intervention

IPS Journal Club: A real time intervention to increase CHG bathing and reduce CLABSIs

norvillephillip Uncategorized , , ,

I’ve written this post in preparation for Wednesday’s IPS Journal Club (register here) in collaboration with IPC Partners

The paper that I have chosen for the Journal Club is this one in the Journal of Infection Prevention, describing a real time intervention to increase chlorhexidine (CHG) bathing to reduce central line-associated blood stream infections (CLABSIs).

Why I choose this paper?

  • CHG bathing has shown promise in reducing various infections (such as CLABSIs) therefore evidence demonstrating the effect on infections is welcome
  • A recent estimate of the cost of CLABSIs is extremely high – $48,108 for every case according to the Agency for Healthcare Research and Quality
  • I was really interested in the use of a ‘real time intervention’ given the challenges which are faced around effective implementation of interventions

Design and methods

  • The study was a quality improvement project (QIP) which aimed to increase the rate of daily CHG bathing adherence for patients
  • The QIP was conducted at a 166-bed acute care community hospital in the US over 4 months
  • A Fishbone Diagram and an Impact Effort Matrix were used to identify barriers. Barriers identified included difficulty in identifying CHG documentation, as well difficulties in identifying patients that are due for CHG bathing
  • This led to the development of a ‘Time Since Bathing Column’ to make identification of missing CHG bathing opportunities more apparent within the Electronic Health Record (EHR). This allowed the hospital IPC team to provide real-time feedback when CHG bathing was overdue for a specific patient
  • A consistent message and message platform within the EHR allowed standardisation of the message content and the method of delivery
  • A sustainability plan was introduced using tools and dashboards to create individual plans focusing on ownership and empowerment of frontline staff to ensure frontline bathing  

Key findings

  • Prior to the intervention CHG bathing rate adherence was 94.9% (already very impressive) with a CLABI rate of 1.89
  • Following the implementation of the real intervention a 0.42% increase in CHG bathing adherence was detected (which was not significantly significant)
  • When including weekend CHG adherence rates in the analysis, a 2.8% increase in CHG adherence was detected (97.6%), which was statistically significant (the QIP identified that CHG bathing adherence was low on weekends)
  • No CLABSIs were identified in the 3-month study period, and 12-month CLABSI rolling rate decreased from 1.78 to 1.07 (however the sample size was too small to perform statistical analysis)

Strengths and limitations

  • CHG adherence was already extremely high, so challenges in a detecting a significant change however the QIP identified reduced CHG adherence over weekend periods
  • Although CLABSIs rate decreased the sample size was too small to identify any statistical significance  

What does this mean for IPC?

  • Cross functional working with informatic and digital teams can improve CHG adherence and potentially reduce CLABSI rates
  • Real time interventions can identify falls in CHG adherence at times where staffing levels are low, such as weekends
  • Real time feedback accompanied by multidisciplinary team engagement with clinicians were important success factors
  • Outreach and reminders effectively improved CHG bathing adherence by emphasizing the importance of consistent communication and follow-up

Are we now over-emphasizing the role of handwashing in preventing spread of infection?

Guest Blogger Hand hygiene , ,

A guest post by Professor Sally Bloomfield explores whether we are over-emphasizing the role of hand washing in preventing the spread of infection…

If you ask whether I think hand hygiene is the single most important intervention for preventing spread of infection, I would answer yes. But I also think the COVID pandemic requires us to re-evaluate how we look at infection prevention (or hygiene) to make it relevant to the issues we now face, which are as much about “airborne “ transmission routes as hands and contact surfaces.

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Antimicrobial copper surfaces and linen and healthcare-associated infection: a review and meta-analysis

Jon Otter (@jonotter) Antimicrobial surfaces , , , , ,

A helpful new review and meta-analysis asks whether treating hard surfaces or linen reduces healthcare-associated infections. The review identified only a small number of studies that had both a copper-related intervention related to surfaces and/or linen and an outcome related to HCAI. But the meta-analysis of the seven studies found that, overall, the risk of HCAI was reduced by 27% (risk ratio 0.73, 95% confidence interval 0.57–0.94).

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Jingle all the weigh: a behavioural intervention to prevent weight gain over Christmas

Jon Otter (@jonotter) behaviour change , , ,

It’s becoming a bit of a tradition for me to post about an article from the fabulous Christmas BMJ with a spurious link to infection (see 2016 [depressing] and 2017’s [uplifting] version here). This year, it’s a short-term behavioural intervention to prevent weight gain over Christmas. And the links to infection: obesity is a big (!) risk factor for all-things-infection, and we’re all about achieving meaningful and sustained behaviour change.

