循证报道和技术估计——预防医院感染

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Evidence Report/Technology Assessment
Number 9
Closing the Quality Gap:
A Critical Analysis of Quality Improvement Strategies
Volume 6—Prevention of Healthcare-Associated Infections
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
www.ahrq.gov


Structured Abstract
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 catheterassociated
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.