Background Healthcare-associated infections are a problem for the Swedish healthcare system. In order to reduce the risk of acquiring healthcare-associated infections, the intensive-care unit attended a breakthrough project in 2004–2005, with the aims of studying methods of increasing patient safety and systematically improving treatment outcomes. The intensive-care unit had no system for registering infections, and the authors wanted to ascertain the prevalence of healthcare-associated infections, and register and prevent them.
Objectives 40% reduction in healthcare-associated infections in ventilated patients. 100% of staff to implement basic hygiene routines.
Design The method used was the Breakthrough Series, originally designed by the Institute for Healthcare Improvement in Boston, Massachusetts, USA. The method aims to bridge the gap between what is known and what is done, spreading best-practice methods even faster. Many ideas for changes are tested on a small scale, with the basic rule that the small changes combine to create large changes that lead towards the final goal.
Results The frequency of healthcare-associated infections in ventilated patients was reduced by 43%. Compliance with the basic hygiene routines improved greatly, from 72% on initial measurement to 98% today.
Conclusion In order to reduce the risk of acquiring healthcare-associated infections and to increase patient safety, a continuous, systematic effort involving continual measurement and review is necessary.
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Healthcare-associated infections are infections affecting patients as a result of in- or outpatient hospital treatment, whatever the mode of transmission or type of infection. Healthcare-associated infections are a significant problem with considerable medical and economic consequences. The frequency of healthcare-associated infections appears to be relatively constant throughout most industrialised countries with similar economic and healthcare standards. Several Swedish point prevalence studies show a frequency of around 10% of hospitalised patients. European studies show a frequency of 7.4–13.5%. This is an average and does not reflect the situation for different specialties. Intensive care, for example, accounts for some 8% of inpatient care but approximately 25% of healthcare-associated infections. Around 30% of intensive-care patients receiving treatment for more than 48 h contract one or more healthcare-associated infection. The best way of reducing healthcare-associated infections is through a combination of infection registration, evaluation and revision of healthcare routines, staff training and a high level of compliance with basic hygiene routines.1
Basic hygiene routines include hand disinfection and the use of protective gloves and clothing. Basic hygiene routines should be observed by all healthcare personnel in all care and examination situations. The most important measures are hand washing with alcohol rubs before and after all contact with patients; the removal of rings, bracelets and wristwatches; and the use of short-sleeved uniforms and disposable plastic aprons in all close contact with patients or their beds.2
Healthcare-associated infections pose a significant problem for patient safety. In Sweden, the term bacteraemia is used to describe the presence of bacteria in the blood system.3 Infections in the blood system are often divided into primary and secondary bacteraemia. Primary bacteraemia arises as a result of the use of intravascular catheters.3–5 The use of central venous catheters constitutes a risk factor for the development of bacteraemia.4 6 There is no national definition in Sweden of healthcare-associated urinary-tract infection,3 but bacteriuria on the third day of treatment or later, without previous negative cultivation, can be used for the simple registration of healthcare-associated urinary infection among hospital patients.3 7 Indwelling catheters cause some 90% of all healthcare-associated urinary infections.3
In intensive care, pneumonia is the most common healthcare-associated infection. Intensive-care patients on ventilators run a noticeably greater risk of developing pneumonia. This has led to the introduction of the term ventilator-associated pneumonia (VAP). VAP is an infection of the lungs directly related to the patient's intubation.3
Healthcare-associated infections are a problem for the Swedish healthcare system. Our intensive-care unit had no system for registering infections, and we wanted to ascertain the prevalence of healthcare-associated infections, and register and prevent them. This project aimed to prevent healthcare-associated infections (healthcare-associated infections with regard to VAP; intubation-related infections in blood vessels; and healthcare-associated urinary infections) among intensive-care unit patients on a ventilator, enhance patient safety and increase compliance with basic hygiene routines.
Methods, design and setting
Healthcare-associated infections are among the most common grounds for claims made to the county councils' mutual insurance company, which compensates patients for hospital injuries. With this in mind, the Federation of Swedish County Councils and the county councils' mutual insurance company initiated a national project in 2004 to combat healthcare-associated infections. The project went under the name VRISS (“Vårdrelaterade infektioner ska stoppas”, Healthcare-associated infections must stop). County councils and local authorities were invited to participate in the project with interdisciplinary teams representing a range of specialties, and teams from hospitals all over Sweden were involved in the project.
The aim of the teams was to reduce the incidence of healthcare-associated infections. Gällivare Hospital, with 110 beds, is a multidisciplinary district hospital in the north of Sweden. Some 1600 patients with various diagnoses are cared for each year in the intensive-care unit which has sections for general intensive, coronary and postoperative care, staffed with doctors, nurses and nursing attendants. In order to reduce the risk of acquiring healthcare-associated infections, the intensive-care unit attended a breakthrough project in 2004–2005, with the aims of studying methods of increasing patient safety and systematically improving treatment outcomes. An interdisciplinary project team was formed, made up of a doctor, nurses and nursing attendants supported by the leadership of the intensive-care unit.
