Mauger Rothenberg Barbara, Marbella Anne, Pines Elizabeth, Chopra Ryan, Black Edgar R, Aronson Naomi
Evid Rep Technol Assess (Full Rep). 2012 Nov(208.6):1-578.
To update the Agency for Healthcare Research and Quality (AHRQ) Evidence Report Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 6-Prevention of Healthcare-Associated Infections on quality improvement (QI) strategies to increase adherence to preventive interventions and/or reduce infection rates for central line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), surgical site infections (SSI), and catheter-associated urinary tract infections (CAUTI).
MEDLINE®, CINAHL®, and Embase® were searched from January 2006 to January 2012 for English-language studies with sample size ≥100 patients, a defined baseline period, and reported statistical analysis for adherence and/or infection rates. Articles from the previous report were screened and those meeting selection criteria were included.
We sought studies that evaluated the following QI strategies to improve adherence to evidence-based preventive interventions and/or reduce healthcare-associated infection (HAI) rates: audit and feedback; financial incentives, regulation, and policy; organizational change; patient education; provider education; and provider reminder systems. Data were abstracted by a single reviewer and fact-checked by a second. Outcomes were adherence to preventive interventions, infection rates, adverse outcomes, and cost savings. Study quality was assessed using relative rankings based on study design, adequacy of statistical analysis, length of followup, reporting and analysis of baseline and postintervention adherence and infection rates, and implementation of the intervention independent of other QI efforts. Combinations of QI strategies were assessed, not individual strategies. Strength of evidence was judged according to the AHRQ Methods Guide.
Sixty-one articles yielded 71 analyses at the infection level, including 9 articles (10 analyses) from the 2007 report, which evaluated the use of one or more QI strategies to improve adherence or infection rates and also controlled for confounding or secular trend. Twenty-six analyses were performed on CLABSI, 19 on VAP, 15 on SSI, and 11 on CAUTI. There were 34 analyses on adherence, of which 31 (91%) showed significant improvement. There were 63 analyses of infection rates, of which 42 (67%) showed significant improvement.
There is moderate strength of evidence across all four infections that both adherence and infection rates improve when either audit and feedback plus provider reminder systems or audit and feedback alone is added to the base strategies of organizational change and provider education. There is low strength of evidence that adherence and infection rates improve when provider reminder systems alone are added to the base strategies. There was insufficient evidence for reduction of HAI in nonhospital settings, cost savings for QI strategies, and the nature and impact of the clinical contextual factors.
更新医疗保健研究与质量机构（AHRQ）的《缩小质量差距：质量改进策略的批判性分析：第6卷——医疗保健相关感染的预防》，内容涉及提高对预防干预措施的依从性和/或降低中心静脉导管相关血流感染（CLABSI）、呼吸机相关性肺炎（VAP）、手术部位感染（SSI）和导尿管相关尿路感染（CAUTI）感染率的质量改进（QI）策略。
检索了2006年1月至2012年1月期间的MEDLINE®、CINAHL®和Embase®，以查找样本量≥100例患者、有明确基线期且报告了依从性和/或感染率统计分析的英文研究。对先前报告中的文章进行筛选，纳入符合选择标准的文章。
我们寻找评估以下QI策略的研究，以提高对循证预防干预措施的依从性和/或降低医疗保健相关感染（HAI）率：审核与反馈；经济激励、监管和政策；组织变革；患者教育；提供者教育；以及提供者提醒系统。数据由一名审阅者提取，并由另一名审阅者进行核实。结果指标为对预防干预措施的依从性、感染率、不良后果和成本节约。根据研究设计、统计分析的充分性、随访时间、基线和干预后依从性及感染率的报告与分析，以及干预措施独立于其他QI工作的实施情况，使用相对排名评估研究质量。评估的是QI策略的组合，而非单个策略。根据AHRQ方法指南判断证据强度。
61篇文章在感染层面产生了71项分析，其中包括2007年报告中的9篇文章（10项分析），这些文章评估了使用一种或多种QI策略来提高依从性或感染率，并对混杂因素或长期趋势进行了控制。对CLABSI进行了26项分析，对VAP进行了19项分析，对SSI进行了15项分析，对CAUTI进行了11项分析。有34项关于依从性的分析，其中31项（91%）显示有显著改善。有63项关于感染率的分析，其中42项（67%）显示有显著改善。
在所有四种感染中，有中等强度的证据表明，当将审核与反馈加提供者提醒系统或仅审核与反馈添加到组织变革和提供者教育的基础策略中时，依从性和感染率都会提高。有低强度的证据表明，当仅将提供者提醒系统添加到基础策略中时，依从性和感染率会提高。对于非医院环境中HAI的降低、QI策略的成本节约以及临床背景因素的性质和影响，证据不足。
