Keystone, Matching Michigan, and Bacteremia Zero

Abstract

W e were interested to see that in a recent issue of Critical Care Medicine, Palomar et al (1) in Spain have reported a reduction in central venous catheter bloodstream infections (CVC-BSIs) similar to that seen in England's "Matching Michigan" program involving 196 adult and 19 pediatric ICUs and using the same multifaceted quality improvement program containing both technical and nontechnical interventions, the results of which we published last year (2). Matching Michigan reported both pre-ICU-and ICU-acquired infections and introduced the quality improvement program stepwise in four clusters. This allowed us to identify a strong secular (systems wide) trend in reducing infection rates, apparently unrelated to the specific ICU-located interventions. Palomar et al (1) do not report pre-ICU infections rates; if they have this information, it would be important to perform the same analysis as in Matching Michigan (2).The Matching Michigan study was accompanied by "Lining Up," a parallel, but independent, ethnographic study of the impact of introducing this improvement program across an entire health system. This showed wide variation in the detection, documentation, and reporting of CVC-BSIs between centers, despite standardized definitions and a web-based data collection system provided by the program (3). Like the Spanish study, we also found very variable enthusiasm for, and uptake of, the nontechnical interventions by the participating ICUs (4).Combining quantitative with qualitative research offers important insights into mechanism of action of interventions intended to improve healthcare delivery (5). The interplay between context, history, ownership, and leadership strongly influences the impact of complex interventions. We recommend that future research in this area begins with a diagnostic phase focused on these four elements and incorporates concurrent feedback on attitudes, behaviors, and performance, thus incorporating reflective learning as a key element as the program unfolds. of the program remains and 2 years later, rates at national level are lower than those obtained during implementation of the BZ program (3). These results exclude potential seasonal bias or spontaneous regression of epidemic outbreaks.The bundle introduction modified routine daily practice in Spain given that the use of chlorhexidine for skin disinfection was not generalized (iodine povidone was the most frequently used). Full barrier precautions were not a standard practice and many ICUs had to develop written insertion instructions or trays with all material including large surgical drapes to facilitate sterility during the whole process. These measures were monitored by means of the insertion checklist, with adherence rates greater than 95%. Other novel strategies were daily assessment of unnecessary central venous catheters withdrawal and disinfection of needless hubs prior to its use. Other benefits related to promotion of hand hygiene and the safety program were also the decrease of ventilator-associated pneumonia (VAP),...

Implementierungsstrategien für Hygienemaßnahmen

“…Das Keystone-Projekt wurde zum Erfolgsmodell und sollte in der Folge auf andere Länder ausgedehnt werden [11,12]. Stets war das Ziel, das Protokoll quasi 1 : 1 zu implementieren und die Inzidenzrate der ZVK-assoziierten Infektionen auf das erreichte Niveau von Keystone in Michigan zu senken.…”

“…Im April 2009 startete die englische National Patient Safety Agency (NPSA) ihr zweijähriges "Matching-Michigan"-Projekt zur Prävention katheterassoziierter Blutstrominfektionen [11]. Das Projekt wurde in mehr als 200 Intensivpflegestationen in England durchgeführt.…”

“…Wie erhofft, nahmen die ZVK-assoziierten Blutstrominfektionen während der Durchführung von "Matching Michigan" signifikant ab, und die Inzidenzrate von "Michigan" wurde tatsächlich erreicht [11]. Es gab aber wesentliche Unterschiede zu Keystone (▶ Tab.…”

“…Und tatsächlich: Die ZVK-assoziierten Blutstrominfektionen haben in allen Gruppen bereits vor der formellen Implementierung der Präventionsstrategie abgenommen. Die Inzidenz zu Beginn der Surveillance entsprach jeweils derjenigen der vorangegangenen Gruppe zum gleichen Zeitpunkt [11,13]. Statistisch gesehen konnte der Erfolg nicht "Matching Michigan" zugeordnet werden und dessen Einfluss blieb letztlich unklar.…”