title: Educational interventions for preventing vascular catheter bloodstream infections in critical care: evidence map, systematic review and economic evaluation.
abstract: BACKGROUND
  Bloodstream infections resulting from intravascular catheters (catheter-BSI) in critical care increase patients' length of stay, morbidity and mortality, and the management of these infections and their complications has been estimated to cost the NHS annually £19.1-36.2M. Catheter-BSI are thought to be largely preventable using educational interventions, but guidance as to which types of intervention might be most clinically effective is lacking.
  
  
  OBJECTIVE
  To assess the effectiveness and cost-effectiveness of educational interventions for preventing catheter-BSI in critical care units in England.
  
  
  METHODS
  Sixteen electronic bibliographic databases - including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, Cumulative Index to Nursing and Allied Health Literature (CINAHL), NHS Economic Evaluation Database (NHS EED), EMBASE and The Cochrane Library databases - were searched from database inception to February 2011, with searches updated in March 2012. Bibliographies of systematic reviews and related papers were screened and experts contacted to identify any additional references.
  
  
  METHODS
  References were screened independently by two reviewers using a priori selection criteria. A descriptive map was created to summarise the characteristics of relevant studies. Further selection criteria developed in consultation with the project Advisory Group were used to prioritise a subset of studies relevant to NHS practice and policy for systematic review. A decision-analytic economic model was developed to investigate the cost-effectiveness of educational interventions for preventing catheter-BSI.
  
  
  RESULTS
  Seventy-four studies were included in the descriptive map, of which 24 were prioritised for systematic review. Studies have predominantly been conducted in the USA, using single-cohort before-and-after study designs. Diverse types of educational intervention appear effective at reducing the incidence density of catheter-BSI (risk ratios statistically significantly < 1.0), but single lectures were not effective. The economic model showed that implementing an educational intervention in critical care units in England would be cost-effective and potentially cost-saving, with incremental cost-effectiveness ratios under worst-case sensitivity analyses of < £5000/quality-adjusted life-year.
  
  
  CONCLUSIONS
  Low-quality primary studies cannot definitively prove that the planned interventions were responsible for observed changes in catheter-BSI incidence. Poor reporting gave unclear estimates of risk of bias. Some model parameters were sourced from other locations owing to a lack of UK data.
  
  
  CONCLUSIONS
  Our results suggest that it would be cost-effective and may be cost-saving for the NHS to implement educational interventions in critical care units. However, more robust primary studies are needed to exclude the possible influence of secular trends on observed reductions in catheter-BSI.
  
  
  BACKGROUND
  The study is registered with PROSPERO as CRD42012001840.
  
  
  BACKGROUND
  The National Institute for Health Research Health Technology Assessment programme.
authors.affiliation: Southampton Health Technology Assessments Centre (SHTAC), Faculty of Medicine, University of Southampton, Southampton, UK.
authors.forename: Geoff K
authors.initials: GK
authors.lastname: Frampton
authors.affiliation: Southampton Health Technology Assessments Centre (SHTAC), Faculty of Medicine, University of Southampton, Southampton, UK.
authors.forename: Petra
authors.initials: P
authors.lastname: Harris
authors.affiliation: Southampton Health Technology Assessments Centre (SHTAC), Faculty of Medicine, University of Southampton, Southampton, UK.
authors.forename: Keith
authors.initials: K
authors.lastname: Cooper
authors.affiliation: Department of Infection Prevention and Control, South London Healthcare NHS Trust, London, UK.
authors.forename: Tracey
authors.initials: T
authors.lastname: Cooper
authors.affiliation: Division of Medical and Dental Education, School of Medicine, University of Aberdeen, Aberdeen, UK.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Cleland
authors.affiliation: Southampton Health Technology Assessments Centre (SHTAC), Faculty of Medicine, University of Southampton, Southampton, UK.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Jones
authors.affiliation: Southampton Health Technology Assessments Centre (SHTAC), Faculty of Medicine, University of Southampton, Southampton, UK.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Shepherd
authors.affiliation: Southampton Health Technology Assessments Centre (SHTAC), Faculty of Medicine, University of Southampton, Southampton, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Clegg
authors.affiliation: Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Graves
authors.affiliation: Southampton Health Technology Assessments Centre (SHTAC), Faculty of Medicine, University of Southampton, Southampton, UK.
authors.forename: Karen
authors.initials: K
authors.lastname: Welch
authors.affiliation: Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.
authors.forename: Brian H
authors.initials: BH
authors.lastname: Cuthbertson
mesh_terms: D055499:Catheter-Related Infections / Q000517:prevention & control*; D003362:Cost-Benefit Analysis; D003422:Critical Care; D019317:Evidence-Based Medicine; D006801:Humans; D007318:Inservice Training; D008505:Medical Staff, Hospital / Q000193:education*