SMART Approaches for Reducing Nosocomial Infections in the ICU

doi:10.1378/chest.08-0809

Chest

Volume 134, Issue 2, August 2008, Pages 447-456

https://doi.org/10.1378/chest.08-0809 Get rights and content

Nosocomial infections are problematic in the ICU because of their frequency, morbidity, and mortality. The most common ICU infections are pneumonia, bloodstream infection, and urinary tract infection, most of which are device related. Surgical site infection is common in surgical ICUs, and Clostridium difficile-associated diarrhea is occurring with increasing frequency. Prospective observational studies confirm that use of evidence-based guidelines can reduce the rate of these ICU infections, especially when simple tactics are bundled. To increase the likelihood of success, follow the specific, measurable, achievable, relevant, and time bound (SMART) approach. Choose specific objectives that precisely define and quantify desired outcomes, such as reducing the nosocomial ICU infection rate of an institution by 25%. To measure the objective, monitor staff adherence to tactics and infection rates, and provide feedback to ICU staff. Make objectives achievable and relevant by engaging stakeholders in the selection of specific tactics and steps for implementation. Nurses and other stakeholders can best identify the tactics that are achievable within their busy ICUs. Unburden the bedside provider by taking advantage of new technologies that reduce nosocomial infection rates. Objectives should also be relevant to the institution so that administrators provide adequate staffing and other resources. Appoint a team to champion the intervention and collaborate with administrators and ICU staff. Provide ongoing communication to reinforce educational tactics and fine-tune practices over time. Make objectives time bound; set dates for collecting baseline and periodic data, and a completion date for evaluating the success of the intervention.

Section snippets

Intravascular Catheter-Related BSI

The Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines¹⁴ for preventing intravascular-catheter-related BSI include educating health-care workers, assessing their knowledge of and adherence to guidelines, and using designated, trained personnel to insert and maintain catheters (Table 1). The guidelines also include routine monitoring to determine infection rates in patients with central venous catheters (CVCs), trends in those rates, and lapses in infection-control

VAP

The American Thoracic Society,¹⁵ Joint Planning Group¹⁶ and HICPAC¹⁷ rate their recommendations on the strength of supporting evidence (Table 3). These guidelines are based on VAP pathogenesis8, 45 and aim to prevent bacterial colonization of the aerodigestive tract (eg, routine hand hygiene between patient contacts) and aspiration (eg, continuous aspiration of subglottic secretions and semirecumbent positioning of the patient). Nonadherence is common among physicians46, 47 and nurses,⁴⁸ and

UTI

HICPAC guidelines¹⁸ for preventing catheter-associated UTI were published in 1981 (Table 5) and are currently under revision. Current category 1 recommendations include educating staff about correct aseptic catheter insertion and care techniques, hand washing before and after catheter manipulation, maintaining a closed system, properly securing catheters, and maintaining unobstructed urine flow. A practice to be avoided in ICUs is routine use of prophylactic antibiotics.⁵⁷

Prospective

SSI

Extensive guidelines are available from the Centers for Disease Control and Prevention for preventing SSI, from before to after operative care (Table 7).¹⁹ For example, antimicrobial prophylaxis should be used only when indicated and based on the most common pathogens for the specific operation and published guidelines. The drug should be administered IV to yield bactericidal concentrations during the surgical procedure.¹⁹ Specifically, dosing should begin 60 min before incision,⁶⁴ and end ≤ 48

Clostridium difficile-Associated Diarrhea

C difficile is the most common cause of nosocomial diarrhea,²⁰ an increasingly common ICU problem. When the Society of Healthcare Epidemiology of America published its 1995 position paper,²⁰ the only guidelines supported by good evidence were using gloves to handle body substances, using disposable thermometers during outbreaks, and antimicrobial stewardship. Studies conducted since 1995 support additional practices aiming at the following: (1) to prevent ingestion of C difficile through

Conclusions

Evidence-based guidelines are available to reduce nosocomial ICU infection rates, especially when simple tactics are bundled. To increase the likelihood of success, follow the SMART approach. Choose specific objectives that precisely define and quantify desired outcomes, such as reducing the nosocomial ICU infection rate of an institution by 25%. Avoid unrealistic objectives, such as attempting to completely eliminate nosocomial infections. To measure the objective, monitor both staff adherence

Acknowledgment

I thank Cindy W. Hamilton for helping to prepare the first draft and to revise it. Ms. Hamilton is a freelance medical writer and consultant for CardinalHealth, C. R. Bard, Inc., OrthoMcNeil, Pfizer, and sanofi-aventis.

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The author has received grant support to conduct animal and feasibility studies with the silver-coated endotracheal tube from Bard, and lecture fees from the following commercial entities: Bard, Merck, Pfizer, and Ortho-McNeil.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

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Chest

Postgraduate Education CornerContemporary Reviews in Critical Care MedicineSMART Approaches for Reducing Nosocomial Infections in the ICU

Section snippets

Intravascular Catheter-Related BSI

VAP

UTI

SSI

Clostridium difficile-Associated Diarrhea

Conclusions

Acknowledgment

Am J Infect Control

Chest

Microbes Infect

Chest

Chest

J Hosp Infect

J Hosp Infect

J Hosp Infect

Am J Infect Control

Chest

Am J Infect Control

Lancet Infect Dis

J Vasc Interv Radiol

Clin Chest Med

Chest

Chest

Am J Med

Microbes Infect

Am J Infect Control

Am J Med

Urology

J Hosp Infect

Ann Thorac Surg

Am J Surg

Chest

Estimating health care-associated infections and deaths in U.S. hospitals, 2002

Public Health Rep

Nosocomial infections in combined medical-surgical intensive care units in the United States

Infect Control Hosp Epidemiol

National Nosocomial Infections Surveillance (NNIS) System Report, data summary from October 1986-April 1998, issued June 1998

National Nosocomial Infections Surveillance (NNIS) System Report: data summary from January 1992 to June 2002, issued August 2002

Am J Infect Control

National Nosocomial Infections Surveillance (NNIS) System Report: data summary from January 1992 through June 2004, issued October 2004

Am J Infect Control

Nonpayment for performance? Medicare's new reimbursement rule

N Engl J Med

The prevention of ventilator-associated pneumonia

N Engl J Med

Improving the appropriateness and effectiveness of ICU practices

Intensive Care Med

Guidelines for the prevention of intravascular catheter-related infections: Centers for Disease Control and Prevention

MMWR Recomm Rep

Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia

Am J Respir Crit Care Med

Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia

Ann Intern Med

Postgraduate Education Corner
Contemporary Reviews in Critical Care Medicine
SMART Approaches for Reducing Nosocomial Infections in the ICU