Systematic Reviews or Meta-analysis on Hand Hygiene and Its Effects on Reducing Clabsis
Clin Infect Dis. 2014 Jul 1; 59(1): 96–105.
Prevention of Primal Line–Associated Bloodstream Infections Through Quality Improvement Interventions: A Systematic Review and Meta-analysis
Koen Blot
oneFaculty of Medicine and Health Sciences, Ghent University
Jochen Bergs
3Health Economic science and Patient Rubber, Hasselt University, Hasselt, Belgium
Dirk Vogelaers
aneFaculty of Medicine and Wellness Sciences, Ghent Academy
2Full general Internal Medicine, Ghent University Infirmary, Ghent
Stijn Blot
1Faculty of Medicine and Health Sciences, Ghent University
4Burns, Trauma and Critical Care Research Middle, The University of Queensland, Brisbane, Commonwealth of australia
Dominique Vandijck
1Kinesthesia of Medicine and Health Sciences, Ghent University
2General Internal Medicine, Ghent University Hospital, Ghent
iiiWellness Economics and Patient Safety, Hasselt University, Hasselt, Belgium
Received 2014 Feb 4; Accepted 2014 Apr 2.
- Supplementary Materials
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Supplementary Data
GUID: E7207694-D699-41D9-A4FE-D622E2FC50EF
GUID: F2C2F619-3AD8-4FF5-8D79-505837BD085D
Abstract
This systematic review and meta-analysis examines the bear upon of quality improvement interventions on central line–associated bloodstream infections in adult intensive care units. Studies were identified through Medline and manual searches (1995–June 2012). Random-effects meta-analysis obtained pooled odds ratios (ORs) and 95% conviction intervals (CIs). Meta-regression assessed the bear upon of bundle/checklist interventions and high baseline rates on intervention effect. Forty-one earlier–later on studies identified an infection charge per unit decrease (OR, 0.39 [95% CI, .33–.46]; P < .001). This consequence was more than pronounced for trials implementing a packet or checklist approach (P = .03). Furthermore, meta-analysis of 6 interrupted time series studies revealed an infection rate reduction 3 months postintervention (OR, 0.thirty [95% CI, .10–.88]; P = .03). At that place was no difference in infection rates betwixt studies with low or loftier baseline rates (P = .eighteen). These results suggest that quality improvement interventions contribute to the prevention of central line–associated bloodstream infections. Implementation of care bundles and checklists appears to yield stronger take a chance reductions.
Keywords: primal line–associated bloodstream infection, catheter-related bloodstream infection, quality improvement intervention, meta-analysis
Central venous catheters are indispensable devices in the intensive care unit (ICU), necessary for infusion of medication, fluid, or blood products; hemodialysis; blood withdrawal; or hemodynamic monitoring. However, these invasive devices predispose patients to preventable central line–associated bloodstream infections (CLABSIs), defined as bloodstream infections in patients with a central line 48 hours before infection onset, non related to some other site (Table 1). CLABSIs are associated with increased morbidity, leading to increased length of hospitalization and resource use [3, 4], and might touch on bloodshed and compromise patient prognosis [five–7].
Tabular array 1.
