several strategies can be employed to optimize health-care providers' adherence to these programs over time. Role models or champions promoting the importance of infection control programs provide professional detailing that can improve compliance. Barrett and Randle27Barrett R Randle J Hand hygiene practices: nursing students' perceptions.J Clin Nurs. 2008; 17: 1851-1857Crossref PubMed Scopus (77) Google Scholar found that nursing students' perceived hand hygiene compliance was influenced by workload and factors such as their skin condition. However, students also perceived other health-care workers as being an important factor influencing their hand hygiene compliance.27Barrett R Randle J Hand hygiene practices: nursing students' perceptions.J Clin Nurs. 2008; 17: 1851-1857Crossref PubMed Scopus (77) Google Scholar In addition to role models, computerized reporting and documentation of ICU core measures has been shown28Wahl WL Talsma A Dawson C et al.Use of computerized ICU documentation to capture ICU core measures.Surgery. 2006; 140: 684-689Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar to improve compliance with infection control practices. Multifaceted and multilevel strategies with built-in redundancies appear to have the greatest likelihood of producing sustained adherence to infection control programs.29Pittet D Hugonnet S Harbarth S et al.Effectiveness of a hospital-wide programme to improve compliance with hand hygiene: Infection Control Programme.Lancet. 2000; 356: 1307-1312Abstract Full Text Full Text PDF PubMed Scopus (1851) Google Scholar, 30Larson EL Bryan JL Adler LM et al.A multifaceted approach to changing handwashing behavior.Am J Infect Control. 1997; 25: 3-10Abstract Full Text PDF PubMed Scopus (177) Google Scholar Finally, nosocomial infection rates are increasingly being employed as a comparative indicator of medical care quality in hospitals for the purposes of reimbursement and patient referral from practice plans.31Trapp D CMS proposes no-pay rules for 3 surgical errors.Available at: www.ama-assn.org/amednews/2008/12/22/gvsa1222.htmGoogle Scholar As a result of this scrutiny, hospitals appear to be more willing to support such programs financially to ensure their success. This type of administrative support also appears to be an important element contributing to the long-term success of these programs.32Amalberti R Auroy Y Berwick D et al.Five system barriers to achieving ultrasafe health care.Ann Intern Med. 2005; 142: 756-764Crossref PubMed Scopus (416) Google Scholar In summary, ICU clinicians should be involved in the development and implementation of infection control programs for their units. This will require collaboration with other groups within the hospital, including infection control, informatics, and those groups involved with quality improvement. However, ongoing surveillance is required to assure the long-term success of such programs. This will require having mechanisms in place to actively monitor health-care workers' compliance with these programs and their efficacy over time. Escalation of infection rates should prompt interventions to increase compliance with the infection control program, introduce new technologies or interventions aimed at reducing the infection rates that are independent of staffing influences, or both. A one-time reduction in nosocomial infection rates should not be accepted as the final result of any intervention or program, as the deterioration or erosion of the program's success is likely to occur over time.
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