Systems initiatives reduce healthcare-associated infections: a study of 22,928 device days in a single trauma unit.
BACKGROUND
"Implementation research" promotes the systematic conversion of evidence-based principles into routine practice to improve the quality of care. We hypothesized a system-based initiative to reduce nosocomial infection would lower the incidence of ventilator-associated pneumonia (VAP), urinary tract infection (UTI), and bloodstream infection (BSI).


METHODS
From January 2006 to April 2008, 7,364 adult trauma patients were admitted, of which 1,953 (27%) were admitted to the trauma intensive care unit and comprised the study group. Tight glycemic control was maintained using a computer algorithm for continuous insulin administration based on every 2-hour blood glucose testing. Centers for Disease Control and Prevention definitions of nosocomial infections were used. Evidence-based infection reduction strategies included the following: a VAP bundle (spontaneous breathing, Richmond Agitation-Sedation Scale, oral hygiene, bed elevation, and deep vein thrombosis/stress ulcer prophylaxis), UTI (expert insertion team and Foley removal/change at 5 days), and BSI (maximum barrier precautions, chlorhexidine skin prep, line management protocol). An electronic dashboard identified the at-risk population, and designated auditors monitored the compliance. Infection rates (events per 1,000 device days) were measured over time and compared annually using Fisher's exact test.


RESULTS
The study group had 22,928 device exposure days: 6,482 ventilator days, 9,037 urinary catheter days, and 7,399 central line days. Patient acuity, demographics, and number of device days did not vary significantly year-to-year. Annual infection rates declined between 2006 and 2008, and decreases in UTI and BSI rates were statistically significant (p < 0.05). These decreases pushed UTI and BSI rates below Centers for Disease Control and Prevention norms.


CONCLUSIONS
Over 28 months, a systems approach to reducing nosocomial infection rates after trauma decreased nosocomial infections: UTI (76.3%), BSI (74.1%), and VAP (24.9%). Our experience suggests that infection reduction requires (1) an evidence-based plan; (2) MD and staff education/commitment; (3) electronic documentation; and (4) auditors to monitor and ensure compliance.
Miller
Richard S
RS
Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Norris
Patrick R
PR
Jenkins
Judith M
JM
Talbot
Thomas R
TR
Starmer
John M
JM
Hutchison
Sarah A
SA
Carr
Devin S
DS
Kleymeer
Christopher J
CJ
Morris
John A
JA
D000328:Adult; D016470:Bacteremia / Q000209:etiology / Q000517:prevention & control; D055499:Catheter-Related Infections / Q000517:prevention & control; D003428:Cross Infection / Q000517:prevention & control*; D055317:Evidence-Based Practice; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D017053:Infection Control / Q000379:methods*; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D053717:Pneumonia, Ventilator-Associated / Q000517:prevention & control; D014552:Urinary Tract Infections / Q000209:etiology / Q000517:prevention & control; D014947:Wounds and Injuries / Q000628:therapy*