Centers for Disease Control and Prevention Definitions for Fundamental Line–Associated Bloodstream Infection Terminology
| Terminology | Definition |
|---|---|
| CLABSI | An LCBI where a key line was in place for >2 calendar days and a primal line was in place on the appointment of outcome or the solar day before. |
| LCBI | To be defined equally LCBI, it must meet one of the post-obit criteria: |
| (1) Patient has a recognized pathogen cultured from 1 or more blood cultures, and organism cultured from claret is not related to an infection at another site; | |
| (2) Patient has at to the lowest degree 1 of the following signs or symptoms: fever (>38°C), chills, or hypotension, and positive laboratory results are non related to an infection at another site and the aforementioned mutual commensal is cultured from 2 or more blood cultures drawn on separate occasions. | |
| Key line days | A daily count of the number of patients with a central line in the patient care location during a time menses. A patient with multiple central lines for a twenty-four hour period only counts as one central line 24-hour interval. |
| Patient-days | A daily count of the number of patients in the patient care location during a fourth dimension period. |
| Device utilization ratio | Fundamental line utilization ratio is calculated by dividing the number of central line days by the number of patient-days. |
Infection prevention measures during primal line insertion or maintenance, such as hand hygiene, maximal sterile barriers during catheter insertion, chlorhexidine peel disinfection, optimal catheter site selection, and daily review of line necessity with prompt removal of unnecessary lines, are known to decrease CLABSI risk [8, 9]. The Institute for Healthcare Comeback (IHI) recommends utilise of aforementioned items, in a central line intendance bundle, to decrease CLABSI occurrence. Despite the availability of testify-based interventions summarized in guidelines [10, 11], CLABSI remains a substantial threat for hospitalized patients, with pooled estimated mean occurrence rates of 4.4 CLABSIs per 100 devices inserted (95% confidence interval [CI], 4.ane–4.ix) and 2.7 CLABSIs per 1000 catheter-days (95% CI, 2.6–2.nine) [12].
In contempo years, it has become articulate that the limiting factor to infection prevention resides in the implementation of published recommendations [xiii]. Introducing prevention measures may be hampered by factors such as lack of problem awareness, poor familiarity or nonagreement with guidelines, low self-efficacy, inability to modify practice, or lack of resources [14, 15]. Quality comeback interventions such equally personnel education or catheter intendance bundles and checklists aim to decrease CLABSIs past improving adherence to prevention measures [xvi]. All the same, efficacy of these interventions has not been fully assessed.
This study examined whether quality comeback interventions reduce CLABSI rates in adult ICUs. Subgroup analysis assessed whether bundle/checklist interventions, high report power, or high baseline CLABSI rates influenced the intervention issue.
METHODS
Search Strategy
Medline was systematically searched (1995–June 2012) through a combination of search terms: catheter-related infections/prevention and control; catheterization, central venous/adverse effects; catheters, indwelling/adverse effects; infection command/methods; infection command/standards; intensive intendance units; quality control; quality of healthcare; and packet (Supplementary Appendix one). Extra studies were identified via reference lists, manually and through Ovid and ScienceDirect databases.
Study Selection
Eligible studies used before–after, interrupted time serial (ITS), controlled earlier–afterward, nonrandomized controlled trial, or randomized controlled trial study designs that complied with the Cochrane Effective Exercise and Organisation of Care Group methodological criteria. ITS studies report at least 3 data points before and subsequently a defined betoken in time in which the intervention is implemented. Participants consisted of adult ICU patients with cardinal line catheters. Trials implemented quality comeback interventions aimed at increasing professional adherence to prove-based infection prevention processes. The primary outcome measure was the number of CLABSIs per catheter-days pre- and postintervention. Only English-language papers were included. Medline search results were screened past championship and abstract. Selected papers underwent a full-text assessment, and eligibility issues were resolved between authors.
Data Extraction
Extracted information included author and yr of publication, settings and study populations, written report designs and periods, quality improvement and preventive interventions implemented in the baseline and intervention periods, compliance measures, number of CLABSI and catheter-days, and applied CLABSI definitions. Report authors were not contacted for boosted data. To obtain effect sizes for ITS studies, infection charge per unit data were extracted from study figures using the program Plot Digitizer. Results reported every bit a mix from both included and excluded written report participants were included. Quality improvement interventions were classified nether general headers (Table two), and only preventive interventions described past Centers for Disease Control and Prevention (CDC) guidelines [10] and applicable to the majority of ICU patients were noted.
Tabular array 2.
