Likely to Be Effective

Institutional Initiatives

for Prevention of Infection: General

Institutional initiatives are interventions done by an organization to facilitate uptake and implementation of new knowledge by healthcare providers, patients, and caregivers to improve care. Interventions include provision of education and distribution of printed materials, and may include development of organizational protocols, procedures, and activities to standardize care. Institutional interventions were evaluated in terms of effect on chronic pain and prevention of infection in patients with cancer.

Research Evidence Summaries

Bundy, D.G., Gaur, A.H., Billett, A.L., He, B., Colantuoni, E.A., Miller, M.R., & Children's Hospital Association Hematology/Oncology CLABSI Collaborative. (2014). Preventing CLABSIs among pediatric hematology/oncology inpatients: National collaborative results. Pediatrics, 134, e1678-e1685. 

Study Purpose

To assess the feasibility of instituting a multicenter effort to standardize central line (CL) care and CL-associated bloodstream infection (CLABSI) tracking while quantifying the impact of standardizing these processes on CLABSI rates among pediatric patients

Intervention Characteristics/Basic Study Process

A CL maintenance bundle was developed using Centers for Disease control and Prevention guidelines and recommendations as well as best practices from previous pediatric CLABSI efforts. These guidelines included (a) a reduction in the number of CL manipulations and entries, (b) the maintenance of a sterile entry to CL (hand hygiene and sterilization of port), (c) and standardized CL care practices (date and time cap, tubing/dressing/needle changes, standardized procedure). Tubing changes were every 96 hours and every 24 hours for blood products and lipids. Staff members audited the CLABSI bundle practice monthly using a standard form and submitted unit profile information. Teams met in two-day learning sessions annually and interacted monthly via webinars.

Sample Characteristics

  • N = 28 separate units  
  • KEY DISEASE CHARACTERISTICS: 50% hematology or oncology and transplant; 36% hematology or oncology; 7.1% oncology and transplant; and 7.1% transplant only
  • OTHER KEY SAMPLE CHARACTERISTICS: Units varied in size (8–48 beds); two thirds of teams were Magnet hospitals; 93% of patients were afebrile, neutropenic, postintensive chemotherapy patients with acute myeloid leukemia in inpatient settings waiting for count recovery; none of the units used antimicrobial impregnated catheters; a third used chlorhexidine gluconate baths in at least some patients; half involved patients and families in daily rounds

Setting

  • SITE: Multi-site    
  • SETTING TYPE: Inpatient    
  • LOCATION: United States

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active antitumor treatment
  • APPLICATIONS: Pediatrics

Study Design

Cohort comparison study

Measurement Instruments/Methods

Teams reported baseline data regarding CLABSI from January 2006 and October 2009. These data were compared to the intervention period from November 2009 to August 2012. CLABSIs were tracked as number per 1,000 CL days per month. CLABSIs occurring more than 48 hours after hospital admission and less than 48 hours prior to hospital discharge were deemed inpatient events and included in measurements.

Results

Across 46 months, precollaborative effort CLABSI rates were 2.85 per 1,000 CL days. During the first 34 months after the intervention, that rate was 2.04 per 1,000 CL days (p = 0.05). The odds for having no CLABSIs per unit per month was 2.59 higher during the collaborative intervention (p = 0.01). The compliance with recommended CL maintenance increased rapidly over the first year from 38% at baseline to 79% by the end of the first year. It remained at a rate of 81%–86% during the remainder of the intervention period.

Conclusions

The 28% reduction during the first 2.5 years suggested the elimination of about 290 CLABSIs over that period with an estimated reported cost savings of about $11 million. It was feasible to implement a standardized CL maintenance care bundle, track CL infections with standardized definitions, and generate benchmark data across a large network of centers. The implementation of a standardized catheter care bundle in a multi-instutituional collaborative effort was associated with reduced CLABSI rates.

Limitations

  • Risk of bias (no control group)
  • Measurement validity/reliability questionable
  • Other limitations/explanation: Retrospective study design; reliability of self-reported adherence to all aspects of the care protocol was not examined; patient characteristics in terms of infection risk were not described

Nursing Implications

Nurses are on the front lines when it comes to CLABSI prevention. This report demonstrated the effectiveness of a multisite collaborative initiative to reduce CLABSI rates. The implementation of a specific care bundle, monthly practice auditing, monthly webinars, and annual education of care teams involved was reported to be effective. This report provides suggested approaches for such initiatives and demonstrates associated improvement in quality and cost reduction.