The method used was the Breakthrough Series, originally designed by the Institute for Healthcare Improvement in Boston, Massachusetts, USA.8 The method aims to bridge the gap between what we know and what we do, spreading best-practice methods even faster. Many ideas for changes are tested on a small scale, with the basic rule that the small changes combine to create large changes that lead towards the final goal.
Base data were collected to provide a background for our work and the changes to be tested. Changes were implemented through instruction, verbal information and written routines.
All personnel were involved in the change process and received continuous information, education and run-throughs of existing and new routines. Reporting and follow-up of measurements, evaluation and discussion took place at departmental meetings every month where all personnel in the intensive-care unit attended. Changes were made in cooperation with the infection-control nurse.
The goal was a 40% reduction in healthcare-associated infections in ventilated patients (healthcare-associated infections with regard to VAP, intubation-related infections in blood vessels and healthcare-associated urinary infections).
The process objective was 100% of staff to implement basic hygiene routines.
To be ascertained
The proportion of ventilator patients with one or more healthcare-associated infection.
The proportion of healthcare staff following basic hygiene routines.
The formulation of a document defining healthcare-associated infections and a protocol for infection registration in ventilated patients. This protocol was used to document indications of acquired infection and also, in conjunction with laboratory data, x-ray and bacteriological results from the patient's notes, to compile a monthly report on the number of verified healthcare-associated infections in patients on ventilators.
Weekly observation of all personnel, with the aid of a specially created test protocol; we wanted to make regular observations and measurements. We observed the use of short-sleeved uniforms, protective clothing, aprons and gloves, hand disinfection with an alcohol rub, and wearing rings and wristwatches while working with patients, in order to measure compliance with basic hygiene routines.
We had a list of evidence-based changes that were tested o a small scale over time. Every change was evaluated like a cycle known as ‘Plan–Do–Study–Act’ (PDSA). Changes that successfully resulted in the desired improvement became standard practices.
Elevation of the head of ventilator patients to 30°
In order to reduce the risk of aspiration of stomach contents and thus the risk of ventilator-associated pneumonia (VAP), all patients on ventilators should if possible have their heads elevated at an angle of 30°.9 10
Accurate temperature measurement
In order to obtain a reliable measurement of patients' body temperatures, all adult patients on ventilators should have continuous temperature monitoring. Temperature is measured with the aid of an indwelling urinary catheter (IUC) with a temperature probe. If an IUC is counterindicated, an IUC with a temperature probe is not used.
We created two documents, one for infection definitions and the other an infection protocol. All ventilator patients were evaluated for any signs of infection using the infection protocol.
New oral-hygiene routines
New, stricter, routines for airway suction
Special training and written procedures for the care of ventilator patients based on specially constructed evidence-based guidelines have reduced the frequency of VAP.3 12–14 We now have written routines that were introduced after training.
Tracheostomy syringes and endotracheal tubes with subglottic aspiration channels
Subglottic aspiration, the suction of secretions above the cuff, reduces the risk of ventilator-associated pneumonia.9 Our endotracheal tubes and tracheostomy syringes of choice are now those with suction channels above the cuff. This makes it easier to completely remove the secretions that have accumulated above the cuff, thus reducing the risk of aspiration.
Closed urine-collection systems for catheter treatment
Closed urine-collection systems, using bags that can be emptied, reduce the risk of bacterial contamination.3 We have introduced bags that can be emptied with IUCs in order to avoid the need to breach the system between IUC and bag.
Arterial-blood-pressure measurement with closed sampling systems
We have introduced a closed sampling system for arterial-blood-pressure measurement. This makes the procedure safer.
Injection valves on intravenous lines
It has been shown that colonisation frequency increases without the use of disinfectable injection membranes.3 We have tested injection valves and have introduced a new routine whereby injection valves are applied to all intravenous lines. The injection membrane is disinfected with chlorhexidine prior to injection.
Reduction in unnecessary disconnection of ventilator tubes
Inhalations are not given to ventilator patients as a matter of routine but only if specifically prescribed.
New trolley and revised contents for epidural catheters, arterial cannulae and central venous catheters
It was difficult to find the required equipment in our previous trolley, which resulted in disorganised work and considerable running backwards and forwards to the ward. This was solved by a thorough review of the contents and the acquisition of a new and more efficient trolley with a separate compartment for each procedure.
Single-use- instead of multiuse ventilator tubing
The risk of ventilator-associated pneumonia is hardly reduced by frequent changes of respirator tubes.13 14 We have introduced single-use ventilator tubing which can be in place for up to a week before needing to be replaced. They are also longer and lighter.
Training in patient care
We have had training in patient care as an ongoing theme throughout the project period in order to present our changes and establish the new routines.