Nomenclature of Quality Improvement Interventions and Number of Studies
| Quality Improvement Intervention(No. of Studies) | Definition and Examples |
|---|---|
| Educational activity (n = 33) | Teaching lectures transmitting theoretical knowledge concerning CLABSI |
| |
| Training (n = four) | Preparation sessions for applied skills associated with CVC care and maintenance |
| |
| Feedback (northward = twenty) | Reporting of CLABSI or care item compliance rates to ICU personnel |
| |
| Clinical reminders (n = 15) | Reminders of optimal clinical exercise strategically placed to improve awareness or application of prevention measures |
| |
| Bundle (north = xi) | A short listing of at least two IHI prevention measures to be used during CVC insertion and/or maintenance |
| |
| Checklist (n = 18) | Checklist of arranged intendance particular prevention measures to increment adherence to evidence-based infection prevention practices |
| |
| Empowerment to stop procedure (north = 10) | Nurses are empowered to halt and restart CVC insertion care or maintenance when a prevention measure out is not implemented correctly to ensure optimal catheter care |
| Surveillance: compliance monitoring (n = 12) | Nurses intermittently or continually supervise CVC insertion or maintenance prevention measures, with/without use of a bundle/checklist |
| Leader designation (n = 11) | A leader is designated to facilitate implementation of quality intervention processes past planning activities to improve awareness or introduction of bundled care items |
| Prepackaging of CVC materials (north = 16) | Use of a CVC cart or kit stocked with all necessary supplies to insert or maintain a fundamental line |
| Infrastructure changes (northward = ii) | Changes to hospital infrastructure to facilitate adherence to prevention measures |
| |
| Organizational changes (due north = 4) | Organizational changes in personnel staffing or duties to ameliorate adherence to prevention measures |
|
Quality Assessment
The Downs and Black checklist ascertained study methodological run a risk of bias [17]. It consists of 27 questions that evaluate the reporting, external validity, internal validity, and power of nonrandomized studies of healthcare interventions. Studies were scored based on these item criteria, adapted for CLABSI prevention inquiry.
Statistical Assay
A random-effects meta-analysis using the DerSimonian-Laird reckoner obtained odds ratios (ORs) and 95% CIs for CLABSI rate reductions. The Higgins I 2 test was predefined to quantify heterogeneity (I ii ≤ 25% for low, 25% < I ii < l% for moderate, and I 2 ≥ 50% for high), and funnel plots assessed publication bias. Subgroup assay through meta-regression for before–after study designs compared studies with or without bundle/checklist interventions, baseline rates in a higher place or below 4.0 CLABSIs per m catheter-days, and ability scores above or below 0.75. Univariate analysis calculated changes in device utilization rates. Sensitivity analysis identified heterogeneous studies that influenced the meta-assay.
Monthly ITS data were standardized for meta-analysis past dividing the upshot and standard error (SE) by the standard deviation (SD) of the preintervention trend. One report reported annual data points, which were used for the 12- and 24-month follow-upwards analyses [18]. SPSS version 22 calculated the intervention consequence using segmented time series regression assay, adjusting for time trend and autocorrelation. A negative alter in level or slope indicated an infection rate reduction [19]. A P value <.05 was considered statistically significant.
RESULTS
The search algorithm identified 634 records (627 in PubMed and vii in Ovid and ScienceDirect). Forty-iii studies, published in English betwixt Jan 1995 and June 2012 involving 584 ICUs, were included for meta-analysis (Figure 1). Two studies [20, 21] connected their quality improvement initiatives and republished quondam data with new results [9, 22]. The older study past Coopersmith et al [20] was included for ITS analysis, and the commodity by Pronovost et al [21] was accessed to supplement data. One trial was non included for subgroup assay because, although pre- and postintervention initiatives were qualitatively different, no new intervention types were implemented [23]. Another study included multiple data sets, of which the set with the longest follow-up menses was chosen [24]. Xi studies could not exist included for ITS assay because they implemented interventions in a stepwise manner [22, 23, 25–33].
Study selection menses diagram. Abbreviations: CLABSI, cardinal line–associated bloodstream infection; QI, quality improvement.
The 43 studies involved primarily medical-surgical ICUs, implemented quality comeback interventions without simultaneously introducing novel prevention measures, and applied CDC methods and definitions for CLABSI diagnosis (Supplementary Appendix 2).
The 584 included ICUs consisted of 564 adult, xi pediatric [24, 34, 35], and nine neonatal units [24]. Four studies reported the number of adult ICUs studied, but did non specify the ICU type (due north = 270) [35–38]. The remaining 294 adult ICUs involved medical-surgical (n = 135), medical (n = 51), and surgical (due north = 61).
