Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 6: Prevention of Healthcare–Associated Infections)
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 6: Prevention of Healthcare–Associated Infections)
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发表时间：
2007
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通讯作者：
S. Ranji;Kanaka D. Shetty;K. Posley;Robyn Lewis;Vandana Sundaram;C. Galvin;L. Winston
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作者：
S. Ranji;Kanaka D. Shetty;K. Posley;Robyn Lewis;Vandana Sundaram;C. Galvin;L. Winston
目的 确定质量改进策略对促进坚持预防特定（手术部位感染 (SSI)、中心导管相关血流感染 (CLABSI)、呼吸机相关肺炎 (VAP) 和导管相关尿路感染 (CAUTI)）医疗保健相关感染 (HAI) 干预措施以及对 HAI 发生率的影响。数据来源 MEDLINE® 和 Cochrane Collaboration 的有效实践和护理组织登记。我们还审查了系统评价和纳入研究的参考文献清单，并联系了专家。检索策略和纳入标准 我们纳入了随机和半随机对照试验、对照前后研究、中断时间序列和简单前后研究，这些研究报告了 HAI 率或对四种目标 HAI 中任何一种的目标预防性质量改进 (QI) 干预措施的遵守率。 QI 策略分为临床医生教育、患者教育、审核和反馈、临床医生提醒、组织变革（包括专业角色的修订、人员配置变化和全面质量管理/持续质量改进）以及财务或监管激励。我们将手部卫生作为所有医院感染的预防性干预措施。针对 SSI 的目标预防干预措施是适当的围手术期抗生素预防（包括适当的抗生素选择、时机和持续时间）、围手术期血糖控制和减少手术部位的剃毛。对于 CLABSI，我们的目标是遵守最大程度的无菌屏障预防措施，使用氯己定进行皮肤消毒，并避免股动脉插管。对于 VAP，我们的目标是半卧位患者体位和每日评估呼吸机脱机准备情况。对于 CAUTI，我们的目标是减少不必要的导管使用，并坚持无菌导管插入和导管护理。我们的主要结局是 HAI 发生率（SSI 定义为每 100 例感染率，CLABSI、VAP 和 CAUTI 定义为每 1,000 个设备日感染率）和预防性干预措施的依从率（定义为接受预防性干预的高危患者百分比）。次要结果包括对成本的影响以及与干预措施相关的不利影响。数据收集和分析 两名评审员独立提取数据。由于研究人群、QI 策略、预防干预措施和结果的异质性，没有尝试进行正式的定量分析。我们根据预先设定的内部和外部有效性标准评估研究质量。主要结果 64 项研究符合所有纳入标准； 28 项研究涉及 SSI 预防，19 项研究涉及 CLABSI 预防，12 项研究涉及 VAP 预防，10 项研究涉及 CAUTI 预防。三项研究的目标是预防多种 HAI。这项研究的方法学质量普遍较差，因为纳入的 64 项研究中有 52 项是简单的前后研究，而且其中大多数（52 项研究中的 33 项）仅报告了干预前后一个时间点的数据。大多数纳入的研究报告了感染率，但没有报告预防性干预措施的依从率。基线 HAI 发生率普遍高于疾病控制和预防中心国家医院感染监测系统 (NNIS) 报告的中位发生率。针对手术部位感染的研究：大多数研究的目标是提供适当的抗生素预防（28 项研究中的 22 项），结合使用教育干预、审核和反馈以及临床医生提醒。其中十六项研究报告了遵守适当抗生素预防指南的数据。在两项对照研究中，临床医生提醒可有效改善适当的预防措施；在三项多中心研究（两项中断时间序列和一项简单的前后研究）中，带有审核和反馈的教育干预措施是有效的。没有 QI 策略在降低 SSI 率或提高对其他有针对性的预防干预措施的依从性方面明显有效。针对中心静脉导管相关血流感染的研究：基于两项对照前后研究、一项中断时间序列以及四项方法学质量相对较好的简单前后研究，对临床医生的积极教育干预似乎可以有效降低 CLABSI 率。其中两项研究将教育与遵守插入部位实践的明确检查表结合起来，并允许护士在不遵守检查表的情况下停止手术，这一策略值得未来研究。针对呼吸机相关性肺炎的研究：根据两项简单的前后研究的证据，积极的教育干预措施（包括使用网络和视频教程）似乎可以降低 VAP 率。由于我们没有发现任何对照研究，因此该领域的结论特别有限。针对导尿管相关尿路感染的研究：向医生发出的印刷或计算机提醒，加上“自动停止指令”，似乎可以有效缩短导尿时间（基于两项对照研究和三项简单的前后研究）。 结论 用于提高医疗保健相关感染预防干预措施依从性的质量改进策略的证据通常质量不理想，主要由单中心、简单的前后研究组成，内部和外部有效性有限。因此，我们无法就预防 HAI 的可行 QI 策略得出任何明确的结论。基于有限的可用数据，我们建议以下策略值得未来研究，并可能更广泛地实施：使用带有自动停止命令的印刷或计算机提醒来减少不必要的导尿，印刷或计算机提醒以改善外科抗生素预防，使用检查表进行积极的教育干预以提高对中心线插入实践的依从性，以及积极的教育干预措施（例如教程）以提高对呼吸机相关性肺炎预防干预措施的依从性。迫切需要对预防 HAI 的 QI 策略进行更高质量的研究。
Objective To determine the effects of quality improvement strategies on promoting adherence to interventions for prevention of selected (surgical site infections (SSI), central line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infections (CAUTI)) healthcare-associated infections (HAIs), and on HAI rates. Data Sources MEDLINE® and Cochrane Collaboration's Effective Practice and Organisation of Care registry. We also reviewed the reference lists of systematic reviews and included studies, and contacted experts. Search Strategy and Inclusion Criteria We included randomized and quasi-randomized controlled trials, controlled before-after studies, interrupted time series, and simple before-after studies that reported either HAI rates or rates of adherence to target preventive quality improvement (QI) interventions for any of the four target HAIs. QI strategies were classified as clinician education, patient education, audit and feedback, clinician reminders, organizational change (including revision of professional roles, staffing changes, and total quality management/continuous quality improvement), and financial or regulatory incentives. We targeted hand hygiene as a preventive intervention for all HAIs. The target preventive interventions specific to SSI were appropriate perioperative antibiotic prophylaxis (including appropriate antibiotic selection, timing, and duration), perioperative glucose control, and decreasing shaving of the operative site. For CLABSI, we targeted adherence to maximal sterile barrier precautions, use of chlorhexidine for skin antisepsis, and avoidance of femoral catheterization. For VAP, we targeted semirecumbent patient positioning and daily assessment of readiness for ventilator weaning. For CAUTI, we targeted reduction in unnecessary catheter use and adherence to aseptic catheter insertion and catheter care. Our primary outcomes