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Gilbert, C.R., Lee, H.J., Akulian, J.A., Hayes, M., Ortiz, R., Hashemi, D., . . . Yarmus, L.B. (2015). A quality improvement intervention to reduce indwelling tunneled pleural catheter infection rates. Annals of the American Thoracic Society, 12, 847–853. 

Study Purpose

To evaluate the effects of an organizational intervention to reduce pleural catheter infections

Intervention Characteristics/Basic Study Process

Medical records of patients receiving indwelling pleural catheters (IPC) for malignant effusions were reviewed to describe the overall findings and practices from 2009 to 2014. The protocol was then updated to include changes so that all placements occurred within a single location, all patients received perioperative antibiotics within 60 minutes prior to IPC insertion, and full body sterile draping was conducted. A review of all cases was done after six months of follow-up.

Sample Characteristics

  • N = 225   
  • MEAN AGE = 63 years
  • AGE RANGE = 22–93 years
  • MALES: 41.5%, FEMALES: 58.5%
  • CURRENT TREATMENT: Not applicable
  • KEY DISEASE CHARACTERISTICS: Of the patients, 88% had IPC insertion because of malignancy. Lung and breast cancer were most prevalent.

Setting

  • SITE: Single site   
  • SETTING TYPE: Multiple settings    
  • LOCATION: Johns Hopkins Medical Institution

Phase of Care and Clinical Applications

  • PHASE OF CARE: Late effects and survivorship

Study Design

  • Cohort comparison

Measurement Instruments/Methods

  • IPC infection defined as either cellulitis and/or tunnel infection
  • Pleural space infection defined by draining of pus from the pleural space or a positive culture of pleural fluid with associated clinical symptoms

Results

Overall, the IPC infection rate was 8.2% prior to the intervention and decreased to 2.2% after the intervention (p = 0.049).

Conclusions

The quality improvement interventions implemented were associated with a significant reduction in overall IPC infection rates.

Limitations

  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Measurement validity/reliability questionable
  • Reliance on medical records data

Nursing Implications

This study showed that a quality improvement intervention involving a review of practices and related outcomes and an implementation of protocol changes aimed at reducing IPC infection rates was successful because of the overall reduction of infection rates. Principles related to surgical site infection and catheter infection prevention were incorporated into the organizational protocol changes that were made.

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Kachare, S.D., Sanders, C., Myatt, K., Fitzgerald, T.L., & Zervos, E.E. (2014). Toward eliminating catheter-associated urinary tract infections in an academic health center. The Journal of Surgical Research, 192, 280–285. 

Study Purpose

To determine if implementing two interventions would cause a reduction in catheter-associated urinary tract infections (CAUTIs) in an inpatient surgical oncology unit (The first intervention was designed to decrease the use of Foley catheters, and the second intervention was designed to initiate early removal while preventing reinsertion of the Foley catheter.)

Intervention Characteristics/Basic Study Process

The first intervention was the development of a hospital-wide guideline outlining the indications for Foley catheter use. There were six defined reasons for the use of a Foley catheter in a patient. If the patient did not meet one of these criteria, then Foley catheter use was not recommended. The second intervention included two measures. The first was aimed at the early removal of the catheter by designing a daily electronic query sent to the attending physician regarding continuing use of the Foley catheter, and the second was direct personal contact with the primary medical team to determine the medical necessity of continued Foley catheter use. They also focused on the prevention of catheter reinsertion by following a developed algorithm for the healthcare team.

Sample Characteristics

  • N = 2,843
  • KEY DISEASE CHARACTERISTICS: Cancer of the liver, pancreas, colon, head and neck, urologic, or gynecologic organs requiring inpatient surgery
  • OTHER KEY SAMPLE CHARACTERISTICS: CAUTIs were defined as the presence of symptomatic urinary tract infection (UTI) or asymptomatic bacteremic UTI in patients with an indwelling catheter in place for greater than 48 hours.

Setting

  • SITE: Single site    
  • SETTING TYPE: Inpatient    
  • LOCATION: Vidant Medical Center, Greenville, NC

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active antitumor treatment

Study Design

This study design was a pre/post design with preintervention data obtained in a retrospective manner followed by the authors obtaining postintervention data.

Measurement Instruments/Methods

  • The authors used total device days for Foley catheters, utilization rate, total number of CAUTI’s, and hand hygiene compliance pre- and postintervention as measurement instruments to determine the effectiveness of their interventions.