The meta-analysis consisted of 35 before–after [viii, 22, 24, 26–28, 33–61], seven ITS [eighteen, 20, xl, 62, 63, 64, 65], and 1 controlled before–after study [66]. V ITS studies were included in the meta-analysis of before–after study designs [eighteen, 40, 63–65]. Duration of study periods ranged from 9 months [58] to 180 months [18], with a hateful length of 26.75 months.
Upwardly to fourteen unlike types of interventions were reported. Studies introduced multiple quality improvement interventions in different combinations, commonly implementing 1–5 interventions (n = 34). Four studies implemented initiatives through improvement systems such as programme-do-written report-act, Six Sigma, and root cause analysis [36, 38, 42, 52].
Quality improvement interventions, details of their description, methods used to apply them, and compliance measure out reporting varied. Educational interventions consisted of single, monthly, quarterly, or yearly sessions. Feedback reporting of infection or compliance rates occurred at monthly or quarterly intervals. Surveillance of compliance with preventive interventions was implemented daily, periodically, or at random intervals. As well, studies reported compliance with different items or only during the intervention menses.
Twenty-viii studies reported before–after device utilization rates (n = x) [viii, 27, 28, 34, 38, 44, 45, 54, 56, 57], catheterization duration (n = eleven) [22, 24, 27, 39, 43, 51, 53, 57, 58, 61, 63], or prevention measure compliance (n = 18) [22, 24, 27, 33, 35, 36, 45, 46, 49, 53, 55–60, 63, 66]. Some studies reduced [24, 51] or increased duration of catheterization [27, 58], however most improved compliance (north = x) [24, 27, 35, 36, 45, 46, 49, 56, threescore, 66]. Assay of 7 studies revealed device utilization rate increases [38, 45, 57] and decreases (Supplementary Appendix 3) [8, 54, 56].
Half of trials implemented bundles or checklists (n = 20). Trials either introduced bundles without checklists (northward = 2) [8, 45], only checklists because bundles were used during baseline (n = ix) [38, 44, 52, 53, 55, 57, 59, 62, 63], or both bundle and checklist interventions (due north = 9) [27, 28, 33, 35, 37, 41, 43, 47, 54].
Differing amounts of preventive care items were grouped together to form a packet or checklist. Two trials [52, 59] did non written report which items their bundle comprised, and 1 trial used a checklist a sole item [53]. Other trials used all five (n = 7) [8, 27, 37, 38, 43, 54, 63], iv (n = 5) [28, 33, 41, 47, 62], 3 (n = three) [35, 44, 55], or ii (n = ii) [45, 57] IHI items in their bundle or checklist. The items "optimal catheter site selection" and "daily review of line necessity" were included least (Figure 2).
Frequency of included care items in bundles and checklists. Xviii trials implementing bundle or checklist interventions reported which care items were implemented during the intervention menstruum. One report used povidone-iodine in their packet instead of chlorhexidine [57]. Manus hygiene: personnel skilful clarified hand hygiene earlier/after procedure; chlorhexidine skin antisepsis: skin disinfection earlier catheter insertion; maximal sterile bulwark precautions: personnel wore sterile coat and gloves, mask, and lid during insertion, optimal catheter site selection: personnel strived to insert catheters in the subclavian vein, daily review of line necessity: catheter demand was assessed daily with prompt removal of unnecessary central lines.
Four studies targeted other healthcare-associated infections such every bit ventilator-associated pneumonia (VAP) [36], both VAP and catheter-associated urinary tract infections [28, 59], or VAP and surgical site infections [34]. Eight studies initiated new prevention measures alongside quality comeback interventions [26, 39, forty, 42, 43, 48, 52, 53].
The baseline CLABSI incidence varied; rates ranged from 2.i [34] to 46.3 CLABSIs per 1000 catheter-days [46]. Trials reported baseline rates <v [26, 27, 34–37, 43, 51–53, 57–59, 61, 62, 64] and >15 CLABSIs per 1000 catheter-days [18, 24, 41, 46, 49, 60].