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The best IPC article of 2018: a blogoff with Brett Mitchell

Jon Otter (@jonotter) environmental hygiene , , , , , ,

In honour of Infection Prevention 2018, Brett Mitchell and I are having a blogoff so that you can choose the best IPC article of 2018. This post presents my case, Brett’s post (here) presents his case, and there’s a vote below so that you can choose. The results will be published next Monday morning at Infection Prevention 2018…

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Should we disinfect the loo BEFORE flushing?

Jon Otter (@jonotter) Disinfection , , , , ,

There is a risk that an infectious aerosol is produced when toilets are flushed. One way of addressing this would be to add a disinfectant to the toilet before flushing. But would this be safe and effective?

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Are our attempts to contain CPE going down the drain?

Jon Otter (@jonotter) CRE , , , , ,

I posted recently on the potential risk of CPE contamination of sinks, drains, and hospital wastewater. The question in my mind then was whether contamination is a smoking gun or innocent bystander regarding CPE transmission? What we really need is an intervention to show that better management of sinks and drains results in reduce CPE transmission. And now, we have one! The findings suggest that attempts to control CPE will go down the drain if we don’t intervene to improvement the management of sinks and drains.

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Reducing Gram-negative BSI…by accident

Jon Otter (@jonotter) MDR-GNR , , , , , , , , , ,

E_choli_Gram

We have precious little data on what works to prevent the transmission of MDR-GNR. An interesting article published recently in CID provides invaluable data that an infection control programme aimed at reducing MRSA (and succeeding) was also effective in reducing GNR BSI!

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Are we passing too much CAUTI?

Jon Otter (@jonotter) CAUTI , , , ,

urine-bag-1449857279oSI

We have blogged before how CAUTI is rather ‘unloved’ as an HCAI prevention target. CLABSI reduction, on the other hand, is all the rage. Now, there is a key reason why this makes sense: outcome! A CLABSI is much worse news for a patient than a CAUTI. However, this doesn’t mean we should turn a blind eye to CAUTI, especially since CAUTI is a common root cause for CLABSI! In the US there is an addiional driver for preventing CAUTI: the costs associated with CAUTI are no longer reimbursed by insurers (since 2008). With this in mind, it was great to see a CAUTI reduction study published in NEJM recently (and see some interesting analysis on the Controversies blog).

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The terms 'horizontal' and 'vertical' intervention leave me feeling upside down, confused

Jon Otter (@jonotter) Epidemiology , , , , , ,

horizontal vertical

I am no expert in HIV, but I know that ‘vertical transmission’ means something very specific:

Vertical transmission: the transmission of a disease from mother to child either during pregnancy, childbirth, or by breastfeeding.

Similarly, the definition of ‘horizontal transmission’ is well defined:

Horizontal transmission: the transfer of an infection from person to person.

So, when I read about ‘vertical’ and ‘horizontal’ interventions in a recent New England Journal of Medicine Editorial and the Controversies blog, I began to get a little confused. I have a PhD in epidemiology so don’t consider myself easy to confuse (in this particular domain), but I would have thought that a ‘horizontal intervention’ would be directed towards preventing horizontal spread of an infectious agent and a ‘vertical intervention’ would be directed towards preventing the vertical transmission of an infectious agent. But this is not how these terms are being applied. Instead, a ‘horizontal intervention’ is being used to describe an intervention applied to every patient (such as chlorhexidine bathing or hospital-wide hand hygiene interventions) whereas a ‘vertical intervention’ is being used to describe an intervention designed to reduce colonization or infection due to a specific pathogen (such as active screening and isolation to prevent the spread of MRSA). The use of the term ‘vertical intervention’ seems especially confusing, since it’s a ‘vertical intervention’ to prevent the horizontal transmission of a specific pathogen!

I fail to see how the terms ‘vertical’ or ‘horizontal’ intervention are useful when there are such well-established definitions for horizontal and vertical transmission. I think that ‘universal intervention’ (such as universal screening or decolonization) and ‘targeted intervention’ (such as active screening and isolation to prevent the spread of MRSA) make a lot more sense. These terms are already in common circulation, so I would urge those who favour the use of ‘vertical’ or ‘horizontal’ intervention to reconsider their terminology.