Results

There was a significant reduction in the use of Foley catheters after the interventions were put in place (P < 0.0001). There also was a significant reduction in CAUTI rates for patients who did require a Foley catheter after interventions were put into place, from 4.6 to 0 (P = 0.03). For patients who required a Foley catheter and had a diagnosed CAUTI during the postintervention time period, none of the Foley catheters were reinserted. The preintervention group had four patients with positive CAUTIs who had a Foley reinserted.

Conclusions

Even though the study was limited to one inpatient surgical oncology unit, the findings support other similar studies of best practice indicating use of Foley catheter insertion criteria as well as algorithm guidelines for care after catheter removal. Because infections can be detrimental in the oncology population, healthcare teams working with these patients should explore the literature surrounding the prevention of CAUTIs and ways of implementing best practices.

Limitations

  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Other limitations/explanation: Retrospective study; self-reporting of hand hygiene compliance; single-unit study

Nursing Implications

Oncology nurses need to be diligent with hand hygiene, not only among themselves but with other members of the healthcare team. They also need to adhere to Foley catheter bundles, including the daily verification of continuing need for the catheter, the use of catheter securement devices, keeping tubing below the level of the bladder, keeping the bag off of the floor, and providing perineal care at least twice per day. If the institution does not have a catheter bundle, nurses need to lead the initiative to implement one. This study demonstrated successful institutional approaches for protocol implementation and ongoing auditing and interventions with care providers.

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Martinez, J.M., Leite, L., França, D., Capela, R., Viterbo, L., Varajão, N., . . . Santo, A. (2015). Bundle approach to reduce bloodstream infections in neutropenic hematologic patients with a long-term central venous catheter. Acta Medica Portuguesa, 28, 474–479. 

Study Purpose

To use a bundle approach to reduce central line–associated bloodstream infections (CLABSI) in patients with hematologic malignancies and neutropenia with long-term central venous catheters (CVC)

Intervention Characteristics/Basic Study Process

Between 2010 and 2012, a bundle of interventions was introduced and outcomes were compared with the results from six months prior to the intervention. Interventions were the use of a different catheter (a neutral pressure mechanical valve connector versus a positive pressure mechanical valve connector), changing needless connectors twice weekly instead of weekly, and the replacement of a chlorhexidine solution to clean needless connectors rather than a solution with 70% alcohol. If blood cultures were obtained, patients were put on broad spectrum antibiotics. All patients were receiving prophylactic co-trimoxazole, itraconazole, and environmental neutropenic precautions.

Sample Characteristics

  • N = 116   
  • AGE = older than 18 years
  • MALES: Not provided  
  • FEMALES: Not provided
  • KEY DISEASE CHARACTERISTICS: Patients with acute leukemia, multiple myeloma, or non-Hodgkin lymphoma
  • OTHER KEY SAMPLE CHARACTERISTICS: All had tunneled catheters

Setting

  • SITE: Single site   
  • SETTING TYPE: Inpatient    
  • LOCATION: Portugal

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active antitumor treatment

Study Design

  • Prospective with historical cohort comparison

Measurement Instruments/Methods

Blood cultures were obtained for the presence of a fever for more than one hour or other signs of infection from peripheral veins and CVC lines.

Results

With the intervention, a 71% reduction in both CLABSIs (risk ratio [RR] = 0.29, p < 0.014) and overall bloodstream infections (RR = 0.28, p < 0.001) occurred. The reduction of gram-positive bacteria was most pronounced.

Conclusions

The institutional protocol changes related to catheter selection and IV access system care were associated with a reduction in CLABSIs.

Limitations

  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Limited sample description.
  • Outcomes measured at 72 hours only
  • No information was provided regarding other aspects of care or techniques used in insertion.

Nursing Implications

The changes implemented here were associated with the reduced incidence of CLABSIs within 72 hours. The authors suggested that changing from a positive pressure valve catheter to a neutral pressure type catheter may have been most relevant, as positive pressure valves tend to develop a biofilm and cannot be cleaned well with routine flushing.

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Tzadok, R., Shapira, M.Y., Moses, A.E., Or, R., Block, C., & Strahilevitz, J. (2015). Reduction in incidence of invasive fungal infection in patients receiving allogeneic stem cell transplantation using combined diagnostic-driven approach and itraconazole oral solution. Mycoses, 58, 694–698. 