Downs and Black quality assessment scores ranged from xv [59] to 26 [22, 24, 49], with a mean of 21.2 (Supplementary Appendix 4). The checklist revealed that two studies did not depict CLABSI definitions [forty, 59], 9 did not sufficiently describe their quality improvement interventions [24, 33, 43, 46, 53, 56, 57, 59, 65], and 34 measured prevention measure compliance [8, 22, 24, 27, 28, 33–41, 43–46, 48–51, 53–61, 63, 66]. Twenty-eight studies reported confounding factors such as device utilization rates, catheterization duration, patient characteristics, or injury severity [8, 20, 22, 24, 26–28, 34, 38, 39, 41, 43–46, 49–54, 56–58, 61, 63, 66], which were comparable between baseline and postintervention in eighteen trials [20, 22, 24, 27, 28, 39, 46, 49, 50, 52–54, 57, 58, 61, 63, 66]. Two trials corrected for these measured differences in patient characteristics [41, 51]. Studies tended to accept either depression (n = 25) or high (n = 14) power scores [8, 18, 20, 22, 24, 26, 34, 37, 38, 47, 49, 52, 56, 65].
Ten before–afterwards trials did non demonstrate CLABSI rate decreases [36, 39, 41, 50, 51, 55, 57, 59, 64, 66]. 2 studies revealed nonsignificant results for neurosurgical, neurological, cardiothoracic, and coronary care units, yet decreased their total CLABSI rate [46, 47]. ITS analysis demonstrated beneficial changes in infection rate slope [18] and levels at iii [62], half-dozen [40], 12 [xviii, xl], and 24 months postintervention [eighteen].
Meta-assay was performed on 41 earlier–after and vii ITS written report designs to assess the impact of quality improvement interventions on the occurrence of CLABSIs. Before–after trials showed reductions in the CLABSI rate (OR, 0.39 [95% CI, .33–.46]; P < .0001, Figure three) with loftier statistical heterogeneity (I ii = 85.four%). Analysis of half-dozen ITS studies, involving 11 ICUs, identified a alter in level for the CLABSI rate at 3 months postintervention (OR, 0.30 [95% CI, .ten–.88]; P = .028, Figure 4) with depression heterogeneity (I 2 = 24.five%). Changes in infection rate slope (OR, 0.81 [95% CI, .59–1.13]; P = .216) and levels at half dozen (OR, 0.36 [95% CI, .11–1.19]; P = .094), 12 (OR, 0.17 [95% CI, .02–1.27]; P = .084), and 24 months postintervention (OR, 0.052 [95% CI, .003–1.02]; P = .051) trended toward reductions, however were not significant (Supplementary Appendix 5).
Meta-analysis and subgroup analysis of before-afterwards studies. Packet/checklist interventions: studies implementing a parcel and/or checklist. Non–bundle/checklist interventions: studies implementing neither a bundle nor checklist. Baseline period: before intervention implementation. Post catamenia: later on start of intervention implementation. Events: total number of central line–associated bloodstream infections. Total: total number of fundamental line days. W, weight assigned per study. Abbreviations: CI, confidence interval; OR, odds ration.
Meta-assay of interrupted time series studies: change in central line-associated bloodstream infection charge per unit level at 3 months postintervention. Abbreviations: CI, confidence interval; OR, odds ratio.
Subgroup analysis of before–after trials revealed that the CLABSI risk reduction was significantly stronger (P = .026; Figure iii) in trials with care bundles or checklists (OR, 0.34 [95% CI, .27–.41]) than in those without them (OR, 0.45 [95% CI, .36–.55]). Further analysis revealed that studies with baseline rates >4.0 CLABSIs per grand catheter-days (OR, 0.37 [95% CI, .33–.46]) did not demonstrate more pronounced risk reductions (P = .18) compared with studies below this baseline infection charge per unit (OR, 0.49 [95% CI, .37–.66]). Low-power (OR, 0.33 [95% CI, .26–.42]) and loftier-power studies (OR, 0.44 [95% CI, .36–.54]) exhibited near-different rate reductions (P = .06).
