ReviewEffectiveness of bundled behavioural interventions to control healthcare-associated infections: a systematic review of the literature
Introduction
Healthcare-associated infections (HAIs) are a serious and growing problem at every level of the healthcare system. HAIs are associated with an increased attributable mortality, length of stay, and healthcare costs incurred by patients, insurers and healthcare facilities.1 A growing proportion of HAIs are attributed to multiple-drug-resistant organisms (MDROs); for example, 60–70% of Staphylococcus aureus strains isolated among inpatients in many countries are resistant to meticillin and often several other first-line antibiotics.2
Strategies for tackling the growing problem of HAIs have historically relied on infection control policies that recommend good hygiene through standard precautions and enhanced precautions such as isolation for patients infected with an MDRO. For these interventions to be effective, provider behaviour must be uniformly congruent with the institutional policies. Additionally, there is lack of consensus among different guidelines for the recommended use of barrier precautions and isolation leading to a lack of clear standards for care, which may further increase the variability of provider behaviour in a single institution.
Our group recently conducted a systematic review of the literature evaluating the effectiveness of barrier precautions, patient isolation, and use of surveillance cultures. We noted an intriguing difference in the findings of three studies evaluating the effectiveness of glove use alone compared with glove and gown use.3 In the two studies that found no difference in infection rates between the two groups, the glove and gown use was monitored and a compliance rate of 50–80% was reported.4, 5 In contrast, no monitoring or compliance rates were reported in another study in which a decrease in infection rates was found.6 With high compliance, gloves alone appeared as effective as gloves and gowns. This observation raised the question as to whether the findings from studies assessing the impact of barrier precautions could be attributed to lack of efficacy (i.e. they don't work) or lack of effectiveness (i.e. they might work, but are not actually performed properly). Moreover, what is the impact of behavioural interventions to improve awareness and compliance with barrier precautions on rates of MDROs and other HAIs? Despite the publication of several recent reviews of infection control practices aimed at reducing HAIs, the impact of behavioural interventions has not been specifically summarized.7, 8 The purposes of this systematic literature review were to identify studies in which behavioural interventions to reduce HAI were evaluated, to assess the quality of these studies, to summarize the findings of the studies with the highest quality scores, and to make recommendations for future investigation.
Section snippets
Literature search
Databases were independently searched by two of the authors, including PubMed, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials. The MeSH terms and key words linked with Boolean ‘AND’ logic included: ‘nosocomial infection’, ‘healthcare associated infection’, ‘clinical practice’, ‘behaviour’, and ‘compliance’, ‘staff’. The search was limited to January 1, 2000 to June 1, 2006. The terms were searched in each database separately and in combination.
Study characteristics
Of the 33 published studies (Appendix 1) that met the inclusion criteria, 51.5% (N = 17) were from North America and the others were from Europe (N = 7), South America (N = 5) and the Middle East or Asia (N = 4). The majority (90.9%) of studies were non-randomized intervention trials comparing pre- with post-intervention outcomes; three studies compared outcomes from different units in a single hospital. Most (81.8%) tested multiple interventions in acute care/intensive care unit (ICU) settings. In
Assessing ‘care bundles’
The Institute for Healthcare Improvement (IHI) and other groups have moved in the direction of recommending the use of ‘care bundles’ defined as, ‘the bundling together of several scientifically grounded elements essential to improving clinical outcome’, to reduce rates of HAI (http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/BundleUpforSafety.htm). These care bundles include three to five practices considered as a cohesive unit. Each component of the care bundle
Acknowledgement
Funded in part by The Center for Interdisciplinary Research on Antimicrobial Research, CIRAR, funded by The National Center for Research Resources, P20 RR020616.
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