Study Purpose

To determine the effectiveness of using antifungal therapy in conjunction with the diagnostic driven approach (DDA) in the management of invasive fungal infection (IFI) among patients undergoing allogeneic bone marrow transplantation (BMT)

Intervention Characteristics/Basic Study Process

Two strategies, DDA and antifungal prophylaxis, were used to diagnose and treat early IFI among allogeneic BMT patients. Two segments of 20 months included a preimplementation period in which medical records and laboratory statistics were used from admission up to six months. The intervention was the implementation of a DDA and the provision of antifungal prophylaxis. Prior to implementation, no routine antifungal prophylaxis was administered and the diagnosis of IFI was based on European Organization for Research and Treatment of Cancer (EORTC) criteria, including galactomannan assays. Antifungal agents were administered based on assay results. With the implementation of a new protocol, antifungal prophylaxis was given to those with graft-versus-host disease (GVHD), those treated with corticosteroid therapy, those with severe aplastic anemia, those undergoing cord blood transplantation, and those in which the standard diagnostic workup was deemed to be less effective. All patients were managed in high-efficiency particulate air (HEPA)-filtered rooms and housed in areas with limited access.

Sample Characteristics

  • N = 130   
  • AGE = 35–45 years
  • MALES: 38%, FEMALES: 28%
  • CURRENT TREATMENT: Other
  • KEY DISEASE CHARACTERISTICS: Malignant and benign, severe aplastic anemia
  • OTHER KEY SAMPLE CHARACTERISTICS: Conditioning regimen (myeloablative or nonmyeloablative), presence of graft-versus-host disease (GVHD), neutropenia phase of absolute neutrophil count [ANC] < 500, and survival rates of three and six months. All had allogeneic hematopoietic stem cell transplantation (HSCT).

Setting

  • SITE: Single site   
  • SETTING TYPE: Inpatient    
  • LOCATION: Referral center for HSCT (Hadassah Medical Center), Israel

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active antitumor treatment
  • APPLICATIONS: Elder care

Study Design

  • Pre-post design in which two periods pre intervention and post intervention segments were analyzed

Measurement Instruments/Methods

  • Breakthrough IFI (not specifically defined)
  • Antifungal use
  • Diagnostic test utilization

Results

A significant reduction in the cases of IFI (p = 0.051) was observed overall. The incidence of mold infection (aspergillosis) decreased substantially in the protocol period (p = 0.054). However, no change was noted in the survival rates and breakthrough fungal infection in the pre and post intervention phases.

Conclusions

The implementation of a clinical management protocol helped diagnose and treat early fungal infection and was associated with an overall reduction in the incidence of IFI.

Limitations

  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Unintended interventions or applicable interventions not described that would influence results
  • Drug toxicity level and poor oral acceptability of the medication
  • No differentiation between individuals who received antifungals prior to the protocol period in comparing outcomes
  • Comparison to a historical cohort with potential related threats to validity

Nursing Implications

Nursing role is vital in identifying the key sign and symptoms of infection and to highlight them to decrease the rates of fungal infections, hence minimizing the mortality and morbidity rates overall. This study demonstrated that a standardized approach to prophylaxis was associated with reduced fungal infections.

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Vanderway, J., Vincent, C., Walsh, S.M., & Obrecht, J. (2017). Implementation of a pathway for the treatment of fever and neutropenia in pediatric patients with cancer. Journal of Pediatric Oncology, 34, 315–321.

Study Purpose

Implement a pathway to achieve Time To Antibiotics (TTA) in less than 60 minutes form presentation for outpatient evaluation of FN in pediatric patients with cancer. Other endpoint was to improve bedside nurses’ understanding of fever, neutropenia, and importance of Rapid Time To Antibiotics (RTTA).

Intervention Characteristics/Basic Study Process

Implementation of Clinical Pathway for RTTA in less than 60 minutes

Inservice and poster board used to educate nurses about fever and neutropenia. Knowledge measured with pre- and post-tests.

Sample Characteristics

  • N: 25 patients and 12 nurses
  • AGE: From birth to age 18 years
  • MALES: Not reported  
  • FEMALES: Not reported
  • CURRENT TREATMENT: Combination radiation and chemotherapy
  • KEY DISEASE CHARACTERISTICS: Pediatric oncology patients in the Ambulatory Infusion Center with fever and neutropenia receiving antibiotics.  Patients without implanted vascular access devices were excluded.

Setting

  • SITE: Single site   
  • SETTING TYPE: Outpatient    
  • LOCATION: University of Chicago

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active anti-tumor treatment
  • APPLICATIONS: Pediatrics

Study Design

TTA was tracked using retrospective chart review to determine pre-pathway metrics.

Measurement Instruments/Methods

Retrospective chart review using electronic health record filters was used for pre-pathway data collection. A computerized spreadsheet was used for post-pathway data collection.