Funnel plots displayed an asymmetrical design for before–subsequently, but not ITS, study designs (Supplementary Appendix half-dozen). The results of the sensitivity analysis of before-later written report designs propose that 2 studies contribute to residual heterogeneity; removing them from the meta-analysis would reduce variability between studies [49, 52]. However, because this did not affect the results, these studies were retained (Supplementary Appendix 7).
Give-and-take
This meta-analysis of 43 studies, involving 584 ICUs, provides evidence that quality improvement interventions reduce CLABSI rates in adult ICUs. The effect size of 41 studies was significant notwithstanding highly heterogeneous. This infection rate decrease was more pronounced in studies using bundles or checklists, suggesting that their implementation alongside other initiatives leads to stronger rate reductions. The change in infection rate level for 6 studies at iii months postintervention likewise demonstrates the beneficial affect of quality improvement interventions, with low heterogeneity. Yet, but 1 of these studies showed pregnant charge per unit decreases [62], and the overall intervention effect was not sustained over longer follow-up periods. These findings may reflect the presence of the Hawthorne effect and need for CLABSI awareness promotion through continuous stepwise, multifaceted quality improvement interventions.
This study offers a wide look on the country of current research and applicative interventions, and applies a novel classification system to synthesize bear witness for quality comeback initiatives. The meta-analysis is the first to include before–after studies and place an condiment preventive issue associated with bundle and checklist interventions. 2 previous systematic reviews were unable to conclude which quality improvement interventions should be recommended for widespread implementation [sixteen, 67]. Another recommended the utilize of educational programs and multidisciplinary teams [68]. A meta-assay of ITS studies likewise demonstrated outcome sizes with broad conviction intervals; withal, they used unlike population criteria and studies, calculated charge per unit reductions per quarter-twelvemonth, reported mixed furnishings with small consequence sizes, and did non investigate compliance measures. Additionally, the exclusion of before–afterward study designs discards much observational evidence, negatively impacting the external validity of the results [19]. Comparable points of criticism were the low quality of included studies due to high baseline infection rates, inadequate reporting of multiple CLABSI data points, compliance measurements, and intervention details.
Although interventions implemented in settings with higher baseline rates would announced more than likely to be successful, no difference (P = .18) was establish between studies with baseline infection rates higher up or beneath a suboptimal rate of 4.0 CLABSI per 1000 catheter-days. Furthermore, high-power studies demonstrated CLABSI charge per unit decreases non significantly unlike from low-ability studies (P = .06). Noteworthy is that the study with the everyman baseline charge per unit (two.1 CLABSI per 1000 catheter-days) still accomplished a significant rate reduction by providing feedback of biannual infection rates [34].
Strengths of this study include the comprehensive search strategy encompassing various quality improvement interventions, the methodological quality assessment of trials, and the random-furnishings model analysis with multiple studies and ITS report designs. It is, however, hampered past certain limitations: a lack of randomized or controlled study designs, inconsistent reporting of prevention mensurate compliance, and heterogeneity. Earlier–afterwards studies run a higher risk of bias due to their liberal report design, as they hamper the ability to recognize phenomena that influence the CLABSI rate such as virulent epidemic outbreaks or spontaneous regression to the mean [sixteen]. There is some evidence to advise that the effects of quality improvement interventions are overestimated when based on earlier–after studies. Time serial designs limit this take chances of bias by detecting whether an intervention had an effect significantly greater than the underlying baseline trend [69]. However, because these designs require initiatives to begin at a well-divers signal in time, 11 studies with multifaceted stepwise intervention implementation had to exist excluded. This limitation could atomic number 82 to an underestimation of the upshot, as there is bear witness for the effectiveness of gradual intervention introduction [70].
There are several bug related to the meta-assay of earlier–after studies. All quality comeback interventions were considered to take an equal impact, yet this assumption may not be fair. Bold interventions take months to implement, those introduced in a later written report period could accept less effect compared with earlier initiatives. Inclusion of studies from identical authors tin can lead to bias [24, 49, 56, 60, 61, 65, 66]. Two of these studies were performed in the same hospital, which could overestimate the intervention effect due to hospital experience in intervention implementation [threescore, 66]. The forest plot of before–subsequently studies revealed a lack of smaller studies with less drastic infection rate decreases, suggesting publication bias; however, subgroup analysis of loftier-power studies revealed CLABSI decreases. Withal, assay of ITS studies aims to avoid these barriers, and in that location was little evidence of publication bias amid those studies.
