National Estimates of Central Line-Associated Bloodstream Infections in Critical Care Patients
(See the commentary by Dixon-Woods and Perencevich, on pages 555-557 .) Objective. Recent studies have demonstrated that central line-associated bloodstream infections (CLABSIs) are preventable through implementation of evidence-based prevention practices. Hospitals have reported CLABSI data to the Centers for Disease Control and Prevention (CDC) since the 1970s, providing an opportunity to characterize the national impact of CLABSIs over time. Our objective was to describe changes in the annual number of CLABSIs in critical care patients in the United States. Design. Monte Carlo simulation. Setting. US acute care hospitals. Patients. Nonneonatal critical care patients. Methods. We obtained administrative data on patient-days for nearly all US hospitals and applied CLABSI rates from the National Nosocomial Infections Surveillance and the National Healthcare Safety Network systems to estimate the annual number of CLABSIs in critical care patients nationally during the period 1990-2010 and the number of CLABSIs prevented since 1990. Results. We estimated that there were between 462,000 and 636,000 CLABSIs in nonneonatal critical care patients in the United States during 1990-2010. CLABSI rate reductions led to between 104,000 and 198,000 fewer CLABSIs than would have occurred if rates had remained unchanged since 1990. There were 15,000 hospital-onset CLABSIs in nonneonatal critical care patients in 2010; 70% occurred in medium and large teaching hospitals. Conclusions. Substantial progress has been made in reducing the occurrence of CLABSIs in US critical care patients over the past 2 decades. The concentration of critical care CLABSIs in medium and large teaching hospitals suggests that a targeted approach may be warranted to continue achieving reductions in critical care CLABSIs nationally.
Available from: Carolyn Tarrant
- "Matching Michigan came into being because there was already strong policy and professional pressure—not least because of the success of Keystone—to do better in reducing rates CVC-BSIs. A recently published analysis of 20 years of data shows that CVC-BSI rates began to plummet from 1990 onward, and the increasing rarity of the infections is likely to have undermined the view that they were the price of doing business in ICUs [24,25]. The forces that brought the program into being continued to intensify over the course of the program. "
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ABSTRACT: Quality and safety improvement initiatives in healthcare often display two disconcerting effects. The first is a failure to outperform the secular trend. The second is the decline effect, where an initially promising intervention appears not to deliver equally successful results when attempts are made to replicate it in new settings. Matching Michigan, a patient safety program aimed at decreasing central line infections in over 200 intensive care units (ICUs) in England, may be an example of both. We aimed to explain why these apparent effects may have occurred.
We conducted interviews with 98 staff and non-participant observation on 19 ICUs; 17 of these units were participating in Matching Michigan. We undertook further telephone interviews with 29 staff who attended program training events and we analyzed relevant documents.
One Matching Michigan unit transformed its practices and culture in response to the program; five boosted existing efforts, and 11 made little change. Matching Michigan's impact may have been limited by features of program design and execution; it was not an exact replica of the original project. Outer and inner contexts strongly modified the program's effects. The outer context included previous efforts to tackle central line infections superimposed on national infection control policies that were perceived by some as top-down and punitive. This undermined engagement in the program and made it difficult to persuade participants that the program was necessary. Individual ICUs' histories and local context were also highly consequential: their past experience of quality improvement, the extent to which they were able to develop high quality data collection and feedback systems, and the success of local leaders in developing consensus and coalition all influenced the program's impact on local practices.
Improved implementation of procedural good practice may occur through many different routes, of which program participation is only one. The 'phenotype' of compliance may therefore arise through different 'genotypes.' When designing and delivering interventions to improve quality and safety, risks of decline effects and difficulties in demonstrating added value over the secular trend might be averted by improved understanding of program mechanisms and contexts of implementation.
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ABSTRACT: This paper aims to describe, using an evidence-based approach, the importance of and the resources necessary for implementing effective infection prevention and control (IPC) programmes. The intrinsic and explicit values of such strategies are presented from a clinical, health-economic and patient safety perspective. Policy makers and hospital managers are committed to providing comprehensive, accessible, and affordable healthcare of high quality. Changes in the healthcare system over time accompanied with variations in demographics and case-mix have considerably affected the availability, quality and ultimately the safety of healthcare. The main goal of an IPC programme is to prevent and control healthcare-associated infections (HAI). Many patient-, healthcare provider-, and organizational factors are associated with an increased risk for acquiring HAIs and may impact both the quality and outcome of patient care. Evidence has been published in support of having an effective IPC programme. It has been estimated that about one-third of HAIs could be prevented if key elements of the evidence-based recommendations for IPC are adequately introduced and followed. However, several healthcare agencies from over the world have reported deficits in the essential resources and components of current IPC programmes. To meet its main goal, staffing, training, and infrastructure requirements are needed. Nevertheless, and given the economic crisis, policy makers and hospital managers may be tempted to not increase or even to reduce the budget as it consumes resources and does not generate sufficient visible revenue. IPC is a critical issue in patient safety, as HAIs are by far the most common complication affecting admitted patients. The significant clinical and health-economic burden HAIs place on the healthcare system speak to the importance of getting introduced effective IPC programmes.
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