were the rate of HAI (defined as infections per 100 cases for SSI and infections per 1,000 device-days for CLABSI, VAP, and CAUTI) and the rate of adherence to preventive interventions (defined as the percentage of patients at risk who received the preventive intervention). Secondary outcomes included effects on costs and adverse effects associated with the interventions. Data Collection and Analysis Two reviewers independently abstracted data. Due to heterogeneity in study populations, QI strategies, preventive interventions, and outcomes, no formal quantitative analysis was attempted. We assessed study quality based on prespecified criteria for internal and external validity. Main Results Sixty-four studies met all inclusion criteria; 28 studies addressed prevention of SSI, 19 CLABSI prevention, 12 VAP prevention, and 10 CAUTI prevention. Three studies targeted prevention of multiple HAIs. The study methodologic quality was generally poor, as 52 of 64 included studies were simple before-after studies, and most of these (33 of 52) reported data at only one time point before and after the intervention. The majority of included studies reported infection rates, but did not report rate of adherence to preventive interventions. Baseline HAI rates were generally above the median rates reported by the Centers for Disease Control and Prevention's National Nosocomial Infection Surveillance System (NNIS). Studies addressing surgical site infections: The majority of studies targeted provision of appropriate antibiotic prophylaxis (22 of 28 studies), using combinations of educational interventions, audit and feedback, and clinician reminders. Sixteen of these studies reported data on adherence to appropriate antibiotic prophylaxis guidelines. Clinician reminders were effective at improving appropriate prophylaxis in two controlled studies; educational interventions with audit and feedback were effective in three multicenter studies (two interrupted time series and one simple before-after study.) No QI strategies were clearly effective at reducing SSI rates or improving adherence to other targeted preventive interventions. Studies addressing central line-associated bloodstream infection: Active educational interventions for clinicians appeared effective at reducing CLABSI rates, based on two controlled before-after studies, one interrupted time series, and four simple before-after studies of relatively good methodologic quality. Two of these studies combined education with an explicit checklist for adherence to insertion site practices and allowed nurses to stop the procedure if the checklist was not followed, a strategy worthy of future study. Studies addressing ventilator-associated pneumonia: Active educational interventions (including use of web-based and video tutorials) appeared to reduce VAP rates, based on evidence from two simple before-after studies. Conclusions in this area are especially limited as we did not identify any controlled studies. Studies addressing catheter-associated urinary tract infection: Printed or computer-based reminders to physicians, coupled with an “automatic stop order”, appear to be effective at reducing the duration of urethral catheterization (based on two controlled studies and three simple before-after studies.) Conclusion The evidence for quality improvement strategies to improve adherence to preventive interventions for healthcare-associated infections is generally of suboptimal quality, consisting primarily of single-center, simple before-after studies of limited internal and external validity. Thus, we were unable to reach any firm conclusions regarding actionable QI strategies to prevent HAIs. Based on the limited available data, we suggest that the following strategies are worthy of future study, and possibly wider implementation: use of printed or computer-based reminders with automatic stop orders to reduce unnecessary urethral catheterization, printed or computer-based reminders to improve surgical antibiotic prophylaxis, active educational interventions with use of of checklists to improve adherence to central line insertion practices, and active educational interventions such as tutorials to improve adherence to preventive interventions for ventilator-associated pneumonia. Higher quality studies of QI strategies for HAI prevention are urgently needed.