Interventions to change gamble exposure derange results. Although statistically equivalent, a catheter-solar day from days 1–2 contains less infection take chances than days 14–fifteen due to microbial biofilm development and accumulating gaps in prevention measure adherence. Studies that reduce device utilization rates with increased boilerplate catheterization duration, reflecting a cohort of patients no longer managed with brusque-term key line usage, could underestimate intervention furnishings and vice versa [27]. This touch is unclear, equally studies with pregnant changes in device utilization rates and duration of catheterization reported mixed effects. Analysis of catheterization elapsing was non feasible because CLABSI definitions practice not business relationship for usage of multiple catheters per patient.
Clinical and methodological heterogeneity stemmed from the use of differing intervention strategies, study designs, population characteristics, and baseline standards of care. No distinction was made between interventions applied every bit function of a general plan or introduced to solve a specific recurring problem. For example, one study formed a team of nurses to evaluate care processes related to an infection charge per unit increment. Past applying a comparable notwithstanding distinct multifaceted quality improvement strategy, they decreased their rate from 1.five to 0 CLABSIs per 1000 catheter-days [23]. Differing standards of care hinder comparing through meta-analysis. The effect of implemented quality improvement interventions is dependent on the efficacy or corporeality of baseline prevention measures. Simultaneous introduction of daily chlorhexidine bathing alongside a quality improvement initiative may have influenced i ITS study's intervention effect [40]. Concluding, this review did not aim to identify strategies that lead to optimal uptake of quality improvement initiatives.
In decision, the results of this meta-analysis provide evidence that quality improvement interventions reduce CLABSI in adult ICUs. Twoscore-i before–after studies demonstrated consistent, beneficial results, which appeared to be more than pronounced among studies implementing bundle and checklist interventions. Quality improvement interventions appeared equally effective in studies with depression and high power or baseline CLABSI rate settings. The CLABSI rate reduction appears to be confirmed past the methodologically more robust interrupted time series studies. Farther enquiry should assess requirements for successful adaptation of quality comeback interventions, for example, through improvement systems, over longer follow- up periods. Studies should report before–after compliance measures, device utilization rates, and catheterization duration. These latter 2 items are necessary to assess confounding factors, because increased catheter use for shorter durations leads to intervention effect overestimations. To properly address these issues, studies need to business relationship for the number of catheters per patient. Finally, studies should employ ITS study designs and, when introducing stepwise initiatives, enough time should be spaced betwixt interventions to facilitate ITS assay.
Supplementary Data
Supplementary materials are available at Clinical Infectious Diseases online (http://cid.oxfordjournals.org). Supplementary materials consist of information provided by the author that are published to benefit the reader. The posted materials are not copyedited. The contents of all supplementary data are the sole responsibility of the authors. Questions or messages regarding errors should be addressed to the author.
Notes
Author contributions. K. B. conceived of and designed the study; performed the search of published work, literature search, data acquisition, interpretation and synthesis, and statistical assay; and wrote the paper. J. B. performed the statistical analysis, contributed to data interpretation, and revised the statistical portions of the report. D. Vo. substantially contributed to data analysis and estimation and critically revised the terminal manuscript. S. B. designed the report; substantially contributed to the search of published work, data interpretation and synthesis; and critically revised the concluding manuscript. D. Va. conceived of and designed the study; essentially contributed to data interpretation and synthesis; and critically revised the last manuscript. The respective author had full admission to all the data in the report and had final responsibleness for the decision to submit for publication.
Fiscal support. S. B. holds a research mandate of the Specific Inquiry Fund at Ghent University.
Potential conflicts of interest. D. Vo. has received an institutional grant for work under consideration for publication from Pfizer, and has been a consultant for Astellas, Pfizer, and Tibotec. All other authors report no potential conflicts.
All authors have submitted the ICMJE Course for Disclosure of Potential Conflicts of Involvement. Conflicts that the editors consider relevant to the content of the manuscript take been disclosed.
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