Nursing knowledge was tested using a 9-item Fever and Neutropenia Questionaire. A bulletin board with key FN concepts and an in-service by APNs were sources of education.

Results

Nurses had a mean score of 7.5 correct answers for the pre-education questionnaire and an 8.92 mean score for post-education (p = 0.0002).

Conclusions

Improvement in nurses knowledge of FN was improved with education and TTA was improved with a clinical pathway. The study included a very small sample of pediatric patients and nurses from one cancer center, resulting in limited application to other settings.

Limitations

  • Small sample (< 30)
  • Measurement validity/reliability questionable 
  • Findings not generalizable

Nursing Implications

Based on literature review and limited findings of this QI project, clinical pathways and nursing education are successful ways to improve care of patients with FN. Recommendations for implementing in other settings will need larger studies demonstrating success with these interventions to demonstrate applicability.

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Vicente, M., Al-Nahedh, M., Parsad, S., Knoebel, R.W., Pisano, J., & Pettit, N.N. (2017). Impact of a clinical pathway on appropriate empiric vancomycin use in cancer patients with febrile neutropenia. Journal of Oncology Pharmacy Practice, 23, 575–581.

Study Purpose

To determine the appropriateness of vancomycin prescribing, based on consistency with guideline (IDSA and NCCN) recommendations before and after implementation of FN clinical pathway. Secondary endpoint was to determine influence of comorbidities with inconsistent vancomycin use based on guideline recommendations.

Intervention Characteristics/Basic Study Process

Using IDSA and NCCN guidelines for prescribing vancomycin in adults patients with cancer with FN and a risk assessment tool for adverse clinical outcomes a pathway was developed to increase compliance with guidelines. 337 patient records were analyzed to evaluate effectiveness of FN clinical pathway at academic medical center. Patients admitted with FN and no allergy to beta-lactam were included. Four groups were evaluated: pre-pathway vancomycin use consistent with guidelines, post-pathway vancomycin use consistent with guidelines, post-pathway vancomycin use inconsistent with guidelines and post-pathway vancomycin use inconsistent with guidelines. Vancomycin use was defined as use for at least 48 hours to exclude those receiving it for procedural prophylaxis.

Sample Characteristics

  • N = 337   
  • AGE: Adults reported in mean and standard deviation for each group. Consistent vancomycin pre = 59 (SD = 13.3), consistent vancomycin post = 59.4 (SD = 15.6), inconsistent vancomycin pre = 55.5 (SD = 15.3), inconsistent vancomycin post = 51.3 (SD = 12.2)
  • MALES: 59%  
  • FEMALES: 41%
  • CURRENT TREATMENT: Chemotherapy, other
  • KEY DISEASE CHARACTERISTICS: Hematologic malignancy, solid tumor malignancy, stem cell transplantation autologous and stem cell transplantation allogeneic
  • OTHER KEY SAMPLE CHARACTERISTICS: Patients with diagnosis of neutropenia ICD 9 codes 288.00, 288.02, 288.03, 288.04, 299.08, and ICD 9 for fever. Adult FN patients who received an appropriate anti-pseudomonal beta-lactam with or without vancomycin were included in the analysis. Patients transferred from outside facility or with documented penicillin or vancomycin allergy were excluded.

Setting

  • SITE: Single site   
  • SETTING TYPE: Not specified    
  • LOCATION: University of Chicago Medical Center

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active anti-tumor treatment
  • APPLICATIONS: Elder care

Study Design

Evaluate appropriate prescribing of vancomycin based on consistency with guideline recommendations pre- and post-implementation of a FN clinical pathway.

Measurement Instruments/Methods

Antimicrobial usage report generated from electronic medical record. Hematopoietic Cell Transplantation Comorbidity Index (HCT CI)

Results

The rate of vancomycin use, inconsistent with guideline recommendations in the pre-pathway implementation time frame, was significantly greater (n = 74, 35.9%) versus use in the post-pathway implementation time frame (n = 5, 11.4%; p = 0.001). No comorbidities or specific HCT CI scores were predictive of vancomycin without indication on multivariate analysis.

Conclusions

Implementation of a guideline-based pathway for FN in adult patients with cancer can significantly improve adherence to guideline recommendations for antimicrobial (vancomycin) use

Limitations

  • Findings not generalizable
  • Other limitations/explanation: The use of HCT CI has not been validated in another malignancy except hematologic

Nursing Implications

Use of clinical pathways can improve compliance with guidelines for managing at-risk patients, leading to better outcomes.

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