Compliance with basic hygiene routines
With the aid of a specially created test protocol, we wanted to make regular observations and measurements in order to see how basic hygiene routines were being followed. One nurse in the staff carried out the observations in the hospital ward at the intensive-care unit using the test protocol in secret. The observer was trained to use the protocol. The observations were made during a 24 h period weekly. The idea was that this change would make staff more aware of basic hygiene routines, and feedback was presented at departmental meetings.
Facilitate, visualise and educate so that basic hygiene routines are followed
Measures include setting up hooks for long-sleeved coats, alcohol hand disinfection at every bed, pictures and posters, and instruction by the infection-control nurse.
Replace multiuse protective gowns with single-use plastic aprons
The use of single-use plastic aprons or gowns instead of multiuse cloth gowns makes it easier to follow the basic hygiene routines for patient care.
More secure handling of infected laundry
In order to prevent the transmission of infection in the intensive-care unit, we have made the handling of infected laundry more secure by placing a laundry bag and holder in each room.
The dirty laundry is placed directly in the laundry bag, which is then removed.
Patients on ventilator with healthcare-associated infections
We reduced the frequency of healthcare-associated infections in ventilated patients by 43%. When the project started, we had no idea of the incidence of patients on ventilator with healthcare-associated infections. Base data for patients on ventilator with healthcare-associated infections were collected between 1 September and 22 November 2004, with the aim to have a starting value for comparison. Data for the project were collected during January 2005 to June 2005. The patient sample was small, and the project time was short, so it is difficult to evaluate the result. The result is not significant, but it provides valuable support for us and our work to prevent healthcare-associated infections. The protocol for infection registration is in use after the project, and present measurements show that the rate of healthcare-associated infections of patients on ventilator is dropping. Changes were tested on a small scale over time, and we could not assess the effectiveness of every single change in the result, but combined, the changes yielded a good result.
Compliance with basic hygiene routines
Compliance with the basic hygiene routines greatly improved, from 72% on initial measurement to 98% today. When the project started, we had no idea of the degree of compliance with basic hygiene routines. The results are from a weekly observation of all personnel using a specially created test protocol. We observed the use of short-sleeved uniforms, protective clothing, aprons and gloves, hand disinfection with an alcohol rub, and wearing rings and wristwatches while working with patients, in order to measure the compliance with basic hygiene routines.
After the project, we continued to carry out regular observations and measurements to determine how well basic hygiene routines are being followed. Our present measurements seem to indicate that we are on the right track. The percentage of patients on a ventilator with healthcare-associated infections is shown in figure 1, and the compliance with basic hygiene routines is shown in figure 2.
We achieved a successful improvement that is not statistically significant, but our measurements indicated that both healthcare-associated infections of patients on the ventilator are decreasing, and compliance with basic hygiene routines has increased. We started to list the evidence-based changes and carried out small-scale tests of changes to see if they worked; those that worked have become standard practices and have led to new changes and tests. Reduced frequency of healthcare-associated infections means less suffering for the patients and reduced healthcare costs. By this project we learnt that this method of work, The Breakthrough Series, is an excellent model for healthcare organisations to make improvements in care.
The objective was to reduce the number of ventilator patients affected by healthcare-associated infections by 40%. Our measurements showed that we reached our goal, as the figure was 43%, but since the patient sample was small, it is difficult to evaluate the result. Our present measurements would seem to indicate that we are on the right track, and we will continue to register healthcare-associated infections and carry out regular measurements to ascertain whether our objectives continue to be maintained. At the same time, we will endeavour to reduce further the number of patients affected by healthcare-associated infections. A reduced frequency of healthcare-associated infections means less suffering for the patients and reduced healthcare costs.
We have not achieved our process objective of 100% compliance with basic hygiene routines, which could be explained by the fact that the intensive-care unit has several different categories of personnel involved in patient care. Despite the difficulty of observing without influencing—which means that the reliability of the findings could be open to discussion—the measurements have given us a good indication of the extent to which we are following basic hygiene routines, and they also show that ICU personnel have become better at following these routines. Watches and rings were common before we started the project, and today they are the exception. We also note a considerable increase in the use of alcohol hand rubs and plastic aprons.
Analysis and future work
To reduce the risk of acquiring healthcare-associated infections and increase patient safety, a continuous, systematic effort involving continual measurement and review is necessary. Continuous information and training are one aspect of this. As part of this process, a new hygiene policy has been introduced into the unit, and further tests and changes are planned.
Before the project started, we had no system of infection registration, and now it feels important that we are aware of the infection situation with respect to our ventilator patients. We will continue to work at expanding the infection registration system to include all intensive-care patients with the aim of preventing healthcare-associated infections.
We know from experience that when new routines are introduced, it is difficult to reach everyone, and it takes time for them to become established. During the project period, we have made several small changes, and these now seem to be established. Our measurements do not enable us to say which particular changes were responsible for achieving our goal, but the changes we have tested seem to have worked well and have resulted in new and better routines that, in the long run, should lead to better and safer care for patients.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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