Elsevier

Journal of Critical Care

Volume 26, Issue 5, October 2011, Pages 489-495
Journal of Critical Care

Outcomes/Predictors
Reduction in ventilator associated pneumonia in a mixed intensive care unit after initiation of a novel hand hygiene program

https://doi.org/10.1016/j.jcrc.2010.12.013Get rights and content

Abstract

Purpose

Healthcare-associated infections (HCAIs) impact 10% of hospitalized patients. Some of these infections result from bacterial cross contamination and poor compliance with guidelines (Pittet D: Compliance with hand disinfection and its impact on hospital-acquired infections. J HospInfect 48 Suppl A:S40-S46, 2001); (Watanakunakorn C, Wang C, Hazy J: An observational study of hand washing and infection control practices by healthcare workers. Infect Control Hosp Epidemiol 19:858-860, 1998). Contamination of provider hands may be a modifiable risk factor. We instituted a novel multimodal system designed to improve hand hygiene by ICU providers.

Materials and Methods

A before and after study design was used to evaluate the impact on the incidence of CRBSI and VAP of a multi-modal program incorporating education, performance feedback, and a body worn hand hygiene device. Compliance was communicated quarterly. Primary outcomes were CRBSIs and VAPs per 1,000 line days or per 1,000 ventilator days and compliance rates. Secondary outcomes were hospital length of stay and mortality.

Results

A total of 1, 262 and 1,331 patients were evaluated during consecutive 12 month periods. VAP per 1000 vent days were significantly reduced after introduction of the program [3.7 vs. 6.9] P < .01. The reduction in CRBSI per 1000 line days was not significant [1.5 vs. 2.6], P = .09. Observed hand hygiene increased during the study period. There was no significant difference in mortality.

Conclusions

A novel multi-modal hand hygiene system resulted in a reduction in VAP. Provider hand contamination during patient care in the ICU is a modifiable risk factor for reducing ventilator associated pneumonias.

Introduction

Healthcare-associated infections (HCAI) affect 10% of patients admitted to acute care facilities, accounting for approximately 90,000 infections, of which many may be preventable, leading to greater than a billion dollars in excess healthcare costs annually. This is occurring within an economic environment that is charged with improving patient safety and quality while reducing healthcare costs [1]. Despite advances in surgical techniques, sterilization and disinfection programs, improvements in medical devices, therapeutic measures and evidence based guidelines, HCAI rates remain unacceptably high. Further, HCAIs have become an increasing dilemma due to the evolving, worldwide problem of multi-drug resistant bacteria and the increasing complexity of the healthcare environment [1], [2], [3]. However, the prevailing view is that many HCAIs are preventable complications, a view highlighted by the Centers for Medicaid and Medicare Services (CMS) decision to no longer reimburse for HCAIs [4].

The etiology of HCAIs in acute care settings is explained at least in part by bacterial cross contamination, a consequence of poor compliance with Center for Disease Control (CDC) guidelines for infection control, in particular hand hygiene [5], [6], [7], [8], [9], [10]. Multiple interventions to improve hand hygiene compliance of healthcare workers (HCWs )have been evaluated, including but not limited to education of HCWs, patient education, provider performance feedback, and various types of hand disinfectants, proximity of disinfectants, and/or educational programs incorporated into multi-modal strategies [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30]. Studies have yielded inconclusive evidence for the best approach to improvements in HCW hand hygiene and/or reduction in HCAIs [15], [31], [32]. However multimodal intervention strategies have been shown to be more effective, than single intervention approaches which are prone to failure [33], [34], [35], [36], [37].

Health care associated infections are particularly important in the intensive care unit where they have been demonstrated to result in increases in morbidity, mortality and cost [38], [39], [40], [41], [42], [43], [44], [45], [46]. We have recently demonstrated that intraoperative use of a novel hand hygiene device designed to improve intraoperative hand hygiene compliance of anesthesia significantly reduced infections in the 30-day postoperative period [47]. This quality improvement tool provided a multimodal approach to improve hand hygiene by overcoming barriers to hand hygiene compliance through proximity for provider use and provision of reliable performance feedback. We hypothesized that this approach would prove useful in the ICU, a similarly fast-paced environment, for reducing HCAIs.

Section snippets

General description

This was a before and after study design conducted in the multidisciplinary (medical-surgical) ICU at Dartmouth-Hitchcock Medical Center, a tertiary care and level one trauma center. Patients admitted to the ICU were followed during two consecutive 12-month periods, 12/06-11/07 (control period) and 12/07-11/08 (study period). After the study period, the multimodal program was no longer supported and a washout period was observed for another 12 months (time interrupted period). The hand hygiene

Results

There was a total of 1, 262 patients with 6463 central line days and 6171 ventilator days in the control period and 1,331 patients with 6850 central line days and 5897 ventilator days in the study period. Patients during the two time periods were comparable in age, gender, and APACHE II score (Table 1).

Ventilator-associated pneumonias per 1000 vent days were significantly reduced after introduction of the program [3.7 study versus 6.9 control, P < .01, OR 0.48 (95% CI 0.29, 0.81)]. The study

Discussion

In ICU's worldwide Vincent et al. recently reported that slightly over half of the patients have infections. Of these infections 64% are respiratory in origin [51]. We have demonstrated that the introduction of a novel hand hygiene improvement system as part of a multimodal program in the ICU was associated with a significant reduction in VAP and a trend towards fewer CRBSIs. This extends our prior findings of the effectiveness of this approach in the intraoperative setting [47]. The

Acknowledgments

Ingrid B. Mroz APRN, Donna Houston RN, Cindy Robison RN, Department of Nursing, Dartmouth-Hitchcock Medical Center. Corey Burchman, MD, Department of Anesthesiology, Dartmouth-Hitchcock Medical Center.

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      Contamination of the hands can result from either direct patient contact or from touching contaminated surfaces of the clinical environment16 and can lead to the transmission of healthcare-associated pathogens.17 Scientific evidence supports that HH alone, if suitably implemented, can significantly reduce the infection risk and device-associated infections.14,18,19 Hence, fostering this practice and increase compliance over time is crucial to improve quality of care.20

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    Research support: Dartmouth-Hitchcock Medical Center Anesthesia and Critical Care, Medicine, and Nursing Department funds, Equipment Support- Sprixx TM Harbor Medical, CA, USA.

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