How do quality of care initiatives impact infection control?

Patient safety is a healthcare priority worldwide, with most hospitals engaging in activities to improve the quality of care (QC), safety and health outcomes. The safest care is also often the most cost-effective care.

Quality of care, quality improvement, or total quality management is names related to different strategies with a single goal: to provide a safer health care, with the best possible health outcomes for the individual patient.

Infection control and prevention activities were, are and will continue to be at the core of this concept. Classic statements, like “you only can improve what can be measured,” are fundamental to infection control practices. Without any doubt, QC initiatives (including “patient safety” ones) are embedded in today’s Infection Control policies.

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What elements of quality of care initiatives are necessary for infection prevention and control?

Quality and safety of care are health priorities. Healthcare-related infections (HCRI) are now considered by many as preventable and therefore unacceptable. Several reports suggest that many HCRI are avoidable with the implementation of evidence-based best practices, a concept inherent to QC activities.

The human factor is very important. Human factors engineering is an area that studies the capabilities and limitations of humans and the design of devices and systems for improved performance. It is used to study the interaction between the HCW and the system that he or she is working with, including the use of devices, the environment and the demands and complexities of patient care. All of them are concepts related to QC and HCRI prevention and control.

What are the conclusions of clinical trials or meta-analyses regarding quality of care initiatives and infection control practices?

A number of evidence-based guidelines are available for the prevention and control of HCRI, including an assessment of the strength of the evidence for each recommendation. Two major hurdles are present: first, they often do not include recommendations regarding performance measures that can be used to assess the effectiveness of the interventions; second, there is also a lack of analysis about resource requirements and feasibility of the recommendations.

A number of recent QC efforts involved the use of simultaneous practice improvements, called “bundles”. A care bundle is a set of a few processes that each individually improves patient’s outcomes and that should be performed together for every patient every time. A systematic review concluded that the relative risk reduction associated with the introduction of a BSI bundle exceeded 25% and that the absolute risk reduction exceeded 9% in all studies included. Bundles for the prevention of HCRI have focused mainly on CVC associated BSI and VAP in the ICUs.

What are the consequences of ignoring quality of care initiatives in infection control?

The demand for the highest quality patient care coupled with pressure on healthcare funding has led to the increasing use of quality improvement (QI) industrial methods. Qi methodologies from industry can have significant effects, for example, improving surgical care, from reducing SSI to increasing OR efficiency. However, the available evidence is not robust, and more rigorous studies are still needed.

What other information supports the conclusions of studies about quality of care initiatives in infection control?

As an example, SSI is recognized as a measure of the quality of patient care by surgeons, infection control practitioners, agencies and the public. There is a growing pressure to measure and compare SSI rates between surgeons, institutions and countries. In order to properly do that, data must be standardized and include post-discharge surveillance. There is a need to advance from theory into practice by the application of SSI bundles. Recent studies suggest that, with a multidisciplinary approach, simple measures can be very effective in reducing SSI rates.

Summary of current controversies.

Some key challenges in infection control and prevention are the delayed feed-back to HCW, high cognitive workload and poor ergonomic design. Human factor engineering can be used for the improvement and for increasing compliance with QC practices that prevent HCRI.

Challenges to implementing HCRI reduction strategies included poor adherence, insufficient resources, staffing problems, lack of culture change, no drive force to change and staff and patient education. Many studies identified engaging physicians as particularly challenging; and ensuring staff and physician engagement and compliance in HCRI reduction efforts remains challenging for most institutions.

The new concept of “Zero HCRIs” (Zero bacteremia, Zero VAP” is pressing, meaning that anything less than aspiring to eradicate the risk of HCRIs is unacceptable. Zero HCRI can be a noble goal, but from the practical point of view, some HCRI are not preventable, and will continue to be the so-called “irreducible minimum”.

A single and well placed “infection control and QC Champion” can implement a new technology. More than one “QC Champion” is needed when an improvement required people to change behaviors. Although this change can be seen as inexpensive and simple, it is not, and implementation of behavioral change is more often more complicated than changing technology. The effectiveness of “QC Champions” was also affected by the quality of organizational networks involved.

What is the impact of quality of care initiatives relative to the impact of other aspects of infection control?

VAP: Hospital-based QC process improvement initiatives aimed at the prevention of VAP have been successfully used. The use of evidence-based bundles targeting VAP and other ventilator-associated complications are a well-known example.

SSI: SSI rates are proposed as QC indicators. However, SSI definitions varied between surveillance programs and hospitals. Recently, the WHO launched the “Safe Surgery Save Lives” campaign, promoting the use of a surgical check-list, a very good, simple and cheap solution to improve patient safety worldwide.

BSI: Data from the CDC show that the number of patients in US ICUs suffering a CVC BSI declined by 63% between 2001 and 2009, an important “success story” in QC improvement and in patient safety. The reduced rates of CVC related BSI in the “zero bacteremia” project was sustained if the ICUs integrate the intervention into routine clinical practice. Broader (hospital wide) use of the intervention could further reduce the morbidity and cost associated with CVC BSI.

UTI: The use of a system or device change (closed indwelling UT catheter) is a good example of QC improvement. The sustained reduction in the UTI rate at nearly all hospitals is related to this change and also to the adherence to safer practices in UT catheterization as well as paying attention of the “stop order” to withdraw, as soon as possible, the UT catheter from all patients.

Hand Hygiene: Monitoring hand hygiene compliance and providing HCW with feedback regarding their performance are integral parts of multidisciplinary hand hygiene improvement programs. Clean Care is Safer Care is a successful WHO sponsored worldwide QC and safety initiative to promote the use of alcohol-based solutions for hand hygiene.

ICU: Attention to the improvement of safety and QC at the ICUs has focused in HCRI, notably BSI and VAP. Teamwork and communication remain the most important aspects in patient safety at the ICUs. The use of different QC and safety check-lists facilitates a sustainable improvement in compliance rates for preventive measures at the ICUs, even without the use of resource-intensive active surveillance and isolation practices for patients with MR microorganisms.

Controversies in detail.

Qualitative research: Quantitative studies are important in the field of QC and HCRI prevention and control, but often they cannot explain us why certain factors affect or not the use of infection control practices. Qualitative research methods, applied with expertise and rigor can contribute to infection prevention and control and to QC efforts.

Resources: Hospital with increased resources has better patient safety indexes, and can deploy more intense QC and infection control and prevention activities. To promote effective QC and patient safety programs, dedicated full-time staff is needed. Appropriate economic support for hospitals will also be required to assure that QC and safety programs are sustainable over time.

One size fits all: We have limited understanding why QC and QI efforts are successful in some hospitals but not in others. The experience and outcomes, for example in preventing BSI, varied significantly despite using similar implementation strategies. The best evidence so far of care bundles effectiveness comes from multicenter ICUs trials, it remains to be seen whether the success that has been achieved in ICUs can be reproduced in general wards.

What national and international guidelines exist related to quality of care initiatives in infection control?

National (US): There are a fair large number of healthcare organizations, professional associations, government agencies and accrediting bodies that issue guidelines for QC and infection control and prevention. The Institute of Medicine, the Joint Commission, the CDC, the National Quality Forum, the Institute for Healthcare Improvement, the Leapfrog Group and scientific societies like SHEA, APIC, IDSA and others as well have addressed this topic recently.

International: In 2004, the WHO launched a Patient safety program, urging WHO Member States to pay the closest possible attention to the problem of patient’s safety as a global healthcare issue. The WHO patient safety program aims to coordinate, disseminate and accelerate improvements in patient safety worldwide, providing also a tool for international collaboration and action. Clean Care is Safer Care (hand hygiene practices) and Safe Surgery Saves Lives (surgical check-list) are two best known WHO initiatives, with good results overall, in this field.


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